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Ambulatory blood pressure monitoring is currently the gold standard for detecting patients with white-coat hypertension. Women and all patients with lower office systolic blood pressures, stage I hypertension, and no target organ damage are more likely to have white-coat hypertension (strength of recommendation [SOR]: B, based on prospective cohort studies) ( TABLE ).
Self or home blood pressure monitoring has also been used to detect patients with white-coat hypertension. However, it has a low sensitivity (61%–68%) and low positive predictive value (PV+) (33%–48%) (SOR: B, short-term prospective cohort studies).
Evidence summary
White coat hypertension, also known as isolated office hypertension, refers to elevated blood pressures in a medical setting and normal blood pressures during regular daily life. Patients with white-coat hypertension are defined as patients 1) with an office blood pressure of >140 mm Hg systolic or >90 mm Hg diastolic on at least 3 separate office visits with 2 measurements each visit and 2) mean daytime blood pressure of <135 mm Hg systolic and <85 mm Hg diastolic on ambulatory blood pressure monitoring.1 Other measures of normal blood pressure on ambulatory blood pressure monitoring are <130/80 mm Hg for full 24-hour blood pressure and <120/70 mm Hg for night-time blood pressure.2 A recent Clinical Inquiry summarized 3 cohort trials—2 showed white-coat hypertension patients had lower risk of cardiovascular events and 1 showed no difference between patients with white-coat hypertension and patients with sustained hypertension.3 Identifying patients with white-coat hypertension is important to avoid overtreating individuals at lower risk of cardiovascular events.
Which patients with elevated blood pressure on repeated visits have white-coat hypertension? In studies of patients, most of whom have Stage I hypertension (140–159/90–99 mm Hg), anywhere from 10% to 50% have white-coat hypertension ( TABLE ). In a joint multivariate analysis of 2 cohort studies, which enrolled 1564 subjects with uncomplicated stage I hypertension, white-coat hypertension was associated with lower office systolic blood pressure, female gender, and nonsmoking.2 Similarly, a large international database of 2492 subjects found that women, older subjects, and those with lower and fewer office systolic blood pressure measurements were more likely to have white-coat hypertension.4 In another analysis of 1333 Italian subjects, the prevalence of white-coat hypertension was 33.3% in those with stage I hypertension, 11% with stage II, and 3 % with stage III.5 A study of more than 600 men over 20 years in Finland compared those who developed white-coat hypertension and those with sustained hypertension. The hypertensive patients had more microalbuminuria, a greater left ventricular mass on echo, increased cholesterol esters, and a greater body-mass index (all P.05) than patients with white-coat hypertension. Smoking status was similar in both groups, in contrast to other studies.6 A recent study did not find body-mass index distinguished white-coat hyperten-sion from sustained hypertension.7
TABLE
Patient attributes and white-coat hypertension
| ATTRIBUTE | SUBJECTS | COMPARISON | P VALUE |
|---|---|---|---|
| Gender, % with WCH | 5716* | 17% of females 14% of males | <.001 |
| % female WCH v SH group | 1564† | 45% v 33% | .002 |
| Ratio female: male with WCH | 2634§ | Odds ratio=1.92 (95% CI, 1.45–2.54) | <.001 |
| Mean age, WCH vs SH | 1564† | 40 vs 39 years | .52 |
| % with WCH in 4 age groups | 5716* | <35 y=12%, | <.001 |
| 35–50 y=14%, | |||
| 50–65 y=16%, | |||
| >65 y=17% | |||
| Currently smoking, % with WCH | 5716* | No=16.7%, Yes=11.3% | <.001 |
| Currently smoking % WCH v SH | 1564† | 7% v 24% | .04 |
| BMI, % WCH in 3 groups | 5716* | < 25=16% | NS |
| 25–30=15% | |||
| >30=15% | |||
| BMI, WCH group vs SH group | 1564† | 25.4 vs 25.9 | NS |
| 414‡ | 23.9 vs 24.7 | <.05 | |
| Original clinic SBP, % with WCH | 5716* | 140–159=31.2% | <.001 |
| 160–170=18.7% | |||
| 171–180=11.8% | |||
| 2492§ | 140–150=65% | .004 | |
| 151–160=53% | |||
| 161–170=33% | |||
| LV Mass (g), WCH v SH | 1564† | 160 vs 180 | .001 |
| LV Mass Index (g/m2) WCH v SH | 414‡ | 126 vs 136 | <.01 |
| WCH, white coat hypertension; SBP, systolic blood pressure; SH, sustained hypertension; CI, confidence interval; BMI, body-mass index; NS, not significant; LV, left ventricular. | |||
| *Patients referred to a blood pressure unit over 22-year period.7 | |||
| † A combination of 2 studies of clinic patients with stage I hypertension (140–159/90–99 mm Hg).2 | |||
| ‡ 50-year-old men in a community in Finland invited to a health survey with a 20-year follow-up.6 | |||
| § Data from 24 pooled studies of ambulatory blood pressure monitoring.4 | |||
Using home blood pressure as a screening tool is a problem because of the low sensitivity and poor PV+. In the THOP study (247 subjects), which used ambulatory blood pressure monitoring as the reference method, home blood pressure had a high specificity (89%) and high negative predictive value (PV–) (97%) but a lower sensitivity (68%) and low PPV (33%).8 In other words, if home blood pressure shows hypertension, there is a 97% chance the patient has sustained hypertension, but if home blood pressure returns to normal in patients with office hypertension, two thirds of patients will still have sustained hypertension. In another study that enrolled patients from a hypertension clinic, 133 untreated patients with dias-tolic blood pressure 90 to 115 mm Hg underwent ambulatory blood pressure monitoring for a reference standard. The sensitivity of home blood pressure monitoring in identifying white-coat hypertension was 61% and the PV+ was 48%.9
Recommendations from others
The European Society of Hypertension Working Group on Blood Pressure Monitoring recommends that subjects with blood pressure 140–159/90–99 mm Hg at several visits should have ambulatory blood pressure monitoring because 33% of those people will have white-coat hypertension. Women, nonsmokers, those with recent hypertension, a limited number of blood pressure determinations and small left ventricular mass on echo should also have ambulatory blood pressure monitoring. There should be a search for metabolic risk factors and target organ damage. Those patients aware that their blood pressures are lower outside the office should be considered for ambulatory blood pressure monitoring.10
The latest Joint National Committee report (JNC VII) indicates that ambulatory blood pressure monitoring may be useful to detect white-coat hypertension among patients with hypertension and no target organ damage, and those with episodic hypertension.11
Ambulatory BP monitoring better than home monitoring for ruling out white-coat hypertension
Joseph Saseen, PharmD, FCCP, BCPS
University of Colorado Health Sciences Center, Denver
Landmark placebo-controlled outcome-based trials demonstrating reduced morbidity and mortality with hypertension treatment did not differentiate essential from white-coat hypertension. Patients were included based on elevated office-based blood pressure measurements. Since we now know that the prevalence of white-coat hypertension is high, it should be ruled out before implementing antihypertensive therapy.
Ambulatory blood pressure monitoring is more accurate than home monitoring for ruling out white-coat hypertension. However, ease, simplicity, and availability makes home monitoring a more realistic option for routine clinical practice. When home blood pressure monitoring is used, reliable measurement devices (eg, newer automatic or manual home devices) should be used and patients should be instructed regarding proper use and documentation of blood pressure values to facilitate an appropriate clinical assessment.
1. O’Brien E, Asmar R, Beilin L, et al. on behalf of the European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21:821-848.
2. Verdecchia P, Palatini P, Schillaci G, Mormino P, Porcellati C, Pessina AC. Independent predictors of isolated clinic (‘white-coat’) hypertension. J Hypertens 2001;19:1015-1020.
3. Rao S, Liu C-T, Wilder L. What is the best way to treat patients with white-coat hypertension?. J Fam Pract 2004;53:408-412.
4. Staessen JA, O’Brien ET, Atkins N, Anery AK. on behalf of the Ad-Hoc Working Group: Short report: Ambulatory blood pressure in normotensive compared with hypertensive subjects. J Hypertens 1993;11:1289-1297.
5. Verdecchia P, Schillaci G, Borgioni C, et al. White-coat hypertension and white-coat effect: Similarities and differences. Am J Hypertens 1995;8:790-798.
6. Bjorklund K, Lind L, Vessby B, Andren B, Lithell H. Different metabolic predictors of white-coat and sustained hypertension over a 20-year follow-up period. Circulation 2002;106:63-68.
7. Dolan E, Stanton A, Atkins N, et al. Determinants of white-coat hypertension. Blood Pressure Monit 2004;9:307-309.
8. Den Hond E, Celis H, Fagard R, et al. Self-measured versus ambulatory blood pressure in the diagnosis of hypertension. J Hypertens 2003;21:717-722.
9. Stergiou GS, Skeva II, Baibas NM, Kalkana CB, Roussias LG, Mountokalakis TD. Diagnosis of hyper-tension using home or ambulatory blood pressure monitoring: comparison with the conventional strategy based on repeated clinic blood pressure measurements. J Hypertens 2000;18:1745-1751.
10. Verdecchia P, O’Brien E, Pickering T, et al. When can the practicing physician suspect white coat hyperten-sion? Statement from the Working Group on Blood Pressure Monitoring of the European Society of Hypertension. Am J Hypertens 2003;16:87-91.
11. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
Ambulatory blood pressure monitoring is currently the gold standard for detecting patients with white-coat hypertension. Women and all patients with lower office systolic blood pressures, stage I hypertension, and no target organ damage are more likely to have white-coat hypertension (strength of recommendation [SOR]: B, based on prospective cohort studies) ( TABLE ).
Self or home blood pressure monitoring has also been used to detect patients with white-coat hypertension. However, it has a low sensitivity (61%–68%) and low positive predictive value (PV+) (33%–48%) (SOR: B, short-term prospective cohort studies).
Evidence summary
White coat hypertension, also known as isolated office hypertension, refers to elevated blood pressures in a medical setting and normal blood pressures during regular daily life. Patients with white-coat hypertension are defined as patients 1) with an office blood pressure of >140 mm Hg systolic or >90 mm Hg diastolic on at least 3 separate office visits with 2 measurements each visit and 2) mean daytime blood pressure of <135 mm Hg systolic and <85 mm Hg diastolic on ambulatory blood pressure monitoring.1 Other measures of normal blood pressure on ambulatory blood pressure monitoring are <130/80 mm Hg for full 24-hour blood pressure and <120/70 mm Hg for night-time blood pressure.2 A recent Clinical Inquiry summarized 3 cohort trials—2 showed white-coat hypertension patients had lower risk of cardiovascular events and 1 showed no difference between patients with white-coat hypertension and patients with sustained hypertension.3 Identifying patients with white-coat hypertension is important to avoid overtreating individuals at lower risk of cardiovascular events.
Which patients with elevated blood pressure on repeated visits have white-coat hypertension? In studies of patients, most of whom have Stage I hypertension (140–159/90–99 mm Hg), anywhere from 10% to 50% have white-coat hypertension ( TABLE ). In a joint multivariate analysis of 2 cohort studies, which enrolled 1564 subjects with uncomplicated stage I hypertension, white-coat hypertension was associated with lower office systolic blood pressure, female gender, and nonsmoking.2 Similarly, a large international database of 2492 subjects found that women, older subjects, and those with lower and fewer office systolic blood pressure measurements were more likely to have white-coat hypertension.4 In another analysis of 1333 Italian subjects, the prevalence of white-coat hypertension was 33.3% in those with stage I hypertension, 11% with stage II, and 3 % with stage III.5 A study of more than 600 men over 20 years in Finland compared those who developed white-coat hypertension and those with sustained hypertension. The hypertensive patients had more microalbuminuria, a greater left ventricular mass on echo, increased cholesterol esters, and a greater body-mass index (all P.05) than patients with white-coat hypertension. Smoking status was similar in both groups, in contrast to other studies.6 A recent study did not find body-mass index distinguished white-coat hyperten-sion from sustained hypertension.7
TABLE
Patient attributes and white-coat hypertension
| ATTRIBUTE | SUBJECTS | COMPARISON | P VALUE |
|---|---|---|---|
| Gender, % with WCH | 5716* | 17% of females 14% of males | <.001 |
| % female WCH v SH group | 1564† | 45% v 33% | .002 |
| Ratio female: male with WCH | 2634§ | Odds ratio=1.92 (95% CI, 1.45–2.54) | <.001 |
| Mean age, WCH vs SH | 1564† | 40 vs 39 years | .52 |
| % with WCH in 4 age groups | 5716* | <35 y=12%, | <.001 |
| 35–50 y=14%, | |||
| 50–65 y=16%, | |||
| >65 y=17% | |||
| Currently smoking, % with WCH | 5716* | No=16.7%, Yes=11.3% | <.001 |
| Currently smoking % WCH v SH | 1564† | 7% v 24% | .04 |
| BMI, % WCH in 3 groups | 5716* | < 25=16% | NS |
| 25–30=15% | |||
| >30=15% | |||
| BMI, WCH group vs SH group | 1564† | 25.4 vs 25.9 | NS |
| 414‡ | 23.9 vs 24.7 | <.05 | |
| Original clinic SBP, % with WCH | 5716* | 140–159=31.2% | <.001 |
| 160–170=18.7% | |||
| 171–180=11.8% | |||
| 2492§ | 140–150=65% | .004 | |
| 151–160=53% | |||
| 161–170=33% | |||
| LV Mass (g), WCH v SH | 1564† | 160 vs 180 | .001 |
| LV Mass Index (g/m2) WCH v SH | 414‡ | 126 vs 136 | <.01 |
| WCH, white coat hypertension; SBP, systolic blood pressure; SH, sustained hypertension; CI, confidence interval; BMI, body-mass index; NS, not significant; LV, left ventricular. | |||
| *Patients referred to a blood pressure unit over 22-year period.7 | |||
| † A combination of 2 studies of clinic patients with stage I hypertension (140–159/90–99 mm Hg).2 | |||
| ‡ 50-year-old men in a community in Finland invited to a health survey with a 20-year follow-up.6 | |||
| § Data from 24 pooled studies of ambulatory blood pressure monitoring.4 | |||
Using home blood pressure as a screening tool is a problem because of the low sensitivity and poor PV+. In the THOP study (247 subjects), which used ambulatory blood pressure monitoring as the reference method, home blood pressure had a high specificity (89%) and high negative predictive value (PV–) (97%) but a lower sensitivity (68%) and low PPV (33%).8 In other words, if home blood pressure shows hypertension, there is a 97% chance the patient has sustained hypertension, but if home blood pressure returns to normal in patients with office hypertension, two thirds of patients will still have sustained hypertension. In another study that enrolled patients from a hypertension clinic, 133 untreated patients with dias-tolic blood pressure 90 to 115 mm Hg underwent ambulatory blood pressure monitoring for a reference standard. The sensitivity of home blood pressure monitoring in identifying white-coat hypertension was 61% and the PV+ was 48%.9
Recommendations from others
The European Society of Hypertension Working Group on Blood Pressure Monitoring recommends that subjects with blood pressure 140–159/90–99 mm Hg at several visits should have ambulatory blood pressure monitoring because 33% of those people will have white-coat hypertension. Women, nonsmokers, those with recent hypertension, a limited number of blood pressure determinations and small left ventricular mass on echo should also have ambulatory blood pressure monitoring. There should be a search for metabolic risk factors and target organ damage. Those patients aware that their blood pressures are lower outside the office should be considered for ambulatory blood pressure monitoring.10
The latest Joint National Committee report (JNC VII) indicates that ambulatory blood pressure monitoring may be useful to detect white-coat hypertension among patients with hypertension and no target organ damage, and those with episodic hypertension.11
Ambulatory BP monitoring better than home monitoring for ruling out white-coat hypertension
Joseph Saseen, PharmD, FCCP, BCPS
University of Colorado Health Sciences Center, Denver
Landmark placebo-controlled outcome-based trials demonstrating reduced morbidity and mortality with hypertension treatment did not differentiate essential from white-coat hypertension. Patients were included based on elevated office-based blood pressure measurements. Since we now know that the prevalence of white-coat hypertension is high, it should be ruled out before implementing antihypertensive therapy.
Ambulatory blood pressure monitoring is more accurate than home monitoring for ruling out white-coat hypertension. However, ease, simplicity, and availability makes home monitoring a more realistic option for routine clinical practice. When home blood pressure monitoring is used, reliable measurement devices (eg, newer automatic or manual home devices) should be used and patients should be instructed regarding proper use and documentation of blood pressure values to facilitate an appropriate clinical assessment.
Ambulatory blood pressure monitoring is currently the gold standard for detecting patients with white-coat hypertension. Women and all patients with lower office systolic blood pressures, stage I hypertension, and no target organ damage are more likely to have white-coat hypertension (strength of recommendation [SOR]: B, based on prospective cohort studies) ( TABLE ).
Self or home blood pressure monitoring has also been used to detect patients with white-coat hypertension. However, it has a low sensitivity (61%–68%) and low positive predictive value (PV+) (33%–48%) (SOR: B, short-term prospective cohort studies).
Evidence summary
White coat hypertension, also known as isolated office hypertension, refers to elevated blood pressures in a medical setting and normal blood pressures during regular daily life. Patients with white-coat hypertension are defined as patients 1) with an office blood pressure of >140 mm Hg systolic or >90 mm Hg diastolic on at least 3 separate office visits with 2 measurements each visit and 2) mean daytime blood pressure of <135 mm Hg systolic and <85 mm Hg diastolic on ambulatory blood pressure monitoring.1 Other measures of normal blood pressure on ambulatory blood pressure monitoring are <130/80 mm Hg for full 24-hour blood pressure and <120/70 mm Hg for night-time blood pressure.2 A recent Clinical Inquiry summarized 3 cohort trials—2 showed white-coat hypertension patients had lower risk of cardiovascular events and 1 showed no difference between patients with white-coat hypertension and patients with sustained hypertension.3 Identifying patients with white-coat hypertension is important to avoid overtreating individuals at lower risk of cardiovascular events.
Which patients with elevated blood pressure on repeated visits have white-coat hypertension? In studies of patients, most of whom have Stage I hypertension (140–159/90–99 mm Hg), anywhere from 10% to 50% have white-coat hypertension ( TABLE ). In a joint multivariate analysis of 2 cohort studies, which enrolled 1564 subjects with uncomplicated stage I hypertension, white-coat hypertension was associated with lower office systolic blood pressure, female gender, and nonsmoking.2 Similarly, a large international database of 2492 subjects found that women, older subjects, and those with lower and fewer office systolic blood pressure measurements were more likely to have white-coat hypertension.4 In another analysis of 1333 Italian subjects, the prevalence of white-coat hypertension was 33.3% in those with stage I hypertension, 11% with stage II, and 3 % with stage III.5 A study of more than 600 men over 20 years in Finland compared those who developed white-coat hypertension and those with sustained hypertension. The hypertensive patients had more microalbuminuria, a greater left ventricular mass on echo, increased cholesterol esters, and a greater body-mass index (all P.05) than patients with white-coat hypertension. Smoking status was similar in both groups, in contrast to other studies.6 A recent study did not find body-mass index distinguished white-coat hyperten-sion from sustained hypertension.7
TABLE
Patient attributes and white-coat hypertension
| ATTRIBUTE | SUBJECTS | COMPARISON | P VALUE |
|---|---|---|---|
| Gender, % with WCH | 5716* | 17% of females 14% of males | <.001 |
| % female WCH v SH group | 1564† | 45% v 33% | .002 |
| Ratio female: male with WCH | 2634§ | Odds ratio=1.92 (95% CI, 1.45–2.54) | <.001 |
| Mean age, WCH vs SH | 1564† | 40 vs 39 years | .52 |
| % with WCH in 4 age groups | 5716* | <35 y=12%, | <.001 |
| 35–50 y=14%, | |||
| 50–65 y=16%, | |||
| >65 y=17% | |||
| Currently smoking, % with WCH | 5716* | No=16.7%, Yes=11.3% | <.001 |
| Currently smoking % WCH v SH | 1564† | 7% v 24% | .04 |
| BMI, % WCH in 3 groups | 5716* | < 25=16% | NS |
| 25–30=15% | |||
| >30=15% | |||
| BMI, WCH group vs SH group | 1564† | 25.4 vs 25.9 | NS |
| 414‡ | 23.9 vs 24.7 | <.05 | |
| Original clinic SBP, % with WCH | 5716* | 140–159=31.2% | <.001 |
| 160–170=18.7% | |||
| 171–180=11.8% | |||
| 2492§ | 140–150=65% | .004 | |
| 151–160=53% | |||
| 161–170=33% | |||
| LV Mass (g), WCH v SH | 1564† | 160 vs 180 | .001 |
| LV Mass Index (g/m2) WCH v SH | 414‡ | 126 vs 136 | <.01 |
| WCH, white coat hypertension; SBP, systolic blood pressure; SH, sustained hypertension; CI, confidence interval; BMI, body-mass index; NS, not significant; LV, left ventricular. | |||
| *Patients referred to a blood pressure unit over 22-year period.7 | |||
| † A combination of 2 studies of clinic patients with stage I hypertension (140–159/90–99 mm Hg).2 | |||
| ‡ 50-year-old men in a community in Finland invited to a health survey with a 20-year follow-up.6 | |||
| § Data from 24 pooled studies of ambulatory blood pressure monitoring.4 | |||
Using home blood pressure as a screening tool is a problem because of the low sensitivity and poor PV+. In the THOP study (247 subjects), which used ambulatory blood pressure monitoring as the reference method, home blood pressure had a high specificity (89%) and high negative predictive value (PV–) (97%) but a lower sensitivity (68%) and low PPV (33%).8 In other words, if home blood pressure shows hypertension, there is a 97% chance the patient has sustained hypertension, but if home blood pressure returns to normal in patients with office hypertension, two thirds of patients will still have sustained hypertension. In another study that enrolled patients from a hypertension clinic, 133 untreated patients with dias-tolic blood pressure 90 to 115 mm Hg underwent ambulatory blood pressure monitoring for a reference standard. The sensitivity of home blood pressure monitoring in identifying white-coat hypertension was 61% and the PV+ was 48%.9
Recommendations from others
The European Society of Hypertension Working Group on Blood Pressure Monitoring recommends that subjects with blood pressure 140–159/90–99 mm Hg at several visits should have ambulatory blood pressure monitoring because 33% of those people will have white-coat hypertension. Women, nonsmokers, those with recent hypertension, a limited number of blood pressure determinations and small left ventricular mass on echo should also have ambulatory blood pressure monitoring. There should be a search for metabolic risk factors and target organ damage. Those patients aware that their blood pressures are lower outside the office should be considered for ambulatory blood pressure monitoring.10
The latest Joint National Committee report (JNC VII) indicates that ambulatory blood pressure monitoring may be useful to detect white-coat hypertension among patients with hypertension and no target organ damage, and those with episodic hypertension.11
Ambulatory BP monitoring better than home monitoring for ruling out white-coat hypertension
Joseph Saseen, PharmD, FCCP, BCPS
University of Colorado Health Sciences Center, Denver
Landmark placebo-controlled outcome-based trials demonstrating reduced morbidity and mortality with hypertension treatment did not differentiate essential from white-coat hypertension. Patients were included based on elevated office-based blood pressure measurements. Since we now know that the prevalence of white-coat hypertension is high, it should be ruled out before implementing antihypertensive therapy.
Ambulatory blood pressure monitoring is more accurate than home monitoring for ruling out white-coat hypertension. However, ease, simplicity, and availability makes home monitoring a more realistic option for routine clinical practice. When home blood pressure monitoring is used, reliable measurement devices (eg, newer automatic or manual home devices) should be used and patients should be instructed regarding proper use and documentation of blood pressure values to facilitate an appropriate clinical assessment.
1. O’Brien E, Asmar R, Beilin L, et al. on behalf of the European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21:821-848.
2. Verdecchia P, Palatini P, Schillaci G, Mormino P, Porcellati C, Pessina AC. Independent predictors of isolated clinic (‘white-coat’) hypertension. J Hypertens 2001;19:1015-1020.
3. Rao S, Liu C-T, Wilder L. What is the best way to treat patients with white-coat hypertension?. J Fam Pract 2004;53:408-412.
4. Staessen JA, O’Brien ET, Atkins N, Anery AK. on behalf of the Ad-Hoc Working Group: Short report: Ambulatory blood pressure in normotensive compared with hypertensive subjects. J Hypertens 1993;11:1289-1297.
5. Verdecchia P, Schillaci G, Borgioni C, et al. White-coat hypertension and white-coat effect: Similarities and differences. Am J Hypertens 1995;8:790-798.
6. Bjorklund K, Lind L, Vessby B, Andren B, Lithell H. Different metabolic predictors of white-coat and sustained hypertension over a 20-year follow-up period. Circulation 2002;106:63-68.
7. Dolan E, Stanton A, Atkins N, et al. Determinants of white-coat hypertension. Blood Pressure Monit 2004;9:307-309.
8. Den Hond E, Celis H, Fagard R, et al. Self-measured versus ambulatory blood pressure in the diagnosis of hypertension. J Hypertens 2003;21:717-722.
9. Stergiou GS, Skeva II, Baibas NM, Kalkana CB, Roussias LG, Mountokalakis TD. Diagnosis of hyper-tension using home or ambulatory blood pressure monitoring: comparison with the conventional strategy based on repeated clinic blood pressure measurements. J Hypertens 2000;18:1745-1751.
10. Verdecchia P, O’Brien E, Pickering T, et al. When can the practicing physician suspect white coat hyperten-sion? Statement from the Working Group on Blood Pressure Monitoring of the European Society of Hypertension. Am J Hypertens 2003;16:87-91.
11. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
1. O’Brien E, Asmar R, Beilin L, et al. on behalf of the European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21:821-848.
2. Verdecchia P, Palatini P, Schillaci G, Mormino P, Porcellati C, Pessina AC. Independent predictors of isolated clinic (‘white-coat’) hypertension. J Hypertens 2001;19:1015-1020.
3. Rao S, Liu C-T, Wilder L. What is the best way to treat patients with white-coat hypertension?. J Fam Pract 2004;53:408-412.
4. Staessen JA, O’Brien ET, Atkins N, Anery AK. on behalf of the Ad-Hoc Working Group: Short report: Ambulatory blood pressure in normotensive compared with hypertensive subjects. J Hypertens 1993;11:1289-1297.
5. Verdecchia P, Schillaci G, Borgioni C, et al. White-coat hypertension and white-coat effect: Similarities and differences. Am J Hypertens 1995;8:790-798.
6. Bjorklund K, Lind L, Vessby B, Andren B, Lithell H. Different metabolic predictors of white-coat and sustained hypertension over a 20-year follow-up period. Circulation 2002;106:63-68.
7. Dolan E, Stanton A, Atkins N, et al. Determinants of white-coat hypertension. Blood Pressure Monit 2004;9:307-309.
8. Den Hond E, Celis H, Fagard R, et al. Self-measured versus ambulatory blood pressure in the diagnosis of hypertension. J Hypertens 2003;21:717-722.
9. Stergiou GS, Skeva II, Baibas NM, Kalkana CB, Roussias LG, Mountokalakis TD. Diagnosis of hyper-tension using home or ambulatory blood pressure monitoring: comparison with the conventional strategy based on repeated clinic blood pressure measurements. J Hypertens 2000;18:1745-1751.
10. Verdecchia P, O’Brien E, Pickering T, et al. When can the practicing physician suspect white coat hyperten-sion? Statement from the Working Group on Blood Pressure Monitoring of the European Society of Hypertension. Am J Hypertens 2003;16:87-91.
11. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
Evidence-based answers from the Family Physicians Inquiries Network