Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions

Abstract

‘Masked hypertension’ is defined as having non-elevated clinic blood pressure (BP) with elevated out-of-clinic average BP, typically determined by ambulatory BP monitoring. Approximately 15–30% of adults with non-elevated clinic BP have masked hypertension. Masked hypertension is associated with increased risks of cardiovascular morbidity and mortality compared to sustained normotension (non-elevated clinic and ambulatory BP), which is similar to or approaching the risk associated with sustained hypertension (elevated clinic and ambulatory BP). The confluence of increased cardiovascular risk and a failure to be diagnosed by the conventional approach of clinic BP measurement makes masked hypertension a significant public health concern. However, many important questions remain. First, the definition of masked hypertension varies across studies. Further, the best approach in the clinical setting to exclude masked hypertension also remains unknown. It is unclear whether home BP monitoring is an adequate substitute for ambulatory BP monitoring in identifying masked hypertension. Few studies have examined the mechanistic pathways that may explain masked hypertension. Finally, scarce data are available on the best approach to treating individuals with masked hypertension. Herein, we review the current literature on masked hypertension including definition, prevalence, clinical implications, special patient populations, correlates, issues related to diagnosis, treatment, and areas for future research.

Masked hypertension—what lies ahead?

“…1,2 White coat hypertension is a well-recognised phenomenon, describing individuals with elevated clinic BP but non-elevated out-of-clinic BP. 3 What Pickering et al coined in 2002 as masked hypertension is the opposite phenomenon, non-elevated clinic BP but elevated outof-clinic BP.…”

“…On the other hand, HBPM may be more practical as it is less cumbersome for the patient and more widely available. 2,8,9 Although guidelines, scientific statements and position papers commonly recommend ABPM over HBPM for assessing out-ofclinic BP, the data supporting one modality over the other for predicting CVD events is inconclusive. A recent systematic review examined studies using both ABPM and HBPM to determine whether either method was more strongly associated with CVD events and mortality.…”

“…An alternative approach could be to screen a smaller number of individuals who have multiple risk factors for masked hypertension such as elevated clinic BP, older age, male sex, smoking and diabetes. 2 Without empiric evidence regarding best screening practices for masked hypertension, it is unlikely that ABPM or HBPM will be routinely incorporated into decisions regarding the diagnosis and management of masked hypertension.…”

Masked hypertension

“…Almost one-third of treated patients with masked hypertension have masked uncontrolled hypertension (22). There are scarce data on how to treat masked hypertension (23). One approach to treating masked hypertension would be to treat 24-hour ambulatory blood pressure (23).…”

“…There are scarce data on how to treat masked hypertension (23). One approach to treating masked hypertension would be to treat 24-hour ambulatory blood pressure (23). I would also aggressively treat modifiable © Annals of Translational Medicine.…”