OVERVIEW
白大衣高血压指诊室血压升高，而诊室外（家庭自测或动态血压测量）血压正常
多数患者无明显不适，少部分患者可出现头晕、头痛、颈项板紧、疲劳、心悸等症状
目前主要的治疗策略是改善生活方式
本病目前无法治愈
Definition.
White coat hypertension is defined as an elevated in-office blood pressure (systolic ≥140 mmHg, and/or diastolic ≥90 mmHg) with a normal out-of-office blood pressure (home self-measurement of <135/85 mmHg, or 24-hour average of <125-130/80 mmHg)[1-3]
Morbidity
White coat hypertension is quite common, accounting for approximately 30% to 40% of the office hypertensive population and 15% of the general natural population [2-3]
Etiology
Causes
The mechanism by which white coat hypertension occurs is still controversial and may be related to the following factors.
The hospital environment as well as physician-patient contact and communication may have created a stimulus that activates the mesencephalic region responsible for cardiovascular and emotional regulation, which in turn activates the sympathetic nerves, leading to increased blood pressure and increased heart rate.
Impaired vagal pressure reflexes in patients with white coat hypertension may result in relative sympathetic activation, leading to elevated blood pressure and increased heart rate.
Some studies have shown that the proportion of anxiety states in patients with white coat hypertension is higher than in the normal and persistently hypertensive populations, possibly suggesting a link between psychological states and the white coat phenomenon.
Patients with white coat hypertension have endothelial dysfunction, which may affect the regulatory response of blood pressure. [4-8]
Pathogenesis
There is no recognized pathogenesis. It may be due to an imbalance in sympathetic and vagal function for a variety of reasons, which leads to activation of the sympathetic nervous system in response to stimulation by the hospital environment and the physician, resulting in elevated blood pressure, which may return to the normal range after removal from the stimulus outside of the clinic.
Symptoms
Main Symptoms
The majority of white coat hypertension is asymptomatic, while a small percentage of patients may experience dizziness, headache, neck plate tightness, fatigue, and palpitations.
Complications
While it was once thought that white coat hypertension was a benign condition with no additional risk, the results of studies over the last two decades have shown that white coat hypertension increases the risk of developing a number of additional diseases compared to normal blood pressure.
White coat hypertension increases the risk of developing persistent hypertension.
White coat hypertension increases the risk of all-cause mortality and cardiovascular events.
White coat hypertension increases the risk of developing metabolic disorders, including type 2 diabetes and impaired glucose tolerance.
White coat hypertension may also lead to associated target organ damage, including left ventricular hypertrophy. [9-10]
Seeking Medical Treatment
Department of Medicine
Cardiovascular Medicine
If in-office blood pressure is elevated, prompt consultation with a cardiovascular physician is recommended.
Preparation
Preparing for the consultation: registration, preparation of documents, common problems
Consultation Tips
Regardless of the patient’s age or gender, if the patient’s blood pressure is higher than 140/90mmHg, further consultation is required to clarify the blood pressure status.
Preparation Checklist
症状清单
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms of dizziness, headache, neck plate tightness, fatigue, palpitations? How many times have they occurred? When did they first appear? How long have they lasted?
Are they aggravated by emotional stress?
病史清单
Is there a family history of this condition?
Is there a history of anxiety? What is your psychological state?
What other medical conditions have you had, what treatments have you received, and how well have they worked?
Are you taking any medications that affect blood pressure, such as licorice tablets, birth control pills or glucocorticoids?
检查清单
Test results in the last 6 months to bring to the doctor’s office
Bring blood pressure measurement results from previous office visits
Bring results of 24-hour ambulatory blood pressure measurements or home blood pressure self-measurements
Diagnosis
Basis of diagnosis
Medical history
Elevated in-office blood pressure and normal out-of-office blood pressure.
Clinical manifestations
症状
Dizziness, headache, palpitations, etc.
体征
Measurement of blood pressure is elevated.
The vast majority have no other abnormal signs.
Laboratory Tests
Routine blood tests to determine the presence of anemia, infection, etc.
Biochemical tests to assess liver and kidney function, blood lipids, etc.
Blood aldosterone/renin test to determine whether there is a possibility of primary aldosteronism.
Blood and urine catecholamines and their metabolites to determine the presence of pheochromocytoma.
Electrocardiogram
It can clarify the heart rhythm and the presence of myocardial hypertrophy.
Ambulatory blood pressure test
This test is one of the most critical tests for diagnosing and ruling out hypertension in white coats.
It allows you to check for blood pressure abnormalities in relation to daily life and time of day, and to calculate the average blood pressure throughout the day, daytime, and nighttime, and is usually monitored for at least 24 hours.
Abnormalities may occur.
Precautions
检查时按照医生要求携带仪器。
检查期间活动时避免磕碰仪器造成损坏。如仪器出现故障，应及时前往医院由医生调试。
检查期间进行日常生活必须活动即可，避免特意增加运动或增加不活动的时间，避免洗澡。
按照医生规定的时间前往医院终止检查。
Imaging
超声心动图
Examines the structure and function of the heart.
Can assist in ruling out and determining the presence of other heart conditions.
冠脉CT血管成像（CTA）
To show the condition of the coronary arteries by contrast.
Can assist in ruling out other diseases, such as coronary heart disease.
Funduscopic examination
To assess the presence of hypertension-related atherosclerosis in the fundus.
Differential Diagnosis
Persistent hypertension
White coat hypertension is characterized by elevated blood pressure in the clinic and normal blood pressure outside the clinic. It can be differentiated from persistent hypertension by 24-hour ambulatory blood pressure measurement, and multiple measurements can be taken if necessary. Self-measurement of blood pressure outside the clinic is also helpful in differential diagnosis; persistent hypertension is characterized by a higher-than-normal upper limit of blood pressure, whether in or out of the clinic.
Physiologic blood pressure increase
Physiological elevation of blood pressure occurs during exercise or emotional excitement, which needs to be clarified by measuring blood pressure in the office three times not on the same day. If the blood pressure is elevated in the office only occasionally, and is normal most of the time, this is considered to be physiological elevation of blood pressure, and if the blood pressure is higher than normal every time, this is considered to be the possibility of white-coat hypertension.
Treatment
Treatment goal: reduce the risk of developing persistent hypertension and reduce the risk of cardiovascular events.
Principles of treatment: Improve lifestyle and monitor blood pressure changes regularly.
Medication
There is insufficient evidence to support pharmacologic treatment of patients with white coat hypertension.
Lifestyle improvement
Go to bed early and get up early, avoid staying up late.
Do more aerobic exercise, such as Tai Chi, jogging and swimming.
Pay attention to emotion regulation, and consult with a psychological clinic if necessary.
Stop smoking and drinking.
Regulate diet, reduce weight and avoid obesity.
Prognosis
Cure
There is currently no cure for this disease, but active lifestyle modification may slow the progression to persistent hypertension and reduce the risk of cardiovascular events.
The efficacy of pharmacologic therapy is currently uncertain.
Prognostic factors
Genetic factors, obesity, and smoking may contribute to worsening blood pressure levels, and the ability to actively improve lifestyle is an important prognostic factor.
Hazards
White coat hypertension can progress to persistent hypertension and increases the risk of cardiovascular events and metabolic disorders.
Daily
Daily Management
Lifestyle management
Go to bed early and get up early to avoid late nights.
Try to get as much aerobic exercise as possible, moderate exercise under the supervision of a physician is required.
Quit smoking and avoid second-hand smoke.
Dietary management
Avoid overeating, try to eat small and frequent meals, and try to eat soft and easily digestible food.
Minimize the intake of high salt and high fat foods, such as salted vegetables, fatty meat, fried foods, etc.
Avoid intake of stimulating beverages such as coffee, strong tea and alcohol.
Emotion Management
Avoid bad emotions such as tension, anxiety, anger and depression.
Keep a good mindset and face life positively.
Prevention
There is no clinical evidence on how to prevent white coat hypertension, but maintaining a good lifestyle may be beneficial, such as maintaining a healthy weight, not smoking, and maintaining a good emotional state.
参考文献
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Mancia G, Facchetti R, Bombelli M, Cuspidi C, Grassi G. White-Coat Hypertension: Pathophysiological and Clinical Aspects: Excellence Award for Hypertension Research 2020. Hypertension. 2021 Dec;78(6):1677-1688. doi: 10.1161/HYPERTENSIONAHA.121.16489. Epub 2021 Nov 10. PMID: 34757765;
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Mancia G, Bombelli M, Seravalle G, Grassi G. Diagnosis and management of patients with white-coat and masked hypertension. Nat Rev Cardiol. 2011 Aug 9;8(12):686-93.
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Ogedegbe G, Pickering TG, Clemow L, Chaplin W, Spruill TM, Albanese GM, Eguchi K, Burg M, Gerin W. The misdiagnosis of hypertension: the role of patient anxiety. Arch Intern Med. 2008 Dec 8;168(22):2459-65. doi: 10.1001/archinte.168.22.2459. PMID: 19064830
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Smith PA, Graham LN, Mackintosh AF, Stoker JB, Mary DA. Relationship between central sympathetic activity and stages of human hypertension. Am J Hypertens. 2004 Mar;17(3):217-22. doi: 10.1016/j.amjhyper.2003.10.010.
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Grassi G, Seravalle G, Trevano FQ, Dell’oro R, Bolla G, Cuspidi C, Arenare F, Mancia G. Neurogenic abnormalities in masked hypertension. Hypertension. 2007 Sep;50(3):537-42. doi: 10.1161/HYPERTENSIONAHA.107.092528.
[8]
Curgunlu A, Uzun H, Bavunoğlu I, Karter Y, Genç H, Vehid S. Increased circulating concentrations of asymmetric dimethylarginine (ADMA) in white coat hypertension. J Hum Hypertens. 2005 Aug;19(8):629-33. doi: 10.1038/sj.jhh.1001867.
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Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Polo Friz H, Grassi G, Sega R. Long-term risk of sustained hypertension in white-coat or masked hypertension. Hypertension. 2009 Aug;54(2):226-32. doi: 10.1161/HYPERTENSIONAHA.109.129882.
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Grandi AM, Solbiati F, Laurita E, Cassinerio E, Marchesi C, Piperno F, Maresca A, Guasti L, Venco A. Isolated office hypertension: a 3-year follow-up study. Blood Press. 2005;14(5):298-305.