Masked Hypertension

HomeCirculation: Cardiovascular Quality and OutcomesVol. 10, No. 7Masked Hypertension Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBMasked HypertensionFinding Trouble Under the Disguise Jacqueline H. Morris, DO and John D. Bisognano, MD, PhD Jacqueline H. MorrisJacqueline H. Morris From the Division of Cardiology, Department of Internal Medicine, University of Rochester Medical Center, Rochester, New York. and John D. BisognanoJohn D. Bisognano From the Division of Cardiology, Department of Internal Medicine, University of Rochester Medical Center, Rochester, New York. Originally published11 Jul 2017https://doi.org/10.1161/CIRCOUTCOMES.117.003945Circulation: Cardiovascular Quality and Outcomes. 2017;10:e003945Masked hypertension is a clinical condition in which a patient has a normal blood pressure in the clinic but an elevated blood pressure outside the office setting. It has been previously suggested with large population cohort studies that 15% to 30% of adults have masked hypertension and that this is associated with an increased risk of cardiovascular morbidity and mortality compared with sustained normotension or even white-coat hypertension.1–3 Only recently has the importance of masked hypertension been fully appreciated. The diagnosis of white-coat hypertension is often a relief to patients and physicians because it illustrates that things are usually better than they first seem and less needs to be done. However, seeking the presence of masked hypertension is a less happy task because even the validity of a seemingly normal office blood pressure is called into question.See Article by Anstey et alA topic of debate has been who should be screened for masked hypertension. An increased prevalence of masked hypertension has been associated with higher clinic blood pressures, older age, male sex, smoking, diabetes mellitus, obesity, and use of an antihypertensive medication.1 A prior analysis using data from the Jackson Heart Study—a prospective cohort of blacks—demonstrated a presence of masked hypertension in 52% of participants with an increased risk of cardiovascular disease among this population.1 In an attempt to identify a population that would benefit from screening, an analysis to determine whether a higher 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk was associated with an increased prevalence of masked hypertension was completed in this population. Identifying target populations for screening is of critical importance because it is presently impractical to place ambulatory blood pressure monitors on all patients who might be at risk but have normal blood pressures in the clinic.In this issue of Circulation: Cardiovascular Quality and Outcomes, Anstey et al4 completed an analysis to evaluate for an association between a higher 10-year predicted ASCVD risk, calculated using the pooled cohort risk equations, and masked hypertension. This study analyzed data from the Jackson Heart Study and included 644 patients from 40 to 79 years of age without clinic hypertension, who completed ambulatory blood pressure monitoring (ABPM). It was determined that there was a high prevalence of masked hypertension, ranging from 31.5% to 54% in this sample of black patients. In comparison with prior studies evaluating the general population for masked hypertension, this population is noted to be at higher risk for subsequent events.1,2 It was also determined that a higher 10-year predicted ASCVD risk was associated with a higher prevalence of any masked hypertension, masked daytime hypertension, masked nighttime hypertension, and masked 24-hour hypertension. Additionally, the majority of patients in each group had a 10-year predicted ASCVD risk ≥10%.So, do these findings suggest we should be screening more patients for masked hypertension? It is neither practical nor feasible to screen all US adults or all black adults because this would include a vast number of patients, but this study provides important information that highlights the overall value of considering masked hypertension in selected patients. Although masked hypertension has not received a prominent focus in most previous guidelines, this study would support its consideration particularly in high risk patients. In 2011, the National Institute of Health and Care Excellence recommended that all patients with elevated clinic blood pressures have ABPM to exclude white-coat hypertension, although no such study has been conducted to assess the feasibility of performing ABPM in individuals with normal blood pressures in the clinic setting.5 The US Preventive Services Task Force recommends ABPM as the reference standard for confirming the diagnosis of hypertension.6 One previously suggested screening method was the evaluation of masked hypertension using ABPM in patients with prehypertension (defined at systolic blood pressure, 120–139 mm Hg or diastolic blood pressure, 80–89 mm Hg) because there has been an established association between masked hypertension and clinic prehypertension.7,8 However, such an approach may also not be the most cost-effective screening approach because it may not truly be selecting the patients at highest risk, and the approach taken in this study may ultimately be the most logical approach to take and to include in guidelines.Although the 2014 evidence-based guidelines for the management of high blood pressure in adults (Eighth Joint National Committee guidelines) do not suggest a method of screening or propose any management strategy for masked hypertension, the 2013 European Society of Cardiology guidelines for the management of arterial hypertension recommend that antihypertensive treatment should be considered in these patients.9,10 A key limitation for screening is that it remains unclear whether the treatment of all patients with masked hypertension would provide outcome benefits. There have been no randomized controlled trials evaluating this question, and such trials would likely be difficult to carry out because of the number of subjects that would be needed. Based on the findings from the study by Anstey et al, there seems to be an important role for masked hypertension screening among black patients with higher ASCVD risk. Although the C statistic for discriminating between participants with versus without hypertension was similar or lower compared with clinic blood pressure, screening patients at high ASCVD risk may truly be identifying a group of patients in whom detection of masked hypertension may have the most clinical impact.There is a significant need for further studies in this area to identify the highest risk factors that may assist in deciding who to screen for masked hypertension. There is also a need to evaluate whether an improvement in cardiovascular outcomes would be associated with treatment of masked hypertension—both in patients with low or high predicted ASCVD risk. This article marks an important step forward in recognizing the clinical impact of masked hypertension and also in constructing a clinical approach for this large population of patients. For masked hypertension, however, much more work is necessary to see what troubles are lurking under the disguise.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to John D. Bisognano, MD, PhD, Division of Cardiology, Department of Internal Medicine, University of Rochester Medical Center, Rochester, New York 14642. E-mail [email protected]References1. Peacock J, Diaz KM, Viera AJ, Schwartz JE, Shimbo D. Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.J Hum Hypertens. 2014; 28:521–528. doi: 10.1038/jhh.2014.9.CrossrefMedlineGoogle Scholar2. Hansen TW, Kikuya M, Thijs L, Björklund-Bodegård K, Kuznetsova T, Ohkubo T, Richart T, Torp-Pedersen C, Lind L, Jeppesen J, Ibsen H, Imai Y, Staessen JA; IDACO Investigators. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals.J Hypertens. 2007; 25:1554–1564. doi: 10.1097/HJH.0b013e3281c49da..CrossrefMedlineGoogle Scholar3. Booth JN, Diaz KM, Seals SR, Sims M, Ravenell J, Muntner P, Shimbo D. Masked hypertension and cardiovascular disease events in a prospective cohort of blacks: the Jackson heart study.Hypertension. 2016; 68:501–510. doi: 10.1161/HYPERTENSIONAHA.116.0755..LinkGoogle Scholar4. Anstey DE, Booth JN III, Abdalla M, Spruill TM, Min YI, Muntner P, Shimbo D. Predicted atherosclerotic cardiovascular disease risk and masked hypertension among blacks in the JHS (Jackson heart study).Circ Cardiovasc Qual Outcomes. 2017; 10:e003421. doi: 10.1161/CIRCOUTCOMES.116.003421.LinkGoogle Scholar5. National Clinical Guideline Centre (UK). Hypertension: the clinical management of primary hypertension in adults: update of clinical guidelines 18 and 34. Royal College of Physicians (UK); 2011.Google Scholar6. Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. preventive services task force recommendation statement.Ann Intern Med. 2015; 163:778–786. doi: 10.7326/M15-2223.CrossrefMedlineGoogle Scholar7. Shimbo D, Newman JD, Schwartz JE. Masked hypertension and prehypertension: diagnostic overlap and interrelationships with left ventricular mass: the masked hypertension study.Am J Hypertens. 2012; 25:664–671. doi: 10.1038/ajh.2012.1..CrossrefMedlineGoogle Scholar8. Booth JN, Muntner P, Diaz KM, Viera AJ, Bello NA, Schwartz JE, Shimbo D. Evaluation of criteria to detect masked hypertension.J Clin Hypertens (Greenwich). 2016; 18:1086–1094. doi: 10.1111/jch.1283..CrossrefMedlineGoogle Scholar9. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC, Svetkey LP, Taler SJ, Townsend RR, Wright JT, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).JAMA. 2014; 311:507–520. doi: 10.1001/jama.2013.28442..CrossrefMedlineGoogle Scholar10. Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).Eur Heart J. 2013; 34:2159–2219. doi:10.1093/eurheartj/eht151.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Shalimova A (2022) INSUFFICIENT CONTROL OF OUT-OF-OFFICE BLOOD PRESSURE: THE PROBLEM OF MASKED UNCONTROLLED HYPERTENSION: review, Inter Collegas, 10.35339/ic.8.4.201-210, 8:4, (201-210) July 2017Vol 10, Issue 7 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.117.003945PMID: 28698193 Originally publishedJuly 11, 2017 Keywordsadultblood pressurehypertensionhypotensionEditorialsPDF download Advertisement SubjectsHigh Blood PressureHypertension