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2 The lower threshold values in the ACC/AHA guidelines are due largely to the findings of the Systolic Blood Pressure Intervention Trial (SPRINT) study. They are deemed to have WCH if day-time ambulatory or average home BP is below 135/85 mmHg. 4 In the NICE guidelines, ABPM or HBPM is offered to those with a clinic BP of 140/90 mmHg or higher. Ambulatory and home BP monitoring (ABPM and HBPM respectively) are offered only when WCH is suspected and following a 3-month intervention of lifestyle modification. ACC/AHA guidelines define WCH as a clinic BP of 130/80 mmHg or above, in the presence of day-time ambulatory or home BP less than 130/80 mmHg. ESH, American College of Cardiology/American Heart Association (ACC/AHA) and National Institute for Health and Care Excellence (NICE) guidelines all differ from one another in this regard ( Table 2). This is not unrelated to the various definitions of hypertension ( Table 1). There is no universally accepted approach to investigate and define WCH. 14 The white coat effect is considered clinically significant if the difference between clinic and out-of-office BP exceeds 20/10 mmHg. This is in contrast to the white coat effect, which describes the difference between an elevated clinic BP and a lower home or ambulatory BP in both untreated and treated patients. 15 The ESH guidance also states that the term WCH should be reserved for untreated individuals only. 1 This updated definition may be preferable as it includes night-time BP, which has been shown to be a stronger predictor of outcomes than day-time BP. 14 This differs from the original definition by Pickering et al., as it uses 24-h rather than day-time ambulatory BP monitoring. The ESH suggest that patients with an office reading of at least 140/90 mmHg and a mean 24-h BP of less than 130/80 mmHg are deemed to have WCH. This BP phenotype is also referred to as white coat syndrome. WCH describes an elevated clinic BP in the presence of normal out-of-office BP values. In individuals with WCH and evidence of hypertension-mediated organ damage or elevated CV risk, it may be appropriate to offer recommendations on lifestyle changes in conjunction with drug treatment. They suggest that patients with WCH and no additional CV risk factors should be managed with lifestyle changes and closely followed due to their increased risk of developing SH and TOD. 12, 13 Based on this limited evidence, the European Society of Hypertension (ESH) has developed guidelines for the treatment of WCH. Some studies are in favour of the treatment of WCH, whilst others suggest that treatment benefits only those with sustained hypertension. These types of analyses have yielded controversial results. The dearth of randomised controlled trial data on WCH has led to inference of results from sub-group analyses performed in patients with numerous forms of hypertension. 10, 11 This apparent lack of clarity deserves further investigation.
8, 9 This is in contrast to other studies, which have found that patients with WCH do not have additional CV risk.
Some evidence suggests that WCH is an intermediate risk category positioned somewhere between those with normotension and sustained hypertension. 6, 7 The association between WCH and CV events is considerably less clear.
5 Furthermore, WCH can lead to impairment of myocardial function and, compared with normotensive patients, there is an increased risk of carotid atherosclerosis. Recently, WCH has been found to increase the relative risk of sustained hypertension by almost three-fold when compared with patients with normal BP. WCH is an important phenomenon to understand because it is a proposed risk factor for the development of sustained hypertension (SH), target organ damage (TOD) and possibly the occurrence cardiovascular (CV) events. It is still not clear what risk is conferred by WCH and whether it warrants treatment. 1 – 4 Despite this, there are considerable gaps in our understanding of WCH. There has been a growing recognition of this phenomenon since it was first noted over three decades ago, and it now features in both national and international hypertension guidelines. White coat hypertension (WCH) describes a blood pressure (BP) phenotype present in untreated individuals with elevated clinic BP, but normal out-of-office values.
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