Editorial comment
Pulse wave velocity, central aortic pressure, and arterial reflection waves in white coat hypertension
A velocidade de onda de pulso, pressão aórtica central e ondas refletidas retrógradas na hipertensão da bata branca
José Mesquita Bastos
Serviço de Cardiologia, Centro Hospitalar do Baixo Vouga, Hospital Infante D. Pedro, Aveiro, Portugal
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Pedro, Aveiro, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A velocidade de onda de pulso, pressão aórtica central e ondas refletidas retrógradas na hipertensão da bata branca" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">White coat hypertension (WCH) is defined as office blood pressure (BP) of >140/90 mmHg but otherwise normal BP in untreated individuals.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1–6</span></a> BP is assessed ideally by ambulatory BP monitoring (ABPM), by self-measurement on at least three occasions, and more than once by office measurement. WCH, first described by Pickering in the 1980s,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> should not be confused with the white coat effect or alerting reaction,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> a rise in BP in the presence of a physician that occurs in normotensives as well as hypertensives, irrespective of whether they are under antihypertensive therapy.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For many authors, the alerting reaction and WCH are expressions of the same pathophysiological phenomenon.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10–12</span></a> They are distinguished in two ways. Firstly, the mechanism behind the alerting reaction may not be the same as that underlying WCH, as pointed out by Pickering, who suggested that the alerting reaction may be an adaptive physiological response by the sympathetic nervous system.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> Secondly, WCH is only found in untreated individuals.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In their study published in this issue of the <span class="elsevierStyleItalic">Journal</span>, Almeida et al.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> restrict the diagnosis of WCH to untreated individuals. The requirement for subjects to be untreated removes some of the confusion surrounding the interpretation of study results by excluding individuals defined as having “false-resistant hypertension in treated patients” in the European guidelines,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,2</span></a> who in some studies are classified as having WCH.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14–18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In pathophysiological terms, it is likely that in normotensive individuals who present high BP only when visiting their physician or at other times of stress (white coat hypertensives) the intrinsic mechanisms that regulate BP will be different from those in hypertensives, even those whose hypertension is controlled by medication and who have high BP in the physician's office. The patient's history of hypertension and comorbidities also need to be taken into account.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The cross-sectional study by Almeida et al. is the first to compare normotensives, white coat hypertensives and hypertensives, matched for age, gender and body mass index (BMI), in terms of pulse wave velocity, aortic stiffness index and data on central pressures including arterial wave reflections. It is also the first study to extend the diagnostic criteria for WCH to nocturnal BP, previous works having considered only daytime BP on ABPM.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,12</span></a> It further specified that hypertensives should have been under antihypertensive therapy for at least six months and should have their BP controlled according to ABPM.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Including nocturnal BP in the definition of WCH increases diagnostic rigor by covering the period with greatest prognostic significance for cardiovascular events<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> and effectively excluding individuals who may have elevated BP only at night (isolated nocturnal hypertension). Furthermore, careful matching for age, gender and BMI reduces the bias inherent in interpreting results from groups that differ significantly in these respects.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,20–23</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However, it would have improved the analysis if information had been provided on the severity and history of hypertension in the hypertensive group and on comorbidities including diabetes, dyslipidemia and smoking in all three groups, since these factors can influence arterial distensibility.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,24,25</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In their discussion, the authors highlight the controversy in the literature concerning the prognostic value of WCH. The conflicting results reported are at least partly due to the inclusion of white coat hypertensives and false-resistant hypertensives in the same sample.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12,26,27</span></a> However, having removed this source of confusion, Almeida et al. clearly showed that indices of arterial stiffness, central pressures and wave reflection in white coat hypertensives do not differ significantly from normotensives and are lower than in hypertensives. Similar results were found when white coat hypertensives were divided into two subgroups according to systolic BP on ABPM (<120 mmHg and 120-129 mmHg), indicating that WCH may be a relatively benign condition compared to hypertension.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pulsatile components of the aortic pressure wave are in fact important predictors of cardiovascular events.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">28–30</span></a> Wimmer et al.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> compared central aortic BP assessed by applanation tonometry in normotensives and white coat hypertensives, the latter having higher central aortic pressures, suggesting increased cardiovascular risk in WCH. It should, however, be noted that the white coat hypertensives were an average of 10 years older than the normotensives in this study.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a longitudinal study with a 15-year follow-up, Sung et al.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> compared pre-hypertension, WCH and sustained hypertension, but once again the white coat hypertensives were 10 years older than the hypertensives. They highlighted two points: arterial aging is one of the main determinants of WCH; and the severity of WCH may depend on the magnitude of wave reflections. With regard to the first point, in a cohort study in two cities in northern Portugal, Cunha et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> found high mean pulse wave velocities using normal European reference values as comparators, particularly in younger individuals, reflecting early arterial aging associated with more severe comorbidities. Concerning the second point, increased arterial wave reflections have been associated with the presence of target organ damage and increased cardiovascular mortality, unlike the relatively normal wave reflection data in WCH. Analysis of Kaplan-Meier event-free survival curves clearly reveals a sharp difference between weak and strong arterial wave reflections. According to the authors, assessment of wave reflections can thus predict cardiovascular prognosis in WCH.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Almeida et al. found a relatively benign profile of aortic stiffness and central pressures in white coat hypertensives compared to hypertensives, suggesting weaker wave reflections. This cross-sectional study is the first to compare white coat hypertensives, hypertensives and normotensives in which the diagnostic criteria for WCH and hypertension included nocturnal BP values, which have the greatest cardiovascular prognostic value.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Further longitudinal studies with greater statistical power are needed to confirm whether WCH is as benign as suggested in this study.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mesquita Bastos J. A velocidade de onda de pulso, pressão aórtica central e ondas refletidas retrógradas na hipertensão da bata branca. Rev Port Cardiol. 2016;35:569–571.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Mancia" 1 => "R. Fagard" 2 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 39 | 31 | 70 |
| 2024 September | 46 | 20 | 66 |
| 2024 August | 64 | 34 | 98 |
| 2024 July | 42 | 22 | 64 |
| 2024 June | 36 | 22 | 58 |
| 2024 May | 40 | 30 | 70 |
| 2024 April | 30 | 22 | 52 |
| 2024 March | 30 | 15 | 45 |
| 2024 February | 31 | 24 | 55 |
| 2024 January | 20 | 23 | 43 |
| 2023 December | 27 | 27 | 54 |
| 2023 November | 28 | 26 | 54 |
| 2023 October | 22 | 13 | 35 |
| 2023 September | 17 | 23 | 40 |
| 2023 August | 25 | 20 | 45 |
| 2023 July | 21 | 12 | 33 |
| 2023 June | 24 | 12 | 36 |
| 2023 May | 41 | 23 | 64 |
| 2023 April | 24 | 6 | 30 |
| 2023 March | 37 | 17 | 54 |
| 2023 February | 28 | 24 | 52 |
| 2023 January | 22 | 18 | 40 |
| 2022 December | 30 | 22 | 52 |
| 2022 November | 68 | 31 | 99 |
| 2022 October | 26 | 21 | 47 |
| 2022 September | 55 | 22 | 77 |
| 2022 August | 62 | 32 | 94 |
| 2022 July | 49 | 34 | 83 |
| 2022 June | 68 | 19 | 87 |
| 2022 May | 34 | 31 | 65 |
| 2022 April | 38 | 21 | 59 |
| 2022 March | 32 | 32 | 64 |
| 2022 February | 37 | 35 | 72 |
| 2022 January | 33 | 23 | 56 |
| 2021 December | 20 | 23 | 43 |
| 2021 November | 40 | 33 | 73 |
| 2021 October | 47 | 35 | 82 |
| 2021 September | 18 | 25 | 43 |
| 2021 August | 31 | 35 | 66 |
| 2021 July | 21 | 25 | 46 |
| 2021 June | 25 | 20 | 45 |
| 2021 May | 36 | 42 | 78 |
| 2021 April | 41 | 37 | 78 |
| 2021 March | 44 | 22 | 66 |
| 2021 February | 87 | 19 | 106 |
| 2021 January | 42 | 11 | 53 |
| 2020 December | 40 | 12 | 52 |
| 2020 November | 38 | 22 | 60 |
| 2020 October | 34 | 16 | 50 |
| 2020 September | 65 | 17 | 82 |
| 2020 August | 22 | 15 | 37 |
| 2020 July | 61 | 10 | 71 |
| 2020 June | 31 | 9 | 40 |
| 2020 May | 50 | 12 | 62 |
| 2020 April | 50 | 8 | 58 |
| 2020 March | 52 | 12 | 64 |
| 2020 February | 69 | 19 | 88 |
| 2020 January | 31 | 9 | 40 |
| 2019 December | 46 | 5 | 51 |
| 2019 November | 48 | 8 | 56 |
| 2019 October | 38 | 5 | 43 |
| 2019 September | 31 | 9 | 40 |
| 2019 August | 38 | 6 | 44 |
| 2019 July | 42 | 12 | 54 |
| 2019 June | 35 | 12 | 47 |
| 2019 May | 43 | 7 | 50 |
| 2019 April | 22 | 12 | 34 |
| 2019 March | 32 | 8 | 40 |
| 2019 February | 62 | 14 | 76 |
| 2019 January | 20 | 3 | 23 |
| 2018 December | 101 | 10 | 111 |
| 2018 November | 76 | 5 | 81 |
| 2018 October | 159 | 20 | 179 |
| 2018 September | 67 | 13 | 80 |
| 2018 August | 27 | 10 | 37 |
| 2018 July | 32 | 6 | 38 |
| 2018 June | 37 | 8 | 45 |
| 2018 May | 36 | 17 | 53 |
| 2018 April | 43 | 6 | 49 |
| 2018 March | 60 | 16 | 76 |
| 2018 February | 18 | 1 | 19 |
| 2018 January | 30 | 10 | 40 |
| 2017 December | 59 | 15 | 74 |
| 2017 November | 66 | 13 | 79 |
| 2017 October | 48 | 10 | 58 |
| 2017 September | 45 | 18 | 63 |
| 2017 August | 45 | 8 | 53 |
| 2017 July | 39 | 19 | 58 |
| 2017 June | 49 | 28 | 77 |
| 2017 May | 47 | 16 | 63 |
| 2017 April | 30 | 9 | 39 |
| 2017 March | 39 | 20 | 59 |
| 2017 February | 38 | 10 | 48 |
| 2017 January | 37 | 13 | 50 |
| 2016 December | 74 | 30 | 104 |
| 2016 November | 79 | 37 | 116 |
| 2016 October | 33 | 8 | 41 |
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