The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared to those with controlled hypertension and reporting adjusted hazard ratio and 95% confidence interval. We identified six studies using ambulatory blood pressure monitoring (12610 patients with 933 events) and five using home blood pressure measurement (17742 patients with 394 events). The global population included 30352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% confidence interval 1.57–2.06) for MUCH versus controlled hypertension. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% confidence interval 1.52–2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% confidence interval 1.38–2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in controlled hypertension independently of follow-up length and types of studied events. MUCH was at significantly higher risk than controlled hypertension in all ethnic groups, but the highest hazard ratio was found in studies including Black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with controlled hypertension. MUCH detected by ambulatory or home blood pressure measurement appear to convey similar prognostic information.

In elderly treated hypertensive patients, high MS of systolic BP predicts coronary events in dippers but not in nondippers. Nondippers, however, show higher risk of coronary events independently of MS in systolic BP.

In elderly treated hypertensive patients evaluated by ambulatory BP monitoring, compared to individuals with CH, those with MUCH have significantly higher risk and those with WCUCH have slightly and not significantly higher risk.

The independent prognostic significance of circadian blood pressure (BP) changes is unclear. We investigated the association between circadian BP changes and cardiovascular risk among elderly-treated hypertensive patients. The occurrence of a composite end point (that is, stroke, coronary events, heart failure and peripheral revascularization) was evaluated among 1191 elderly-treated hypertensive patients (age range 60-90 years). According to the nighttime change and the morning surge (MS) of systolic BP, subjects were divided into groups of dippers with a normal or high MS (DNMS and DHMS, respectively), non-dippers (ND), reverse dippers (RD) and extreme dippers with a normal or high MS (EDNMS and EDHMS, respectively). During the follow-up (9.1±4.9 years, range 0.4-20 years), 392 events occurred. The event rate was 3.63 per 100 patient-years. After adjustment for various covariates, including 24-h BP, the DHMS (hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.02-2.16, P=0.04), ND (HR 1.71, 95% CI 1.28-2.27, P=0.0001), RD (HR 2.05, 95% CI 1.44-2.93, P=0.0001) and EDHMS (HR 3.40, 95% CI 1.96-5.90, P=0.001) were at higher cardiovascular risk than the DNMS. The population attributable risk was 0.6, 7.1, 7.3 and 1.4% for the DHMS, ND, RD and EDHMS, respectively. In elderly-treated hypertensive patients, circadian BP changes were independently associated with increased cardiovascular risk. At the patient level, the highest risk was observed among the EDHMS, followed by the RD, ND and DHMS. At the population level, the highest risk was observed among the RD, followed by the ND, EDHMS and DHMS.

BACKGROUND Masked uncontrolled hypertension (MUCH), that is, nonhypertensive clinic but high out-of-office blood pressure (BP) in treated patients is at increased cardiovascular risk than controlled hypertension (CH), that is, nonhypertensive clinic and out-of-office BP. Using ambulatory BP, MUCH can be defined as daytime and/or nighttime and/or 24-hour BP above thresholds. It is unclear whether different definitions of MUCH have similar prognostic information. This study assessed the prognostic value of MUCH defined by different ambulatory BP criteria. METHODS Cardiovascular events were evaluated in 738 treated hypertensive patients with nonhypertensive clinic BP. Among them, participants were classified as having CH or daytime MUCH (BP ≥135/85 mm Hg) regardless of nighttime BP (group 1), nighttime MUCH (BP ≥120/70 mm Hg) regardless of daytime BP (group 2), 24-hour MUCH (BP ≥130/80 mm Hg) regardless of daytime or nighttime BP (group 3), daytime MUCH only (group 4), nighttime MUCH only (group 5), and daytime + nighttime MUCH (group 6). RESULTS We detected 215 (29%), 357 (48.5%), 275 (37%), 42 (5.5%),184 (25%) and 173 (23.5%) patients with MUCH from group 1 to 6, respectively. During the follow-up (10 ± 5 years), 148 events occurred in patients with CH and MUCH. After adjustment for covariates, compared with patients with CH, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 2.01 (1.45–2.79), 1.53 (1.09–2.15), 1.69 (1.22–2.34), 1.52 (0.80–2.91), 1.15 (0.74–1.80), and 2.29 (1.53–3.42) from group 1 to 6, respectively. CONCLUSIONS The prognostic impact of MUCH defined according to various ambulatory BP definitions may be different.