Hipertensión enmascarada Alejandro de la Sierra Hospital Mútua Terrassa Universitat de Barcelona
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
Definitions Masked hypertension Untreated subjects presenting with normal BP in the office but elevated ABP (or HBP) Masked uncontrolled hypertension (MUCH) Treated patients controlled at the office but uncontrolled at home or by ABPM
Definición Prevalencia Características clínicas Riesgo derivado HTA enmascarada Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
Distribution of hypertension phenotypes in untreated patients from the Spanish ABPM Registry Office BP mmhg 26.2% 50.2% Normotension Sustained hypertension White-coat hypertension Masked hypertension 140/90 15.6% 8.1% 130/80 24-hour ambulatory BP mmhg
Prevalence of MH and MUCH depending on guidelines criteria and the circadian period selected Prevalence of MH, n (%) (N=3477) ESH proposed criteria Prevalence of MUCH, n (%) (N=5934) Daytime BP 135 or 85 mmhg 497 (14.3%) 881 (14.8%) 24-hour BP 130 or 80 mmhg 671 (19.3%) 1204 (20.3%) Night-time BP 120 or 70 mmhg 977 (28.1%) 2149 (36.2%) Any of the above 1147 (33.0%) 2349 (39.6%) ACC/AHA proposed criteria Daytime BP 130 or 80 mmhg 1033 (29.7%) 1682 (28.3%) 24-hour BP 125 or 75 mmhg 1337 (38.5%) 2302 (38.8%) Night-time BP 110 or 65 mmhg 1919 (55.2%) 3730 (62.9%) Any of the above 2094 (60.2%) 3956 (66.7%) De la Sierra et al. Circulation 2018
Other isssues on MH prevalence ESHWG recommends diagnosis of MH or MUCH when either daytime BP, nighttime BP, or 24-hour BP are elevated O Brien E, et al. J Hypertens 2013 40% of patients with MUCH were due to isolated nocturnal BP elevation Banegas JR, et al. Eur Heart J 2014 Nocturnal period should be tailored to patient s dairy.
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
Prevalence of MH decreases with age Conen D, et al. Hypertension 2014
Clinical variables associated with MH or MUCH Young age Male gender Smoking Normal weight LVH or microalbuminuria Overt CV or renal disease Banegas et al. Eur Heart J 2014 De la Sierra et al. Circulation 2018
Some typical circumstances Mental stress at work Typical among physicians and nurses High variability of office BP measurements Combined normal and elevated BP recordings Sleep disorders, especially sleep apnea High normal office BP with documented TOD
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
Increased TOD in MH Increased prevalence of LVH Increased carotid IMT Increased prevalence of CKD Reduced forearm FMD (increased endothelial dysfunction)
Definición Prevalencia Características clínicas Riesgo derivado HTA enmascarada Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Tratamiento
Reproducibility of MH diagnosis after 1 year without pharmacological intervention 50 47,4 45 40 35 30 25 20 15 16,7 33,3 NT WCH MH SH 10 5 2,6 0 MH at baseline
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Tratamiento
Figure S4 Panel A All-cause mortality P<0.001 Masked hypertension Masked uncontrolled hypertension Sustained hypertension White-coat hypertension P=0.774 Sustained uncontrolled hypertension White-coat uncontrolled hypertension Normotension P=0.811 Controlled hypertension P=0.655 Risk of MH and MUCH Number at risk Normotension 4220 4068 3561 2901 2273 1527 1068 664 396 320 237 Controlled hypertension 6692 6477 5806 4832 3892 2869 2126 1388 912 754 578 White-coat hypertension 6628 6436 5725 4930 3924 2847 2152 1273 709 553 412 White-coat uncontrolled hypertension 11042 10740 9660 8560 6944 5268 4036 2643 1701 1419 1049 Masked hypertension 2278 2194 1917 1623 1272 885 610 376 201 160 119 Masked uncontrolled hypertension 3092 2984 2635 2277 1808 1392 1064 705 450 382 295 Sustained hypertension 12555 12199 10888 9351 7480 5573 4229 2722 1645 1339 998 Sustained uncontrolled hypertension 17402 16929 15366 13403 11196 8642 6650 4479 3017 2603 1913 Banegas, Ruilope, de la Sierra, et al. NEJM 2018
Risk of MH and MUCH Banegas, Ruilope, de la Sierra, et al. NEJM 2018
Risk of MUCH vs CH Pierdomenico SD, et al. Hypertension 2018
HTA enmascarada Definición Prevalencia Características clínicas Riesgo derivado Asociación con LOD Progresión a la HTA sostenida Riesgo de eventos CV Posicionamiento en las guías y tratamiento
Screening and diagnosis of hypertension Williams B, et al. Eur Heart J 2018
Management of masked hypertension Recommendations In masked hypertension, lifestyle changes are recommended to reduce CV risk, with regular follow-up, including periodic out-of-office BP monitoring. Antihypertensive drug treatment should be considered in masked hypertension to normalize the out-of-office BP based on the prognostic importance of out-of-office BP elevation. Antihypertensive drug up-titration should be considered in treated patients whose out-of-office BP is not controlled (i.e. masked uncontrolled hypertension), because of the high CV risk of these patients. I IIa IIa C C C Williams B, et al. Eur Heart J 2018
Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.
Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy Detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy Office BP at goal Yes No Increased CVD risk or target organ damage Office BP 5 10 mm Hg above goal on 3 agents Yes No Yes No Screen for masked uncontrolled hypertension with HBPM (Class IIb) Screening not necessary (No Benefit) Screen for white coat effect with HBPM (Class IIb) Screening not necessary (No Benefit) HBPM BP above goal HBPM BP at goal Yes Masked uncontrolled hypertension: Intensify therapy (Class IIb) ABPM BP above goal No Continue current therapy (Class IIa) White coat effect: Confirm with ABPM (Class IIa) Continue titrating therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring. Yes No
Management Although there is no evidence-based data, it seems reasonable to treat MH patients to reduce their CV risk. Future clinical trials should consider ABPM and phenotype distribution when assessing the protective effect of antihypertensive treatment Office BP is not useful for follow-up and treatment titration in MH or MUCH patients. HBPM or yearly ABPM are the methods of choice