Abstract P114: White Coat Effect is Common Among Stroke Survivors

Background and Purpose: Among stroke survivors, uncontrolled hypertension is a major risk factor for recurrent stroke. Blood pressure (BP) medication titration often relies on office BP measures, which may be inaccurate due to the white coat effect (WCE). We sought to determine the prevalence of the WCE in stroke survivors and to determine whether clinical and demographic factors were associated with WCE. Methods: We followed ischemic and hemorrhagic stroke and transient ischemic attack patients with prior hypertension presenting to our stroke clinic for a BP study. Sitting BP was obtained by a medical assistant using an office automated BP machine (OABP). Patients also underwent BP measurement using BPtru, an automated machine that measures and averages five BPs with the patient alone in a room. BPtru approximate BPs obtained by the gold standard ambulatory blood pressure machine. Systolic BP (SBP) obtained by BPtru was subtracted from that obtained by OABP. WCE was defined as SBP difference ≥ 10mmHg. Uncontrolled BP was defined as SBP ≥ 135 mmHg by BPtru or ≥ 140 mmHg by OABP. We used student t-tests (continuous) and chi-squared or Fischer’s exact tests (categorical) for univariate analyses. Results: Of 94 patients, mean age was 60 (SD 12), 60.6% were male, 26.6% were Non-Hispanic White, 46.8% were Black, and 23.4% were Hispanic. Systolic OABP was 13.2 mmHg (SD 19.3) higher than BPtru SBP (student t-test; p <0.001). WCE was present in 58.5 % of participants and BP was misclassified as uncontrolled in 21.2%. In univariate analyses, age (p = 0.14), sex (p = 0.78), race (0.07), stroke type (0.92), body mass index (p = 0.65), and tobacco use (p = 0.35) were not significantly associated with presence of WCE. The presence of normal SBP by OABP was associated with a decreased likelihood of WCE (p = 0.006). Conclusions: Among hypertensive stroke patients following in a clinic, WCE was highly prevalent and one-fifth of patients were misclassified as uncontrolled. Neither race nor other previously described predictors of WCE were associated with WCE in this study. Our findings suggest that in patients with elevated office BP, findings should be confirmed with an automated machine like BPtru in order to avoid over-titration of medication or incorrect assessment of BP control.

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Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White-Coat Effect and Masked Uncontrolled Hypertension

Hypertension ◽

10.1161/hypertensionaha.120.15300 ◽

2020 ◽

Vol 76 (4) ◽

pp. 1090-1096

Author(s):

Lama Ghazi ◽

Laura P. Cohen ◽

Paul Muntner ◽

Daichi Shimbo ◽

Paul E. Drawz

Keyword(s):

Blood Pressure ◽

White Coat ◽

Uncontrolled Hypertension ◽

Similar Proportion ◽

Hypertension Treatment ◽

Intervention Trial ◽

Treatment Groups ◽

Ancillary Study ◽

White Coat Effect ◽

Ambulatory Bp Monitoring

Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal <140/90 mm Hg has been reported. However, the prevalence of these phenotypes when targeting an office systolic/diastolic BP goal <120/80 is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory BP Ancillary study evaluated out-of-office BP using ambulatory BP monitoring in 897 participants 27 months after randomization to intensive versus standard BP targets (office systolic BP <120 versus <140 mm Hg). We used office and daytime BP to assess the proportion of participants with white-coat effect (standard target: office BP ≥140/90 mm Hg and daytime BP <135/85 mm Hg versus intensive target: office BP ≥120/80 mm Hg and daytime BP <120/80 mm Hg) and masked uncontrolled hypertension (standard target: office BP <140/90 mm Hg and daytime BP ≥135/85 mm Hg versus intensive target: office BP <120/80 mm Hg and daytime BP ≥120/80 mm Hg) in each treatment arm. The prevalence of white-coat effect and masked uncontrolled hypertension was 9% and 34%, in both treatment groups. Among participants with uncontrolled office BP, white-coat effect was present in 20% and 23% in the intensive and standard groups, respectively. Among participants with controlled office BP, masked uncontrolled hypertension was present in 62% and 56% in the intensive and standard groups, respectively. In conclusion, a more intensive BP target resulted in a similar proportion of patients with white-coat effect and masked uncontrolled hypertension compared with a standard target.

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The white-coat effect is associated with increased blood pressure reactivity to physical activity

Blood Pressure Monitoring ◽

10.1097/00126097-200208000-00002 ◽

2002 ◽

Vol 7 (4) ◽

pp. 209-213 ◽

Cited By ~ 10

Author(s):

Andrew C. Leary ◽

Peter T. Donnan ◽

Thomas M. MacDonald ◽

Michael B. Murphy

Keyword(s):

Physical Activity ◽

Blood Pressure ◽

White Coat ◽

Blood Pressure Reactivity ◽

White Coat Effect ◽

Pressure Reactivity

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Examining the effectiveness of telemonitoring with routinely acquired blood pressure data in primary care: challenges in the statistical analysis

BMC Medical Research Methodology ◽

10.1186/s12874-021-01219-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Richard A. Parker ◽

Paul Padfield ◽

Janet Hanley ◽

Hilary Pinnock ◽

John Kennedy ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Statistical Analysis ◽

Propensity Score ◽

Random Coefficient ◽

White Coat ◽

White Coat Effect ◽

Regression Adjustment ◽

The Impact

Abstract Background Scale-up BP was a quasi-experimental implementation study, following a successful randomised controlled trial of the roll-out of telemonitoring in primary care across Lothian, Scotland. Our primary objective was to assess the effect of telemonitoring on blood pressure (BP) control using routinely collected data. Telemonitored systolic and diastolic BP were compared with surgery BP measurements from patients not using telemonitoring (comparator patients). The statistical analysis and interpretation of findings was challenging due to the broad range of biases potentially influencing the results, including differences in the frequency of readings, ‘white coat effect’, end digit preference, and missing data. Methods Four different statistical methods were employed in order to minimise the impact of these biases on the comparison between telemonitoring and comparator groups. These methods were “standardisation with stratification”, “standardisation with matching”, “regression adjustment for propensity score” and “random coefficient modelling”. The first three methods standardised the groups so that all participants provided exactly two measurements at baseline and 6–12 months follow-up prior to analysis. The fourth analysis used linear mixed modelling based on all available data. Results The standardisation with stratification analysis showed a significantly lower systolic BP in telemonitoring patients at 6–12 months follow-up (-4.06, 95% CI -6.30 to -1.82, p < 0.001) for patients with systolic BP below 135 at baseline. For the standardisation with matching and regression adjustment for propensity score analyses, systolic BP was significantly lower overall (− 5.96, 95% CI -8.36 to − 3.55 , p < 0.001) and (− 3.73, 95% CI− 5.34 to − 2.13, p < 0.001) respectively, even after assuming that − 5 of the difference was due to ‘white coat effect’. For the random coefficient modelling, the improvement in systolic BP was estimated to be -3.37 (95% CI -5.41 to -1.33 , p < 0.001) after 1 year. Conclusions The four analyses provide additional evidence for the effectiveness of telemonitoring in controlling BP in routine primary care. The random coefficient analysis is particularly recommended due to its ability to utilise all available data. However, adjusting for the complex array of biases was difficult. Researchers should appreciate the potential for bias in implementation studies and seek to acquire a detailed understanding of the study context in order to design appropriate analytical approaches.

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Abstract P634: The Influence Of Virtual Learning Environment On Therapy Adherence And On The White Coat Effect

Hypertension ◽

10.1161/hyp.66.suppl_1.p634 ◽

2015 ◽

Vol 66 (suppl_1) ◽

Author(s):

Isabela R Fistarol ◽

Chao L Wen ◽

Luiz Bortolotto ◽

Margarida Vieira ◽

Miriam Tsunemi ◽

...

Keyword(s):

Quality Of Life ◽

Blood Pressure ◽

Educational Technology ◽

Learning Environment ◽

Statistical Difference ◽

Virtual Learning Environment ◽

White Coat ◽

Study Group ◽

White Coat Effect

Systemic arterial hypertension is a risk factor for cardiovascular diseases and has become a common public health problem. Health education associated with educational technology may be used to encourage patients’ adherence to treatment and enable them to adequately understand how harmful hypertension can be to health, thereby promoting their quality of life. OBJECTIVE: To evaluate the influence of a strategy in an individual orientation program using educational technology associated with virtual learning environment (VLE) of hypertension care on the reduction in the white coat effect and the improvement in blood pressure control to be promoted by a nurse in a hypertension unit in a government state hospital in São Paulo. METHODS AND MATERIALS:This was a randomized clinical education study conducted with two groups, the VLE group (study group, 10 patients) and the control group (16 patients). Both groups were interviewed 6 times by nurses during the 120-day follow-up at 20-day intervals. At baseline (randomization) and at the end of the study, the patients took Spielberg’s State-Trait Anxiety Inventory (STAI), the Morisky test, and the WHOQOL, a quality of life instrument, and had their blood pressure taken (ambulatory blood pressure monitoring [ABPM]). Both groups had their blood pressure, weight, and abdominal circumference measured. Only the study group had remote access to the VLE. This consisted of 6 specific educational modules, each released according to the encounter number. RESULTS: At baseline, there were no statistical differences between the two groups with respect to the sociodemographic and hemodynamic variables. At the end of the study, there was a significant statistical difference between the groups on the Morisky test (p=0.001) and on the WHOQOL with respect to domain 3 social (p=0.001). There was no statistical difference with respect to the white coat effect between the groups. Nor was there any statistical difference between the groups with respect to the association of the anxiety degree measured by STAI and the white coat effect.CONCLUSION: In light of the results, our strategy improved the quality of life in the social domain and changed the adherence behavior of the study group in relation to the forgetfulness of medication schedules.

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Abstract 17130: Variables Associated With Uncontrolled Blood Pressure Early After Stroke

Circulation ◽

10.1161/circ.138.suppl_1.17130 ◽

2018 ◽

Vol 138 (Suppl_1) ◽

Author(s):

Saviour Achilike ◽

Austin Wang ◽

Gabretta Cooksey ◽

Evelyn Hinojosa ◽

Munachi Okpala ◽

...

Keyword(s):

Blood Pressure ◽

Logistic Regression ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Uncontrolled Blood Pressure ◽

Factors Associated ◽

Multivariable Analyses ◽

Medication Complexity ◽

Ischemic Attack

Introduction: Uncontrolled blood pressure (BP) is a major risk factor for recurrent stroke; however, up to 50% of stroke survivors have uncontrolled BP 6 months after stroke. Characterization of factors associated with uncontrolled BP early after stroke discharge (DC) may help to identify patients for BP interventions. Hypothesis: We sought to identify factors associated with uncontrolled BP in the first month after stroke discharge. We hypothesized that African American (AA) race, insurance status, medication complexity, and hospital BP prior to discharge would be associated with uncontrolled BP. Methods: We identified hypertensive patients with ischemic or hemorrhagic stroke or transient ischemic attack scheduled to follow-up in the stroke clinic 2 to 4 weeks after hospital DC. Office BP was obtained using BpTRU, an automated machine that averages five unattended BP measures. Uncontrolled BP was defined using 2017 American College of Cardiology Guidelines as BP ≥ 130/80 mmHg. We used univariate logistic regression to assess relationships between uncontrolled BP and selected variables. Variables with statistically significant associations in the univariate models and variables associated with uncontrolled BP in the literature were included in the multiple logistic regression model. Results: Of the 230 patients identified, 55.7% had uncontrolled BP at clinic follow-up. In univariate and multivariable analyses, AA race, young stroke (age < 50), and systolic BP (SBP) 24-hours prior to DC were significantly associated with uncontrolled BP early after stroke DC. BP medication complexity was not associated with uncontrolled BP in this study. Conclusions: AA race, young age, and elevate SBP in the 24 hours prior to of stroke DC were associated with uncontrolled BP early after stroke. These variables can be used to identify patients who may benefit from early interventions aimed at reducing the risk of uncontrolled BP after stroke and stroke recurrence.

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Abstract P132: Clinical Outcomes In Ischemic Stroke Patients With Uncontrolled Hypertension

Hypertension ◽

10.1161/hyp.78.suppl_1.p132 ◽

2021 ◽

Vol 78 (Suppl_1) ◽

Author(s):

Zahra Abuzaid ◽

Sara Almuslem ◽

Farah Aleisa

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Clinical Outcomes ◽

Recurrent Stroke ◽

Uncontrolled Hypertension ◽

Stroke Recurrence ◽

Stroke Patients ◽

Stroke Event ◽

Uncontrolled Blood Pressure

Background: Hypertension is considered major risk factor for incidence of ischemic stroke, controlling blood pressure reduces this risk, the relationship of uncontrolled blood pressure and stroke outcomes is complex, post stroke uncontrolled blood pressure remains one of the major contributing factors for stroke recurrence and mortality, in our study we studied the long term effects of uncontrolled hypertension in modern health care setting. Methodology: Patients in the study were admitted to the neurology department at KFSH-D between March 2015- August 2019, we included 102 acute ischemic stroke patients whom had hypertension, all patients had follow up appointments at stroke clinic a minimum of 2 visits over 4 years. We retrospectively compared blood pressure data from stroke patients with recurrent ischemic stroke events vs. patients with initial stroke event, and recurrent stroke, also we studied blood pressure readings for different stroke severity groups, patients who had severe stroke with mRS>4, compared to milder stroke group of mRS<4. Results: We found 48 patients identified with recurrent stroke event, those with uncontrolled hypertension had significantly higher stroke recurrence events (P=0.002), despite acute stroke treatment, patients who had history of uncontrolled hypertension were found to have more severe stroke deficits than those who had controlled blood pressure (P=0.029). We found significant difference in the long term stroke clinical outcomes between patients who had uncontrolled blood pressure and patients who had controlled blood pressure recordings within the same hospital setting (P=0.064). Conclusion: Based on our findings, uncontrolled hypertension was associated with higher risk of stroke recurrence, it also increased susceptibility to worse stroke clinical outcomes up to 1 year after initial stroke event, which deserved further close attention and better blood pressure control.

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Abstract P198: Clinic versus Out-of-Clinic Daytime Blood Pressure Among Older Adults: Data From the Jackson Heart Study

Circulation ◽

10.1161/circ.131.suppl_1.p198 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Rikki M Tanner ◽

Daichi Shimbo ◽

Samantha Seals ◽

Gbenga Ogedegbe ◽

Paul Muntner

Keyword(s):

Blood Pressure ◽

Older Adults ◽

Blood Pressure Monitoring ◽

White Coat ◽

Older Individuals ◽

Jackson Heart Study ◽

Large White ◽

Younger Adults ◽

White Coat Effect ◽

Heart Study

In the US, antihypertensive medication treatment decisions are primarily based on blood pressure (BP) measurements obtained in the clinic setting. The optimal systolic BP (SBP) goal for adults ≥60 years is controversial and a large difference between clinic and out-of-clinic daytime BP, a white-coat effect, may be present in older individuals. We estimated the white-coat effect and calculated the percentage of untreated and treated adults <60 and ≥60 years with elevated clinic BP (defined as SBP/diastolic BP [DBP] ≥140/90 mmHg), but non-elevated out-of-clinic daytime BP (“daytime BP”, defined as SBP/DBP <135/85 mmHg) among 257 African-American participants in the Jackson Heart Study with at least 10 daytime ambulatory BP measurements. For the overall population, the white-coat effect for SBP was 12.2 mmHg (95% confidence interval [CI]: 9.2-15.1) in older adults and 8.4 mmHg (95% CI: 5.7-11.1) in younger adults (p=0.06). After multivariable (MV) adjustment, this difference was 1.3 mmHg. Among those without diabetes or chronic kidney disease (CKD), the white coat effect for SBP was 15.2 mmHg (95% CI: 10.1-20.2) and 8.6 mmHg (95% CI: 5.0-12.3) for older and younger adults, respectively (p=0.04). After MV adjustment, this difference was 5.9 mmHg. Also, SBP ≥150 mmHg versus <150 mm Hg was associated with a larger white-coat effect in the overall population after MV adjustment. Among those without CKD or diabetes, older age and SBP ≥150 mmHg were associated with a larger white-coat effect after MV adjustment. Among younger and older participants with elevated clinic BP, the prevalence of non-elevated daytime BP was 34% (95% CI: 26%-44%) and 32% (95% CI: 24%-40%), respectively (p=0.64), in the overall population and 35% (95% CI: 24%-48%) and 43% (95% CI: 31%-56%), respectively, for those without CKD or diabetes (p=0.37). In conclusion, a large white-coat effect was present among older adults. These data suggest a role for ambulatory blood pressure monitoring in preventing potential over-treatment for hypertension among older adults.

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Hypertension Subtypes among Thai Hypertensives: An Analysis of Telehealth-Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project

International Journal of Hypertension ◽

10.1155/2020/3261408 ◽

2020 ◽

Vol 2020 ◽

pp. 1-9

Author(s):

Sakolwat Montrivade ◽

Pairoj Chattranukulchai ◽

Sarawut Siwamogsatham ◽

Yongkasem Vorasettakarnkij ◽

Witthawat Naeowong ◽

...

Keyword(s):

Blood Pressure ◽

Blood Pressure Monitoring ◽

Demographic Data ◽

Real Life ◽

Antihypertensive Agents ◽

Home Blood Pressure ◽

White Coat ◽

White Coat Hypertension ◽

Routine Practice ◽

White Coat Effect

Background. White-coat hypertension (HT), masked HT, HT with white-coat effect, and masked uncontrolled HT are well-recognized problems of over- and undertreatment of high blood pressure in real-life practice. However, little is known about the true prevalence in Thailand. Objectives. To examine the prevalence and characteristics of each HT subtype defined by mean home blood pressure (HBP) and clinic blood pressure (CBP) using telemonitoring technology in Thai hypertensives. Methods. A multicenter, observational study included adult hypertensives who had been diagnosed for at least 3 months based on CBP without the adoption of HBP monitoring. All patients were instructed to manually measure their HBP twice a day for the duration of at least one week using the same validated automated, oscillometric telemonitoring devices (Uright model TD-3128, TaiDoc Corporation, Taiwan). The HBP, CBP, and baseline demographic data were recorded on the web-based system. HT subtypes were classified according to the treatment status, CBP (≥or <140/90 mmHg), and mean HBP (≥or <135/85 mmHg) into the following eight subtypes: in nonmedicated hypertensives, there are four subtypes that are normotension, white-coat HT, masked HT, and sustained HT; in treated hypertensives, there are four subtypes that are well-controlled HT, HT with white-coat effect, masked uncontrolled HT, and sustained HT. Results. Of the 1,184 patients (mean age 58 ± 12.7 years, 59% women) from 46 hospitals, 1,040 (87.8%) were taking antihypertensive agents. The majority of them were enrolled from primary care hospitals (81%). In the nonmedicated group, the prevalence of white-coat and masked HT was 25.7% and 7.0%, respectively. Among the treated patients, the HT with white-coat effect was found in 23.3% while 46.7% had uncontrolled HBP (a combination of the masked uncontrolled HT (9.6%) and sustained HT (37.1%)). In the medicated older subgroup (n = 487), uncontrolled HBP was more prevalent in male than in female (53.6% vs. 42.4%, p=0.013). Conclusions. This is the first nationwide study in Thailand to examine the prevalence of HT subtypes. Almost one-fourth had white-coat HT or HT with white-coat effect. Approximately half of the treated patients especially in the older males had uncontrolled HBP requiring more intensive interventions. These results emphasize the role of HBP monitoring for appropriate HT diagnosis and management. The cost-effectiveness of utilizing THAI HBPM in routine practice needs to be examined in the future study.

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P803Automatic measurement of blood pressure for one hour in the clinic predicts results of 24-hour ABPM in elderly hypertensive patients

European Heart Journal ◽

10.1093/eurheartj/ehz747.0402 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

B S Stender ◽

J Stender

Keyword(s):

Blood Pressure ◽

White Coat ◽

White Coat Hypertension ◽

Waiting Room ◽

General Applicability ◽

Non Invasive ◽

White Coat Effect ◽

Disturbed Sleep ◽

Elderly Hypertensive

Abstract Introduction The gold standard in non-invasive assessment of blood pressure (BP) is 24-hour ambulatory BP measurement (24h-ABPM) due to frequent “office-” or “white coat hypertension” effects by measurement in the clinic. But 24h-ABPM is demanding, patients may report discomfort and stress from disturbed sleep. We compared BP measured automatically during one hour (1h-BP) in the waiting room of our clinic with that of 24h-ABPM among elderly hypertensives. Our aim was to investigate whether this less stressful procedure may replace 24h-ABPM in the outpatient follow-up of hypertensives. Hypotheses I) Mean diastolic and systolic BP values measured during one hour in a clinic equal those obtained by 24h-ABPM. II) The minimal BP during 1h-BP measurement equals mean 24h-BP during sleep. Material and methods The population comprised patients referred with known or suspected hypertension. Office BP was measured with Omron M7 Intelli IT. An ABPM apparatus reprogrammed to every 5 min. for one hour was mounted, and 1h-BP was obtained with the patient seated in the waiting room. 24h-ABPM was then performed at home. 110 patients were considered, 11 were excluded due to reported pain, stress or changes of medication, leaving 99 (m/f 32/66, age (SD) 70 (11)) for analysis. Sample size was set in a pilot study by a=0.05, b=0.05, effect size of BP differences systolic 5 (SD 13) and diastolic 3 (SD 8) mmHg. Results were analyzed with Student's paired t-test. Results We found a significant BP drop from office- to 1h- and 24h- BP measurements, i.e. a “white coat” effect. However, mean systolic 1h-BP and mean systolic 24h-BP did not differ, neither did minimal systolic 1h-BP and mean systolic 24h-BP during sleep. Mean diastolic 1h-BP was 4 mm Hg higher than that of 24h-ABPM, and minimal diastolic 1h-BP was 4 mmHg higher than mean diastolic 24h-BP during sleep. mmHg avg (SD) Office-BP 1h-BP mean 24h-BP mean 1h-BP minimum 24h-BPs mean during sleep Systolic 155 (18) 136 (13)* 135 (11)* 127 (12) 127 (13) Diastolic 90 (11) 80 (9)* 76 (8)* 74 (9) 70 (7) *“White-coat effect” significant in comparison with office-BP. No difference between mean systolic 1h-BP and mean systolic 24h-BP, p=0.67. No difference between mean diastolic 1h-BP minus 4 and mean diastolic 24h-BP, p=0.92. No difference between systolic 1h-BP minimum and mean systolic 24h-BP during sleep, p=0.65. Conclusion BP measurement for one hour in the waiting room by an ABPM apparatus may provide sufficient elimination of “office-” or “white coat effects” to replace 24h-ABPM in selected instances. The finding should be challenged in different clinical subpopulations to ensure general applicability.

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