White-coat effect on orthostatic hypotension: a nationwide survey of Japanese general practitioners

Abstract

Objective The relationship between the white-coat effect (WCE), defined as white-coat hypertension under treatment, and the frequency of orthostatic hypotension (OH) is not known. We conducted an orthostatic test in patients with WCE to determine the frequency of OH. Methods This was a cross-sectional study of 5631 patients with hypertension visiting general practitioners nationwide, in which 4305 patients with hypertension recorded their home blood pressure (BP) and consented to the orthostatic test. Patients with hypertension were divided into four groups: controlled hypertension (CHT), masked hypertension (MHT), sustained hypertension (SHT), and WCE. The orthostatic test was performed, and BP and pulse rate were measured immediately and 1 min after orthostasis. Results The OH frequencies immediately after standing in CHT, WCE, SHT, and MHT patients were 7, 11.7, 12.1, and 6.6%, respectively, and those at 1 min after standing were 7.1, 13.1, 11.6 and 6.9%, respectively (Chi-square test, P < 0.01, respectively). Logistic regression analysis was performed to examine the relationship between WCE and the frequency of OH. The frequency of OH immediately after standing was significantly increased [adjusted odds ratio (AOR), 1.702; 95% confidence interval (CI), 1.246–2.326; P < 0.01]. The frequency of OH at 1 min after standing was also significantly higher (AOR, 1.897; 95% CI, 1.396–2.578; P < 0.01). Conclusion When the standing test was performed for patients with WCE, the frequency of OH increased. Thus, it is important to recognize the possibility of OH in patients with WCE to avoid adverse events associated with excessive hypotension.

Orthostatic hypotension, orthostatic hypertension, and ambulatory blood pressure in patients with chronic kidney disease in CRIC

“…WCE is often present among older adults and represents a state of discordant BP in clinic and at home [33,34]. Adults with WCE have low or normal BPs measured via ambulatory BPs at home versus elevated or high BPs in clinic, and some speculate that these adults may be at a greater risk of hypotensive events or syncope from hypertension treatment [24,35,36]. The role of sympathetic hyperactivation in the clinic setting has been well-described [37][38][39].…”

Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association

“…48 One study involving 4305 patients with hypertension demonstrated that early OH (OH within 1 minute of standing) was present in ≈7% of those with white-coat hypertension. 49 Another study examining 897 adults (a subpopulation of SPRINT) undergoing BP treatment showed that OH was positively associated with white-coat effects. 50 Another common pattern is nocturnal nondipping (ie, the absence of a normal drop in BP while asleep) or nocturnal hypertension (high BP while sleeping), [50][51][52][53] which may be more pronounced in older adults because of aging-related changes in circadian BP regulation 54 and could reflect an incipient neurodegenerative disorder (see the discussion of neurogenic OH).…”

“…48 One study involving 4305 patients with hypertension demonstrated that early OH (OH within 1 minute of standing) was present in ≈7% of those with white-coat hypertension. 49 Another study examining 897 adults (a subpopulation of SPRINT) undergoing BP treatment showed that OH was positively associated with white-coat effects. 50…”

Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021

“…12 OH also associates with distinct ambulatory BP phenotypes. 14,16 In a subgroup analysis of 849 adults from SPRINT, OH was found to be associated with white coat hypertension (a state where BP measured in the clinic are higher than BP measured at home) and nocturnal elevations in BP. 13…”

“…11 Along these lines, OH has been shown to be useful in predicting hypotensive events 12 as well as patterns of BPV outside of the clinic among adults with hypertension. [13][14][15][16]…”