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ESC/ESH Guidelines 17

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4.6 Advantages and disadvantages of . . . elevated when measured by HBPM or ABPM. The term ‘true nor-
ambulatory blood pressure monitoring . . . . motension’ is used when both office and out-of-office BP measure-
and home blood pressure monitoring . . . ments are normal, and ‘sustained hypertension’ is used when both
are abnormal. In white-coat hypertension, the difference between
A major advantage of both ABPM and HBPM is that they enable the . . . the higher office and the lower out-of-office BP is referred to as the
diagnosis of white-coat and masked hypertension (see section 4.7). . . . ‘white-coat effect’, and is believed to mainly reflect the pressor
The relative advantages and disadvantages of HBPM and ABPM are . . . . response to an alerting reaction elicited by office BP measurements
shown in Table 10. A particularly important advantage of HBPM is . . . by a doctorora nurse, 82 although other factors are probably also
that it is much cheaper and thus more available than ABPM. Another . . . involved. 83
is that it provides multiple measurements over several days or even . . . Although the terms white-coat and masked hypertension were
longer periods, which is clinically relevant because day-to-day BP vari- . . . originally defined for people who were not being treated for hyper-
ability may have an independent prognostic value. 79 Unlike ABPM, . . . tension, they are now also used to describe discrepancies between
typical HBPM devices do not provide BP measurements during rou- . . . office and out-of-office BP in patients treated for hypertension, with
tine daily activities and during sleep, although recent technical advan- . . . the terms masked uncontrolled hypertension (MUCH) (office BP
ces may allow BP during sleep to be measured by HBPM. A further . . . controlled but home or ambulatory BP elevated) and white-coat
consideration is the potential impact of impaired cognition on the . . . uncontrolled hypertension (WUCH) (office BP elevated but home
reliability of HBPM measurements and rare instances of obsessional . . . or ambulatory BP controlled), compared with sustained uncontrolled
behaviour, circumstances that may favour the use of ABPM if out-of- . . 84
. . hypertension (SUCH) (both office and home or ambulatory BP are
office BP readings are required. In general, both methods should be . . uncontrolled).
regarded as complementary rather than absolute alternatives. . . . The white-coat effect is used to describe the difference between
Despite the advances in out-of-office BP measurement over the . . . an elevated office BP (treated or untreated) and a lower home or
past 50 years, some fundamental questions remain, the most impor- . . . ambulatory BP in both untreated and treated patients.
tant of which is whether HBPM- or ABPM-guided therapy results in . . .
greater reductions in morbidity and mortality than conventional . . .
office BP-guided treatment, which has been the diagnostic strategy . . . 4.7.1 White-coat hypertension
for all clinical outcome trials. . . . . . Although the prevalence varies between studies, white-coat hyper-
tension can account for up to 30- 40% of people (and >50% in the

4.7 White-coat hypertension and masked . . . . . very old) with an elevated office BP. It is more common with increas-
ing age, in women, and in non-smokers. Its prevalence is lower in
hypertension . . . . patients with HMOD, when office BP is based on repeated measure-
White-coat hypertension refers to the untreated condition in which . . . . ments, or when a doctor is not involved in the BP measurement. A
BP is elevated in the office, but is normal when measured by ABPM, . . . significant white-coat effect can be seen at all grades of hypertension
HBPM, or both. 80 Conversely, ‘masked hypertension’ refers to . . . (including resistant hypertension), but the prevalence of white-coat
untreated patients in whom the BP is normal in the office, but is . hypertension is greatest in grade 1 hypertension.

Table 10 Comparison of ambulatory blood pressure monitoring and home blood pressure monitoring

ABPM HBPM
Advantages Advantages
• Can identify white-coat and masked hypertension • Can identify white-coat and masked hypertension
• Stronger prognostic evidence • Cheap and widely available
• Night-time readings • Measurement in a home setting, which may be more relaxed than
• Measurement in real-life settings the doctor’s office
• Additional prognostic BP phenotypes • Patient engagement in BP measurement
• Abundant information from a single measurement session, including • Easily repeated and used over longer periods to assess day-to-day BP
short-term BP variability variability
Disadvantages Disadvantages
• Expensive and sometimes limited availability • Only static BP is available
• Can be uncomfortable • Potential for measurement error
• No nocturnal readings a

ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.
a
Techniques are being developed to enable nocturnal BP measurement with home BP devices.

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