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Abstract
The prognostic significance of white-coat hypertension (WCHT) is controversial, and different findings on self-measured home measurements and 24-h ambulatory monitoring make identifying WCHT difficult. We examined whether individuals with partially or completely defined WCHT, as well as masked hypertension, as determined by different out-of-office blood pressure measurements, have a distinct long-term stroke risk. We followed 1464 participants (31.8% men; mean age, 60.6±10.8 years) in the general population of Ohasama, Japan, for a median of 17.1 years. A first stroke occurred in 212 subjects. Using sustained normal blood pressure (events/n=61/776) as a reference, adjusted hazard ratios for stroke (95% confidence intervals; events/n) were 1.38 (0.82–2.32; 19/137) for complete WCHT (isolated office hypertension), 2.16 (1.36–3.43; 29/117) for partial WCHT (either home or ambulatory normotension with office hypertension), 2.05 (1.24–3.41; 23/100) for complete masked hypertension (both home and ambulatory hypertension with office normotension), 2.08 (1.37–3.16; 38/180) for partial masked hypertension (either home or ambulatory hypertension with office normotension), and 2.46 (1.61–3.77; 42/154) for sustained hypertension. When partial WCHT and partial masked hypertension groups were further divided into participants only with home hypertension and those only with ambulatory hypertension, all subgroups had a significantly higher stroke risk (adjusted hazard ratio ≥1.84, P≤0.04). In conclusion, impacts of partial WCHT as well as partial masked hypertension for long-term stroke risk were comparable to those of complete masked hypertension or sustained hypertension. We need both home and 24-h ambulatory blood pressure measurements to evaluate stroke risk accurately.
Introduction
White-coat hypertension (WCHT) is characterized by elevated office blood pressure findings with normal out-of-office blood pressure findings.1–3 WCHT is different from masked hypertension (MHT), which is used to describe normal office blood pressure findings and high out-of-office blood pressure findings. Data regarding cerebro- and cardiovascular risk in subjects with WCHT are conflicting.4–12
Not only daytime or nighttime recordings, but full 24-h ambulatory recordings are required to identify WCHT, which has been shown to have a low cardiovascular risk when 24-h ambulatory blood pressure monitoring is used as the measurement standard.13 At the same time, one study showed that an elevated self-measured home blood pressure result was associated with a significantly increased long-term risk for cardiovascular mortality even in individuals with WCHT detected by 24-h ambulatory blood pressure monitoring.14 These authors indicated that home blood pressure monitoring might also be needed for prediction of future cardiovascular disease.14 However, they did not address whether this was also the case in subjects with MHT, and nonfatal cardiovascular outcomes were not evaluated.14
Stroke incidence accounts for a substantial portion of total cardiovascular disease in the Asian population.15 Blood pressure is most strongly associated with stroke among all types of cardiovascular disease.15 The introduction of stroke units in healthcare facilities has reduced the case-fatality rate of stroke in the past decades.16,17 We therefore aimed to investigate the long-term first stroke risk in WCHT, as well as MHT, based on home blood pressure measurement and 24-h ambulatory blood pressure monitoring.
Methods
Study Population
This report was part of the Ohasama study, an ongoing community-based blood pressure measurement project started in 1986. Socioeconomic and demographic characteristics of this region and details of the study have been described previously.18,19 The study complies with the Declaration of Helsinki, and the study protocol was approved by the institutional review board of Tohoku University School of Medicine and Pharmaceutical Sciences and by the Department of Health of the Ohasama Town Government.
From 1988 until 1995, we contacted all 4969 residents aged ≥35 years in Ohasama. Residents were not eligible if they were not at home during working hours of nurses or study investigators who performed the data collection (n=1057) or if they were hospitalized (n=166) or incapacitated (n=94). Of the remaining 3652 residents, 3092 (84.7%) participated in baseline and follow-up examinations. We excluded 1628 participants from analysis because, at enrollment, they had a history of stroke (n=149), did not measure home morning blood pressure ≥3 days (n=318), did not measure 24-h ambulatory blood pressure adequately (n=1049), did not measure office blood pressure (n=60), or had ≥3 years between the 3 blood pressure measurements (n=52). Thus, the total number of participants analyzed was 1464, including 461 receiving antihypertensive drug treatment (Figure S1 in the online-only Data Supplement). All participants gave informed consent. The 1628 excluded from the present analysis were younger and had a higher proportion of men (56.9±14.5 years old; men 52.9%) than included participants (P<0.0001), but no significant difference in stroke risk between excluded and included participants without history of stroke was observed after adjustments for sex and age (P=0.8).
Blood Pressure Measurements
Physicians and public health nurses instructed participants how to measure their home blood pressure using an Omron HEM 401C cuff-oscillometric device (Omron Healthcare, Kyoto, Japan).20 Participants recorded their home blood pressure for 4 weeks after ≥2 minutes of rest in the morning within 1 hour after awakening, maintaining the arm-cuff position at heart level during rest, and if applicable, before taking their blood pressure-lowering medications.3,21,22 Although participants sometimes measured blood pressure twice or more per occasion, we used the first value from each measurement to exclude individual selection bias.21 We defined home blood pressure as the mean of all measurements.
We programmed the 24-h ambulatory blood pressure monitoring device, Omron Colin ABPM-630 (Omron Healthcare),23 to obtain oscillometric blood pressure readings at 30-minute intervals throughout an entire day. Participants noted the hour of awakening and going to sleep on monitoring days. According to the diary, daytime and nighttime were determined as the awakening and sleeping periods, respectively.
Office blood pressure was measured twice by nurses at local medical centers using a semiautomatic blood pressure measuring device (USM-700F24; UEDA Electronic Works, Tokyo, Japan) based on the microphone method with participants in a seated position after resting for ≥2 minutes, maintaining the cuff position at heart level. The mean of the 2 readings was used in this analysis.
According to current guidelines,2,3 hypertension was defined as systolic/diastolic blood pressure ≥135/85 mm Hg for home measurements, ≥130/80 mm Hg for 24-h ambulatory measurements, ≥135/85 mm Hg for daytime ambulatory measurements, ≥120/70 mm Hg for nighttime ambulatory measurements, and ≥140/90 mm Hg for office measurements. As shown in Table 1, participants were classified into the following 6 groups: sustained normal blood pressure (SNBP); complete WCHT (isolated office hypertension); partial WCHT (either home or 24-h ambulatory normotension and office hypertension); complete MHT (both home and 24-h ambulatory hypertension and office normotension); partial MHT (either home or 24-h ambulatory hypertension and office normotension); and sustained hypertension (SHT). We also divided the study participants into the 6 groups similarly but based on daytime or nighttime ambulatory blood pressure instead of 24-h ambulatory blood pressure. The present study contains participants treated with antihypertensive drugs. The WCHT group included treated participants with uncontrolled blood pressure status only under medical settings. Similarly, the MHT group included those with masked uncontrolled hypertension. These concepts are consistent with those used in previous studies6,25 and are based on previous reports showing that an insufficient duration of action for antihypertensive drugs represents an important factor in causing higher ambulatory or home blood pressure levels compared with casual blood pressure measurements.26
Blood Pressure Classification
Follow-Up and Outcome
Residence in Ohasama (as of November 30, 2010) was confirmed by the residents’ registration cards. In Japan, these cards are considered accurate and reliable because they are used for pensions and social security benefits. The incidence of stroke until November 30, 2010, was determined by reviewing the Stroke Registration System of Iwate Prefecture, death certificates, National Health Insurance receipts, and questionnaires sent to each household at the time of health checkups. This information was then confirmed by checking the medical charts of Ohasama Hospital, which was the only hospital in the town and where ≥90% of participants had regular checkups. Among all stroke cases registered until 2010, 97.7% were confirmed by computed tomography or magnetic resonance imaging of the brain. The diagnostic criteria of stroke subtypes were based on the Classification of Cerebrovascular Disease III of the National Institute of Neurological Disorders and Stroke.17 Transient ischemic attack was not treated as stroke in the present study. The underlying causes of death were coded according to the 10th International Classification of Diseases. Baseline date in individuals was defined as the start date of the last measurement among home, 24-h ambulatory, and office measurements.
Data Collection
Study nurses administered a standardized questionnaire. Previous cardiovascular disease included transient ischemic attack, coronary heart disease, and atrial fibrillation; participants with history of stroke were excluded in the present study because this study evaluated a first stroke. Serum total cholesterol and blood glucose levels were measured enzymatically. Diabetes mellitus was defined as a fasting glucose level ≥7.0 mmol/L (≥126 mg/dL), a random glucose level ≥11.1 mmol/L (≥200 mg/dL), or the use of insulin or oral antidiabetic drugs.
Statistical Analysis
To analyze the difference in participant characteristics between hypertension groups, we compared means and proportions using analysis of variance followed by pairwise t tests and the χ2 test, respectively. We interpolated missing values of body mass index (n=111) and total cholesterol (n=25) from the regression slope on age after stratification for sex. In participants with unknown drinking status (n=175), we set the design variable to sex-specific mean of the codes (0, 1). The cumulative event rate was estimated by the Kaplan–Meier method followed by Sidak pairwise comparisons. We calculated adjusted hazard ratios for stroke among hypertension groups using the Cox model with the SNBP group as a reference. In the fully adjusted model, covariates were sex, age, body mass index, current smoking, alcohol consumption, diabetes mellitus, total cholesterol, history of cardiovascular disease, and antihypertensive drug treatment. We then subdivided participants by home hypertension and 24-h ambulatory hypertension. Differences in the adjusted hazard ratios among hypertension groups across subgroups according to sex, age, or use of antihypertensive treatment were evaluated by the likelihood ratio test comparing the models with and without the appropriate interaction term. Statistical significance was an α-level of <0.05 on 2-sided tests. Data are expressed as mean±standard deviation unless otherwise noted. SAS version 9.3 (SAS Institute, Cary, NC) was used for statistical analysis.
Results
Characteristics
The 1464 participants (31.8% men; mean age, 60.6±10.8 years) consisted of 776 (53.0%) with SNBP, 137 (9.4%) with complete WCHT, 117 (8.0%) with partial WCHT, 100 (6.8%) with complete MHT, 180 (12.3%) with partial MHT, and 154 (10.5%) with SHT. Age, the proportion of the participants using antihypertensive drugs, and blood pressure levels were significantly lower in the SNBP group than in other hypertension groups (P<0.0001; Table 2). Significant differences in body mass index and the proportion of men, current smokers, alcohol consumption, and history of cardiovascular disease between groups were also observed (P≤0.04; Table 2).
Baseline Characteristics
Cumulative Stroke Incidence
During a median follow-up of 17.1 years (interquartile range, 12.8–19.3; maximum, 22.5 years), a first stroke occurred in 212 participants, including 156 with cerebral infarction, 41 with intracerebral hemorrhage, 13 with subarachnoid hemorrhage, and 2 with other types. Figure 1 shows the cumulative stroke incidence. Stroke risk in the SNBP group was significantly lower than that in the other 5 groups (P<0.0001; Figure 1). The cumulative stroke incidence in the partial WCHT group did not differ from that in the complete MHT (P=1.0), partial MHT (P=1.0), or SHT groups (P=0.3) but tended to be higher than that in the complete WCHT group (P=0.07). The numbers for total mortality (sex- and age-adjusted total mortality rate, per 1000 person years) were 171 (17.3%) in the SNBP group, 49 (22.9%) in the complete WCHT group, 49 (23.6%) in the partial WCHT group, 44 (24.7%) in the complete WHT group, 77 (24.5%) in the partial MHT group, and 82 (29.4%) in the SHT group.
Kaplan–Meier survival function estimates for stroke incidence by hypertension group. Significant differences between sustained normal blood pressure (SNBP) and other groups in stroke incidence were observed (P<0.0001). MHT indicates masked hypertension; SHT, sustained hypertension; and WCHT, white-coat hypertension.
Multivariable Adjusted Analyses
Compared with the SNBP group, stroke risks were significantly higher (P≤0.006) in the partial WCHT, complete and partial MHT, and SHT groups, but not in the complete WCHT group (P=0.2) after adjustments for confounding factors (Table 3). When we used daytime hypertension instead of 24-h ambulatory hypertension, adjusted hazard ratios for stroke (95% CI) were 1.51 (0.89–2.55) in the complete WCHT group, 1.92 (1.19–3.09) in the partial WCHT group, 2.25 (1.36–3.72) in the complete MHT group, 2.02 (1.33–3.06) in the partial MHT group, and 2.71 (1.77–4.16) in the SHT group (Table S1). Similarly, when we used nighttime hypertension, the adjusted hazard ratios were 1.63 (0.99–2.68) for the complete WCHT group, 1.88 (1.17–3.01) for the partial WCHT group, 2.05 (1.24–3.39) for the complete MHT group, 1.86 (1.23–2.83) for the partial MHT group, and 2.39 (1.55–3.69) for the SHT group (Table S2).
Adjusted Hazard Ratios for Stroke Among Hypertension Groups
We further stratified the partial WCHT and partial MHT groups according to home hypertension and 24-h ambulatory hypertension (Figure 2). Home hypertension without 24-h ambulatory hypertension as well as 24-h ambulatory hypertension without home hypertension were significantly associated with a higher risk for stroke in the partial WCHT and partial MHT groups than in the SNBP group (P≤0.04; Figure 2).
Adjusted hazard ratios among groups after further stratification according to home hypertension and 24-h ambulatory hypertension. Filled squares express adjusted hazard ratios for stroke and are sized in proportion to the number of events observed among hypertension groups. Covariates were sex, age, body mass index, current smoking, alcohol consumption, diabetes mellitus, total cholesterol, history of cardiovascular disease, and use of antihypertensive drugs. Hypertension was defined as systolic/diastolic blood pressure ≥135/85 mm Hg for home, ≥130/80 mm Hg for 24-h ambulatory, and ≥140/90 mm Hg for office. The mark + indicates hypertension. *P<0.05, †P<0.0001 versus sustained normal blood pressure (SNBP) group. MHT indicates masked hypertension; SHT, sustained hypertension; and WCHT, white-coat hypertension.
Sensitivity Analyses
Similar results were obtained after censoring the events that occurred during the initial 5 years (adjusted hazard ratios [95% CI]: complete WCHT group, 1.49 [0.84–2.65]; partial WCHT group, 2.34 [1.39–3.94]; complete MHT group, 1.86 [1.02–3.38]; partial MHT group, 1.74 [1.05–2.88]; and SHT group, 2.16 [1.30–3.59]). Interaction between sex (men versus women; Table S3), age (<65 versus ≥65 years; Table S4), or use of antihypertensive drugs (Table S5) and hypertension groups on the risk for stroke did not reach significant levels (P for interaction ≥0.2). A similar tendency was observed in 939 participants who measured blood pressure using all 3 blood pressure measurements within 1 year, although the hazard ratio for stroke in the partial WCHT group did not reach statistical significance (Table S6). We also tested the association of hypertension groups with ischemic heart disease mortality (10th International Classification of Diseases codes: I20–25, n=40). In the fully adjusted model, hazard ratios (95% CI) for ischemic heart disease mortality were 1.21 (0.33–4.49) for complete WCHT, 1.35 (0.41–4.46) for partial WCHT, 2.87 (1.00–8.27) for complete MHT, 1.91 (0.71–5.15) for partial MHT, and 3.40 (1.34–8.63) for SHT (Table S7).
Increased risks for stroke in the partial WCHT group and partial MHT group remained significant after further adjustment for either home or 24-h ambulatory systolic blood pressure (P≤0.04), but were weakened to nonsignificant levels after further adjustment for the mean level of home and 24-h ambulatory systolic blood pressures (adjusted hazard ratios [95% CI]: complete WCHT group, 1.24 [0.73–2.09]; partial WCHT group, 1.39 [0.81–2.40]; complete MHT group, 1.00 [0.49–2.02]; partial MHT group, 1.42 [0.87–2.31]; and SHT group, 1.07 [0.53–2.17]). In this model, the adjusted hazard ratio per 10 mm Hg increase in the average of 2 out-of-office systolic blood pressure measurements was 1.38 (95% CI: 1.11–1.72).
Discussion
The novel finding of the present study is that participants with partial WCHT, complete and partial MHT, but not complete WCHT, had a significantly increased risk for stroke. Unlike complete WCHT, impacts of partial WCHT as well as partial MHT for long-term stroke risk were comparable to those of complete MHT and SHT. In the latter 2 groups, the stroke risk were >2 times higher than that in the SNBP group. In the present study, 46.1% of participants with WCHT were classified in the partial WCHT group when they measured both home and ambulatory blood pressure. Likewise, 64.3% of all MHT was partial MHT, and the present results suggest that at least half of partial MHT can be misclassified as SNBP using either of the 2 out-of-office blood pressure measurements. Although current guidelines have not focused on this point,1–3 both home and 24-h ambulatory blood pressure measurements are necessary to detect these partial conditions.
The Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study showed a significant increased risk for cardiovascular death among 2051 Italian subjects with partial WCHT, based on home, 24-h ambulatory, and office blood pressure measurements.14 This previous study indicated the importance of the increased cardiovascular risk in individuals with partial WCHT for the first time.14 However, the authors did not consider MHT in their analyses and used a unique threshold for determining hypertension, in which hypertension was defined as systolic/diastolic blood pressure ≥132/83 mm Hg for home measurements and ≥125/79 mm Hg for 24-h ambulatory measurements.14 Home blood pressure was based only on 2 readings obtained one morning and one evening in their study.14 The external validity of their findings are therefore not warranted.14 The number of cardiovascular deaths was relatively small (n=77), and only fatal outcomes were evaluated.14 The case-fatality rate after ischemic stroke or hemorrhage stroke is ≈7% and 20%, respectively, in Italian16 and in Japanese27 populations. Thus, most of the stroke events may have been missed in the PAMELA study,14 while we evaluated stroke incidence.
In the previous results by the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes (IDACO) study,13 the hazard ratios for cardiovascular disease in the WCHT group based on full 24-h ambulatory, daytime ambulatory, and nighttime ambulatory hypertension were 1.20 (P=0.01), 1.30 (P=0.048), and 1.30 (P=0.03), respectively. Similar to the previous report,13 full 24-h ambulatory recordings tended to more strictly detect the truly low stroke risk in the complete WCHT group than daytime or nighttime ambulatory recordings in the present study (adjusted hazard ratios in the complete WCHT group: 1.38 versus 1.51 versus 1.63, respectively; Table 2, Table S1 and S2). However, even in participants without 24-h ambulatory hypertension, home hypertension was significantly associated with an increased risk for stroke (Figure 2). This finding suggests a specific significance of home and 24-h ambulatory blood pressure measurements, although these 2 out-of-office blood pressure measurements have similarly greater prognostic values than office blood pressure measurements.21 Home blood pressure measurements provide blood pressure information obtained over a relatively long period, under fixed conditions.21 Although 24-h ambulatory blood pressure monitoring is generally performed on a particular day during unrestricted routine daily activities, it provides blood pressure information at many points during a whole day, including sleeping time.21 To improve the ability to predict future stroke events, an individual’s blood pressure should be evaluated by both home blood pressure measurements and 24-h ambulatory blood pressure monitoring. Though monitoring ambulatory blood pressure in a whole population would be difficult,2,3 the National Institute for Health and Clinical Experience Guidelines recommend ambulatory blood pressure monitoring for diagnosis of hypertension based on its cost-effectiveness and accuracy.28 Furthermore, we reported the cost-effectiveness of self-measured home blood pressure from the perspective of the Japanese healthcare system.29 Depending on the model applied, estimates of the cost savings produced by using home blood pressure measurements ranged from $674 000 to $2.51 million per 5000 person-years. Adjustment of antihypertensive treatment based on home30 or ambulatory blood pressure measurements31 instead of office blood pressure measurements can save medical costs in hypertensive patients. We emphasize that a significantly higher stroke risk was already observed in individuals who met either of the 2 out-of-office hypertension cut-off points (Figure 2). As mentioned in the European and Japanese Guidelines, home blood pressure measurements are cheaper and more widely available than ambulatory blood pressure monitoring. One can, therefore, measure home blood pressure first, and ambulatory blood pressure monitoring can be performed for individuals with high normal home blood pressure levels. Although the application of these out-of-office blood pressure measurements is still controversial,2,21,28 the feasibility of long-term home blood pressure–based antihypertensive drug treatment was demonstrated in Japanese patients nationwide,32 and the cost of healthcare and the risk of stroke can be effectively reduced by these 2 blood pressure measurements.30,31
The Ohasama study reported that WCHT was associated with a significantly higher risk for development of home hypertension than SNBP based on a mean follow-up of 8 years.7 In the PAMELA study, not only partial WCHT but also complete WCHT was significantly associated with a higher risk for developing SHT over a 10-year period.14 In the present study, further adjustment for the mean of 2 out-of-office systolic blood pressure levels weakened the hazard ratios for stroke among hypertension groups. Although participants might have been reclassified during the follow-up period, the 2 out-of-office blood pressure levels at baseline per se might be important for the prediction of future stroke, suggesting a prolonged carryover effect of high out-of-office blood pressure levels on stroke risk.
The present study must be interpreted within the context of its potential limitations. First, the present population might be subject to selection biases because it included volunteers. Although stroke risk did not differ by participation group, the 1628 excluded participants were younger and included a higher proportion of men, suggesting that the present study might have tended to select unemployed individuals. Consequently, our study population consisted of middle-aged to elderly residents from a Japanese rural district. Our current findings might not be generalizable to Western populations, in whom not stroke, but myocardial infarction, is the overriding cardiovascular complication associated with high blood pressure. The difference in nature between countries might also limit external validity of the present findings. However, 2 international meta-analyses, including the Ohasama study, indicated small differences in cardiovascular risk of WHCT and MHT between before and after excluding the Ohasama study.12,33 A similar cardiovascular risk of WHCT or MHT was also observed only in the Ohasama study.6 Therefore, the present findings may be generalizable to other populations, including Eurasia and South America.12,33 Second, office blood pressure levels were defined as 2 measurements on a single occasion, which was considered the standard measurement method at baseline. The Canadian guidelines recently recommended automated and multiple blood pressure measurements in an office.34 The predictive power of office blood pressure for stroke would be enhanced by such a method. In this regard, however, even 2 blood pressure measurements during each office visit are not necessarily performed by physicians in a general medical practice.35–37 Finally, we did not collect information on nonfatal ischemic heart disease. The association between the hypertension groups and death from ischemic heart disease did not differ largely from that of stroke events in the present study (Table S7). Further investigations based on cardiac events are needed.
Perspective
Individuals with partial WCHT, in which either home or ambulatory blood pressure was really high, as well as those with partial MHT, had a high stroke risk similar to those with complete MHT or SHT in the general population. Previous studies demonstrating the comparably low risk for cardiovascular disease in individuals with WCHT and the high risk for cardiovascular disease in those with MHT were based on either home or ambulatory blood pressure measurements.5,6,10,11 We need both home and 24-h ambulatory blood pressure measurements to evaluate the stroke risk more accurately.
Acknowledgments
We are grateful to the residents and staff members in Ohasama and staff members of the Hanamaki City Government, Ohasama Hospital, Iwate Prefectural Stroke Registry, General Hanamaki Hospital, Tohoku University Graduate School of Pharmaceutical Sciences, and Teikyo University School of Medicine for their valuable support on the Ohasama study project. M. Satoh wrote the first draft of this article. All authors conducted the Ohasama study and commented on the article.
Sources of Funding
This study was supported by Grants for Scientific Research (23249036, 23390171, 24390084, 24591060, 24790654, 25253059, 25461083, 25461205, 25860156, 26282200, and 26860093) from the Ministry of Education, Culture, Sports, Science, and Technology, Japan; a Grant-in-Aid from the Japan Society for the Promotion of Science (JSPS) fellows (25*7756, 25*9328, and 26*857); the Japan Arteriosclerosis Prevention Fund, an Intramural Research Fund; (22-4-5) for Cardiovascular Diseases of National Cerebral and Cardiovascular Center; and a Health Labor Sciences Research Grant (H26-Junkankitou [Seisaku]-Ippan-001) from the Ministry of Health, Labor, and Welfare; and A Scheme to Revitalize Agriculture and Fisheries in Disaster Area through Deploying Highly Advanced Technology (NouEi 2–02) from the Ministry of Agriculture, Forestry and Fisheries, Japan.
Disclosures
None.
Footnotes
The online-only Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYPERTENSIONAHA.115.06461/-/DC1.
- Received September 18, 2015.
- Revision received October 2, 2015.
- Accepted October 5, 2015.
- © 2015 American Heart Association, Inc.
References
Novelty and Significance
What Is New?
In the general population, the stroke risks in partial white-coat hypertension (either home or ambulatory normotension with office hypertension), complete masked hypertension (both home and ambulatory hypertension with office normotension), partial masked hypertension (either home or ambulatory hypertension with office normotension), and sustained hypertension were >2× higher than those in the sustained normal blood pressure group.
No significant difference in stroke risk between complete white-coat hypertension group and sustained normal blood pressure group was observed.
What Is Relevant?
Both home and 24-h ambulatory blood pressure measurements are necessary to detect partial white-coat hypertension and partial masked hypertension.
Summary
The present study demonstrated that impacts of partial white-coat hypertension as well as partial masked hypertension for long-term stroke risk were comparable to those of complete masked hypertension or sustained hypertension. We need both home and 24-h ambulatory blood pressure measurements to evaluate stroke risk accurately.
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