White coat and masked hypertension

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1 White coat and masked hypertension

2 Conflict of interest Support from Spacelabs, Microlife. Honoraria from Novartis, Elpen, Boeringer-Ingelheim, CANA, Lilly, MSD, Sanofi, Menarini, Ciezi, Astra-Zeneca.

3 Limitations of clinic BP measurements Overestimation of initial BP Alerting reaction

4 Limitations of clinic BP measurements Observer bias and digit preferences J Hum Hypertens. 2003;17(12):

5 Limitations of clinic BP measurements Inability to account for BP variability

6 Limitations of clinic BP measurements Underestimation of the effect of treatment N= 876 Treated Subjects Kotsis et al J Hypertens 2004 Suppl II Underestimation of the effect of treatment in 12.7% of the patients

7 Limitations of clinic BP measurements Limited reproducibility of isolated office readings Staessen et al, Syst-Eur Trial. J Hypertens 1994;12:

8 Limitations of clinic BP measurements Underestimation of the real BP of selected patients Young age <30 years Current Smoking Alchohol Increased psycical activity Increased work stress High-normal office BP (prehypertension status) Male gender

9 Out of office measurements of blood pressure Self BP monitoring at home (SBPM) Ambulatory BP monitoring (ABPM)

10 Ambulatory blood pressure monitoring Ambulatory blood pressure (ABP) monitoring is a noninvasive, fully automated technique in which blood pressure is recorded over an extended period of time, typically 24 hours

11 ABPM equipment The standard equipment includes a cuff, a small monitor attached to a belt and a tube connecting the monitor to the cuff Most ABP devices use an oscillometric technique Of the available ABP devices, most have undergone validation testing

12 ABPM data and analysis ABPM report provides mean values by hour and period (daytime, nighttime and 24-h) both for systolic and diastolic blood pressure

13 Normal 24h ABPM study

14 Abnormal 24h ABPM study (isolated systolic hypertension-non dipping pattern)

15 Recommendations of normal ABPM values Desirable Normal Abnormal Daytime BP (mmhg) Nighttime BP (mmhg) 24h BP (mmhg) <130/80 <135/85 >140/90 <115/65 <120/70 >125/75 <125/75 <130/80 >135/85 O brien et al, J Hypertens 2003;21: , Pickering et al, Circulation 2005;111:

16 Definition of Masked hypertension Office blood pressure normotension Ambulatory daytime blood pressure hypertension PICKERING T et al

17 Combining office and out-of-office BP measurements DAYTIME PICKERING T et al

18 Masked hypertension The definition of true normotension needs out of office blood pressure measurements. Kotsis, Vasilios; Stabouli, Stella Journal of Hypertension. 28(8): , August DOI: /HJH.0b013e32833cd087

19 Prevalence of Masked Hypertension in Various Studies Author Population N ABP criterion Prevalence (%) Imai et al. Hypertens Res 1996; 19: Ohasama /78 10 Sega et al. Circulation 2001; 104: PAMELA 3, /79 9 Björklund et al. Circulation 2003; 107: year-old men /85 14 Liu et al Ann Intern Med 1999; 131: Healthy volunteers /85 21 Kotsis et al Am J Hypertens 2008;21(4): Hypertension center untreated population 1, / Stabouli et al Pediatr Nephrol 2005; 20: Children th Percentile for sex and height 9.4 Selenta et al Arch Fam Med 2000; 9: Healthy volunteers /85 23

20 Treated hypertensives: masked hypertension 876 Treated Subjects Modified from Kotsis et al J Hypertens 2004 Suppl II

21 Prevalence of masked hypertension in the pediatric-adolescent population White-Coat Hypertensives 12,9% Confirmed Normotensives 52,9% Masked Hypertensives 9,4% Confirmed Hypertensives 24,7% Stabouli et al. Pediatr Nephrol 2005

22 Definition of the negative WCE (masked effect) Modified from Kotsis et al, Blood Press Monit. 2006;11:9-15.

23 TOD in masked hypertension No Patients Population Results Liu et al, Ann Intern Med Hypertension Center patients LVMI and cimt Sega et al, Circulation 2001 (Pamela study) Stabouli et al Pediatr Nephrol General population LVMI 85 Children LVMI Kotsis et al, Am J Hypertens Hypertension Center patients LVMI and cimt

24 Left ventricular mass in children with masked hypertension Children with masked hypertension had significantly greater left ventricular mass indices than confirmed normotensive subjects Left ventricular mass indices in children with masked hypertension were similar on average to confirmed hypertensive subjects Stabouli et al. Pediatr Nephrol 2005

25 LVMI in masked hypertension Kotsis et al, Am J Hypertension 2009

26 cimt in masked hypertension Kotsis et al, Am J Hypertens 2009

27 24h versus office SBP to predict TOD

28 Silent cerebrovascular lesions in individuals with 'masked hypertension by home blood pressure measurement: the Ohasama study Ohkubo et al Journal of Hypertension. 27(5): , May

29 Masked hypertension in obstructive sleep apnea syndrome N=130 OSA patients Modified from Baguet et al. Journal of Hypertension 2008, 26:

30 TOD in Masked Hypertension in OSAS Baguet et al. Journal of Hypertension 2008, 26:

31 Cardiovascular risk in patients with Masked hypertension in the Pamela study In the PAMELA study the prognostic value of selective and combined elevations of home, office and ambulatory BPs assessed in over 2000 patients of the general population of Monza followed up for 148 months drew the conclusion that both WCH and masked hypertension are not benign conditions WCH and masked hypertension were associated with an increased risk in all cause and cardiovascular mortality Mancia G et al. Hypertension 2006; 47:

32 Ohasama study

33 Incidence of cardiovascular events in masked hypertension vs. true normotension Robert H. Fagard et al. J Hypertens 2007, 25:

34 Prognostic significance of masked hypertension in the Finn-Home study Margo-Riitta A et al J Hypertens 2012 in press

35 Ageing and Blood pressure continuum B P WCH Masked Hypertension Hypertension Normotension Age

36 Office Blood pressure (mhg) V Kotsis 2009 Hypertension 24h ABPM center Papageorgiou Hospital Thessaloniki Trough effect and normal clinic BP Drug dosing VISIT AT CLINIC 07:00 11:00 15:00 19:00 23:00 03:00 07:00 Time During 24h

37 Conclusions I Masked hypertension is common in subjects referred for elevated BP ABP hypertension organ damage predicts blood pressure-related target Individuals with masked hypertension appear to be at increased risk for blood pressure-related complications compared with those with a normal BP and similar to that of sustained hypertensives

38 Suggestions for the use of ABPM Current evidence may suggest that male, obese, smoking, prehypertensive subjects could selectively undergo ABPM MH subjects need to be treated for hypertension and probably followed up for reversal of target organ damage V Kotsis et al Am J Hypertens 2008; 21:

39 Aknowledgements S Stabouli V Pitiriga S Toumanidis C Papamicael J Lekakis S Papakatsika S Goulopoulou I Karafyllis C Antza G Kotronis Thank you very much for your attention

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