Page 18 - GUIAS ESC ESH 2018

18 ESC/ESH Guidelines

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HMOD is less prevalent in white-coat hypertension than in sus- . . . BP should be remeasured at least every 3 years. Patients with
tained hypertension, and recent studies show that the risk of cardio- . . . high–normal BP (130–139/85–89 mmHg) should have their BP
vascular events associated with white-coat hypertension is also lower . . . recorded annually because of the high rates of progression of
than that in sustained hypertension. 68,85,86 Conversely, compared . . . high–normal BP to hypertension. This is true also for people in
with true normotensives, patients with white-coat hypertension have . . . whom masked hypertension is detected.
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increased adrenergic activity, a greater prevalence of metabolic risk . . .
factors, more frequent asymptomatic cardiac and vascular damage, . . .
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and a greater long-term risk of new-onset diabetes and progression . 4.9 Confirming the diagnosis of
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to sustained hypertension and LVH. 82 In addition, although the out- . . hypertension
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of-office BP values are, by definition, normal in white-coat hyperten- . . . BP can be highly variable, thus the diagnosis of hypertension should
sion, they tend to be higher than those of true normotensive people, . . . not be based on a single set of BP readings at a single office visit,
which may explain the increased long-term risk of CV events . . . unless the BP is substantially increased (e.g. grade 3 hypertension)
reported in white-coat hypertension by recent studies after adjust- . . . and there is clear evidence of HMOD (e.g. hypertensive retinopathy
ment for demographic and metabolic risk factors. 85,86,88–90 White- . . . with exudates and haemorrhages, or LVH, or vascular or renal dam-
coat hypertension has also been shown to have a greater CV risk in . . . . age). For all others (i.e. almost all patients), repeat BP measurements
isolated systolic hypertension and older patients, 91 and does not . . . at repeat office visits have been a long-standing strategy to confirm a
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appear to be clinically innocent. The diagnosis should be confirmed . . . persistent elevation in BP, as well as for the classification of the hyper-
by repeated office and out-of-office BP measurements, and should . . . tension status in clinical practice and RCTs. The number of visits and
include an extensive assessment of risk factors and HMOD. Both . . . the time interval between visits varies according to the severity of the
ABPM and HBPM are recommended to confirm white-coat hyper- . . . hypertension, and is inversely related to the severity of hypertension.
tension, because the CV risk appears to be lower (and close to sus- . . . Thus, more substantial BP elevation (e.g. grade 2 or more) requires
tained normotension) in those in whom both ABPM and HBPM are . . . fewer visits and shorter time intervals between visits (i.e. a few days
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both normal; for treatment considerations see section 8.4. . . . . . or weeks), depending on the severity of BP elevation and whether
there is evidence of CVD or HMOD. Conversely, in patients with BP
4.7.2 Masked hypertension . . . . . elevation in the grade 1 range, the period of repeat measurements
Masked hypertension can be found in approximately 15% of patients . . . . may extend over a few months, especially when the patient is at low
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with a normal office BP. The prevalence is greater in younger peo- . . . risk and there is no HMOD. During this period of BP assessment, CV
ple, men, smokers, and those with higher levels of physical activity, . . . risk assessment and routine screening tests are usually performed
alcohol consumption, anxiety, and job stress. 54 Obesity, diabetes, . . . (see section 3).
CKD, family history of hypertension, and high–normal office BP are . . . These Guidelines also support the use of out-of-office BP meas-
also associated with an increased prevalence of masked hyperten- . . . urements (i.e. HBPM and/or ABPM) as an alternative strategy to
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sion. Masked hypertension is associated with dyslipidaemia and dys- . . . repeated office BP measurements to confirm the diagnosis of hyper-
glycaemia, HMOD, 92 adrenergic activation, and increased risk of . . . tension, when these measurements are logistically and economically
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developing diabetes and sustained hypertension. 81,93 Meta-analyses . . . feasible (Figure 2). This approach can provide important supple-
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and recent studies have shown that the risk of CV events is substan- . . . mentary clinical information, e.g. detecting white-coat hypertension
tially greater in masked hypertension compared with normotension, . . . (see section 4.7.1), which should be suspected, especially in people
and close to or greater than that of sustained hypertension. 68,93–96 . . . with grade 1 hypertension on office BP measurement and in whom
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Masked hypertension has also been found to increase the risk of CV . . . there is no evidence of HMOD or CVD (Table 11). A particular
and renal events in diabetes, especially when the BP elevation occurs . . . challenge is the detection of masked hypertension (see section 4.7.2).
during the night. 95,97 . . . . . Masked hypertension is more likely in people with a BP in the
high–normal range in whom out-of-office BP should be considered
4.8 Screening for the detection of . . . . . to exclude masked hypertension (see Table 8). Out-of-office BP
measurements are also indicated in specific circumstances (see sec-
hypertension . . . . tion 4.10 and Table 11).
Hypertension is predominantly an asymptomatic condition that is . . .
best detected by structured population screening programmes or . . .
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opportunistic measurement of BP. When structured population . 4.10 Clinical indications for out-of-office
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screening programmes have been undertaken, an alarming number of . . blood pressure measurements
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people (>50%) were unaware they had hypertension. 12,98 This high . . . Out-of-office BP measurements are increasingly used, especially
rate of undetected hypertension occurred irrespective of the income . . . HBPM but also ABPM, to confirm the diagnosis of hypertension.
status of the countries studied across the world. . . . Out-of-office BP measurement provides important complementary
All adults should have their BP recorded in their medical record . . . information, as discussed above. The clinical indications for out-of-
and be aware of their BP, and further screening should be undertaken . . . office BP measurements are shown in Table 11. HBPM is also increas-
at regular intervals with the frequency dependent on the BP level. For . . . . ingly used by patients to monitor their BP control, which increases
healthy people with an optimal office BP (<120/80 mmHg), BP should . . . their engagement and may improve their adherence to treatment
be remeasured at least every 5 years and more frequently when . . . and BP control. 61,101,102 It is likely that, with increased availability and
opportunities arise. In patients with a normal BP (120–129/80–84), . lower cost of these devices, this will become more commonplace.

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