Elevated pulse pressure and white coat effect

Can we differentiate white coat effect from true hypertension in the office?
Difficult(we usually need either a 24 hr ambulatory BP monitoring or frequent home BP measurements.....both of which are cumbersome, and cant be done regularly).....but may be possible.....says Dr.Ahn from Korea, when he presented his study in the American College of Cardiology Scientific sessions earlier this month. Lets see what they found out..

They took 1087 outpatients with chronically treated hypertension, and checked home BP twice daily for 2 week, and then checked it in the office. White coat effect was defined as a difference between the physician's BP and the home BP of above 20 mm Hg systolic or 10 mm Hg diastolic BP. White-coat hypertension was found in 31% of patients. Pulse pressure of 60 mm Hg and above positively correlated with WCE by multivariate analysis. So the author concluded that... if a patient has an elevated BP reading in the clinic along with elevated pulse pressure, we can consider WCE before recommending antihypertensive agents. 


Some other interesting associations from the study : 
1. White-coat hypertension was not associated with age or gender in the study, 
2. Those with a family history of premature coronary disease were more likely to display WCE.
3. Those with diabetes or organ damage including the heart, as well as smokers, were less likely to show WCE.


The positive relationship with family history might be the result from the effects of anxiety and emotional stress, and the negative relationship with diabetes or smoking means that the WCE was relatively benign in these patients. Also pts with diabetes and organ damage may not be able to mount a stress response due to autonomic imbalance, LV dysfuction etc.


Is this important? Well.... it is...as we all know that white coat hypertension is a predecessor for chronic hypertension, as based on the findings from Italy(Hypertension 2009) ...in which thy followed nearly 1400 pts with white coat or masked hypertension , and found that 40% of patients with white coat effect progressed to develop Hypertension over a period of 10 years. So..YES...WHITE COAT HYPERTENSION needs to be identified and monitored closely. We usually dont treat WCH due to risk of hypotension...but they need to be monitored closely for development of hypertension.