A practical approach to persistent elevation of blood pressure in the hypertension clinic

Patients seen with persistent elevation of office blood pressure (BP) in the hypertension clinic are common and pose a significant challenge to the hypertension specialist. These are usually patients sent to the clinic because of difficulty in achieving BP goals. In this clinical setting there is usually data available from home self measurement and ambulatory BP readings. We propose a scheme to encourage specialists to consciously consider the causes of persistent elevation of office BP. The scheme relies initially on consideration that the measured office readings are falsely elevated due to pseudohypertension, small cuff size or other equipment problems. If this is not the case then the measured office BP is truly elevated. If so, a further distinction can be made in this group into those with (1). transient office BP elevation and normal home and/or ambulatory readings and (2). elevated office and out of office readings. The first subgroup is usually called white-coat hypertension but may also be seen with transient increases in BP due to talking or other factors. The second subgroup probably is the majority of patients with persistent high office BP and reflects sustained hypertension and its own list of causes including secondary hypertension. The nature and intensity of evaluation for secondary hypertension varies depending on the clinical presentation of the patient. We recommend an explicit consideration of reasons for persistent high office BP in the hypertension clinic.