White coat syndrome in refractory hypertension

The study defines refractory hypertension as office blood pressure ≥135/85 mmHg while the patient is taking at least 5 medications, including chlorthalidone and spironolactone. Authors find that white coat syndrome is negligible in adults with refractory high blood pressure. In perspective, about 30-40% of hypertensive patients have some degree of white coat BP elevation.




July 2017

Refractory hypertension is a recently described phenotype of antihypertensive treatment failure defined as uncontrolled blood pressure (BP) despite the use of ≥5 different antihypertensive agents, including chlorthalidone and spironolactone. Recent studies indicate that refractory hypertension is uncommon, with a prevalence of around 5-10% of patients referred to a hypertension specialty clinic for uncontrolled hypertension.

The prevalence of white coat effect, that is; uncontrolled automated office BP ≥135/85 mm Hg while controlled out-of-office BP <135/85 mm Hg, by awake ambulatory BP monitor in hypertensive patients overall is around 30-40%.

The prevalence of white coat effect among patients with refractory hypertension has not been previously reported. In this prospective evaluation, consecutive patients referred to the University of Alabama at Birmingham Hypertension Clinic for uncontrolled hypertension were enrolled. Refractory hypertension was defined as uncontrolled automated office BP ≥135/85 mm Hg with the use of ≥5 antihypertensive agents, including chlorthalidone and spironolactone.

Automated office BP measurements were based on 6 serial readings, done automatically with the use of a BpTRU device unobserved in the clinic. Out-of-office BP measurements were done by 24-hour ambulatory BP monitor. Thirty-four patients were diagnosed with refractory hypertension, of whom 31 had adequate ambulatory BP monitor readings.

White coat effect was present in only 2 patients, or 6.5% of the 31 patients with refractory hypertension, suggesting that white coat effect is largely absent in patients with refractory hypertension. These findings suggest that white coat effect is not a common cause of apparent lack of BP control in patients failing maximal antihypertensive treatment.