BMJ 1998;317:565-570 ( 29 August )

Papers

Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey

Michael W Muscholl, clinical fellow in cardiology, a Hans-W Hense, professor of clinical epidemiology, b Ulrich Bröckel, clinical fellow in cardiology, a Angela Döring, research fellow, c Günter A J Riegger, professor of internal medicine, a Heribert Schunkert, assistant professor. a

a Klinik und Poliklinik für Innere Medizin II, University of Regensburg, D-93042 Regensburg, Germany, b Institut für Epidemiologie und Sozialmedizin, University of Münster, Münster, Germany, c Institut für Epidemiologie, GSF Forschungszentrum, Munich-Neuherberg, Germany

Correspondence to: Dr Schunkert heribert.schunkert{at}klinik.uni-regensburg.de

Objectives: To assess the relation between white coat hypertension and alterations of left ventricular structure and function.
Design: Cross sectional survey.
Setting: Augsburg, Germany.
Subjects: 1677 subjects, aged 25 to 74 years, who participated in an echocardiographic substudy of the monitoring of trends and determinants in cardiovascular disease Augsburg study during 1994-5. 
Outcome measures: Blood pressure measurements and M mode, two dimensional, and Doppler echocardiography. After at least 30 minutes' rest blood pressure was measured three times by a technician, and once by a physician after echocardiography. Subjects were classified as normotensive (technician <140/90 mm Hg, physician <160/95 mm Hg; n=849), white coat hypertensive (technician <140/90 mm Hg, physician >= 160/95 mm Hg; n=160), mildly hypertensive (technician >= 140/90 mm Hg, physician <160/95 mm Hg; n=129), and sustained hypertensive (taking antihypertensive drugs or blood pressure measured by a technican >= 140/90 mm Hg, and physician >= 160/95 mm Hg; n=538).
Results: White coat hypertension was more common in men than women (10.9% versus 8.2% respectively) and positively related to age and body mass index. After adjustment for these variables, white coat hypertension was associated with an increase in left ventricular mass and an increased prevalence of left ventricular hypertrophy (odds ratio 1.9, 95% confidence interval 1.2 to 3.2; P=0.009) compared with normotensive patients. The increase in left ventricular mass was secondary to significantly increased septal and posterior wall thicknesses whereas end diastolic diameters were similar in both groups with white coat hypertension or normotension. Additionally, the systolic white coat effect (difference between blood pressures recorded by a technician and physician) was associated with increased left ventricular mass and increased prevalence of left ventricular hypertrophy (P<0.05 each). Values for systolic left ventricular function (M mode fractional shortening) were above normal in subjects with white coat hypertension whereas diastolic filling and left atrial size were similar to those in normotension.
Conclusion: About 10% of the general population show exaggerated inotropic and blood pressure responses when mildly stressed. This is associated with an increased risk of left ventricular hypertrophy.

Key messages

  • About 10% of the general population display white coat hypertension

  • After adjustment for age, body mass index, and baseline blood pressure, white coat hypertension is associated with increased left ventricular mass and increased risk of left ventricular hypertrophy

  • In white coat hypertension, after adjustment for covariates, systolic function has values above normal whereas diastolic filling is unchanged

  • White coat hypertension cannot be dismissed as a benign condition



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Rapid Responses:

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How should white coat hypertension be defined?
Thomas G Pickering
bmj.com, 1 Oct 1998 [Full text]
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