'Wait and Watch' Young Patients With White-Coat Hypertension

Marlene Busko

June 17, 2015

MILAN, ITALY — For young to middle-aged adult patients with mildly elevated office blood pressure but no cardiovascular risk factors, it is probably best to watch and wait before initiating antihypertensive treatment, according to new research based on the Hypertension and Ambulatory Recording Venetia Study (HARVEST)[1].

The study also identified young patients who were more likely to have normal blood pressure a decade later: those with normal ambulatory blood-pressure readings and those whose blood-pressure readings that dropped after 1 year.

These findings can help spot which young patients are likely to have white-coat hypertension who do not need to be started on antihypertensive therapy, said Dr Francesca Saladini (University of Padua, Italy), presenting these findings here at the European Society of Hypertension (ESH) 2015 Scientific Sessions.

"Hypertension in young subjects is very different from . . . hypertension in older patients . . . where it is well-known that this [increases] the risk of cardiovascular events," she told heartwire from Medscape. In their clinic they often see soccer or rugby players who have slightly elevated blood pressure, but further analysis often reveals that this is benign and these athletes do not need to curtail their physical activity, she noted.

"One very important point in this study is that in young people in which you suspect the development of hypertension, the best approach is to stop and watch . . . to just observe and reevaluate the patient in a while, in order to not overtreat," session cochair Dr Stefano Perlini (University of Pavia, Italy) told heartwire .

When to Initiate Antihypertensive Therapy?

It is unclear how long subjects with stage 1 hypertension should be managed by lifestyle changes alone before deciding that antihypertensive treatment should be initiated, Saladini said.

They aimed to evaluate whether and to what extent normal ambulatory blood pressure can predict long-term normal blood pressure, using data from HARVEST.

As reported by heartwire , the observational HARVEST study enrolled patients with grade 1 hypertension (140–159/90–99 mm Hg) and followed them to determine whether they had white-coat, masked, or sustained hypertension.

Saladini and colleagues analyzed data from 1104 participants in HARVEST who had no diabetes or previous cardiovascular events and who had not received antihypertensive therapy. The subjects had a mean age of 33, and, not unexpectedly, 74% were male, since men are more likely than women to have mildly elevated hypertension at this age, Saladini said.

The patients' blood-pressure values (based on three readings) were determined at clinic visits at baseline; at 1, 2, 3, and 6 months; and at 6-month intervals until study end (up to 20 years).

The participants were divided into two groups based on their clinic (or office) blood-pressure readings:

  • Those who had normal blood pressure at study end (normotensive subjects; n=214).

  • Those who developed hypertension requiring antihypertensive treatment during follow-up (hypertensive subjects; n=890).

Patients who remained normotensive were followed for an average of 11 years, and those who developed hypertension were followed for an average of 7 years.

Compared with patients who developed hypertension, the normotensive patients were younger at enrollment (29.5 vs 33.9 years) and had lower baseline office blood-pressure readings (142/91 mm Hg vs 146/94 mm Hg). Participants who were normotensive also had a better baseline metabolic profile—a lower body-mass index (24.5 vs 25.6), lower serum glucose levels, lower triglycerides, and higher HDL-cholesterol levels. They were also more physically active.

In the normotensive patients, on average, blood pressure declined by 7/5 mm Hg after 1 year and by 14/8 mm Hg by 11 years.

Compared with their peers who developed hypertension, subjects who remained normotensive were more likely to have white-coat hypertension at baseline (35% vs 19%; P<0.001).

At 3 months, 42% of the participants who were normotensive at study end and 22% of the participants who developed hypertension requiring therapy had normal ambulatory blood pressure (P<0.001).

Ambulatory blood pressure after 11 years remained virtually unchanged in the subjects with normal blood pressure at study end (1/1 mm Hg) and increased by 4/3 mm Hg in hypertensive patients.

Thus, having a normal ambulatory blood pressure at baseline (hazard ratio [HR] 0.76, 95%CI 0.64–0.90) or after 3 months (HR 0.69, 95% CI 0.58–0.81) was a significant predictor of future normal blood pressure.

Moreover, an office blood pressure decline of more than 10 mm Hg after 1 year was an additional potent predictor of future normal blood pressure (HR 0.58, 95% CI 0.47–0.72).

Patients who met the criteria for hypertension were more likely to have prediabetes and diabetes, atrial fibrillation, cardiovascular events, and a greater gain in body weight than their peers at study end.

Thus, the study provides support for waiting before initiating antihypertensive treatment in low-risk, young to middle-aged patients with stage 1 hypertension, and it helps to identify which patients are likely to have normal blood pressure without antihypertensive therapy, Saladini concluded.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.