13 A Toolkit for Health Care Professionals Unmet Needs in Hypertension White Coat and Masked Hypertension Inaccurate BP measurements can masquerade as RH. How the patient is prepared, environmental conditions, cuff size and BP measurement technique can all contribute to significant variability in BP results.1-4.1, Table 8 White coat hypertension (white coat effect) occurs when a person’s in-office BP is above goal while out-of-office BP readings are below goal. In contrast, masked hypertension (and masked uncontrolled hypertension) occurs when a person’s in-office BP is below goal while out-of-office BP readings are above goal. Both effects can be misleading and lead to misdiagnosis for the patient and underestimation of BP control rates in the office.1-4.4 AHA guidelines call for at least two readings on two or more separate occasions due to the inherent irregularity in BP measurements.1-4.1.1 Between 28% and 39% of people diagnosed with RH may be misdiagnosed due to the white coat effect.5-White-Coat Effect According to population-based studies, masked hypertension occurs in 10% to 26% of people.1-4.4 Masked hypertension is more common (up to 30%) in patients with CKD.1-9.3 Out-of-office BP readings are essential to confirm a diagnosis of RH and prevent misdiagnosis. The gold standard for out-of-office BP measurement is 24-hour ambulatory BP monitoring (ABPM), but ABPM may be unavailable due to cost, lack of insurance reimbursement, equipment shortage and other factors. Home BP monitoring generally correlates with daytime ABPM values and is an acceptable alternative if ABPM is not available. Clinicians should instruct the patient on how to perform home BP monitoring using a validated, calibrated device to accurately confirm or exclude white coat or masked hypertension.5-White-Coat Effect See page 8 for a full list of substances and common drugs that can elevate BP. How Common Is aTRH? The overall prevalence of aTRH is about 19.7% in the U.S., but it varies by population.4-Results The National Health and Nutrition Examination Survey (NHANES; n=2586) 2005-2008 showed a total aTRH, controlled plus uncontrolled, of 14.5% of adults with treated hypertension. REGARDS (n=14,731) 2003-2007 reported 14.1% while the subset of REGARDS CKD (n-3134) reported 28.1%. The ALLHAT clinical trial (n-14,684) 1994-2002 reported 12.7% and INVEST (n=17,190) 1997-2003 reported 37.8%.5-Table 1 Common RH Comorbidities Resistant hypertension is characterized by a variety of distinct demographics, comorbidities, physiological aberrations and metabolic abnormalities that can be significantly interdependent. Factors such as being male, older age and/or Black people could increase the probability of developing RH.5-Patient Characteristics Patients with RH are at higher risk for poor outcomes compared to patients with hypertension that is responsive to treatment.5-Prognosis In a retrospective study, those with RH were found to be nearly twice as likely to suffer from CVD events, myocardial infraction (MI), heart failure (HF), stroke, chronic kidney disease (CKD) and/or death, across an average of four years of monitoring. Most people with RH have sleep apnea and/or other sleep abnormalities. Vascular disease/dysfunction including elevated rates of atherosclerosis, impaired endothelial function, reduced arterial compliance and elevated systemic vascular resistance are also common. 5-Patient Characteristics
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