Role of ambulatory blood pressure monitoring in hypertensive patients having controlled office blood pressure

Background and objectives: Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In this study we tried to know the role of office and ambulatory BP in treated hypertensive patients. Methods and patients: Prospective cohort of 561 treated hypertensive patients were enrolled in the study. Hypertension definitions were according to JNC 8 classification. Office BP and ambulatory BP monitoring was done according to defined protocol. Results: From a subgroup of 158 treated hypertensive patients, 91(16.2%) patients were having white coat hypertension (p value 0.00 by Pearson chi square test). In a subset of 403 patients who were having controlled BP on the day of enrolment as well as on the day of attaching ambulatory BP monitor; 98 (17.4%) patients were having masked uncontrolled hypertension (MUCH). In addition there was very significant percentage of non-dippers and reverse dippers. In our study we found that office BP has a moderate to low specificity and sensitivity and low negative predictive value for overall control in treated hypertensive patients. Conclusion: Ambulatory BP monitoring should be included in the management protocol of treated hypertensive patients, for the optimal BP control.

Comparison of ambulatory blood pressure monitoring and self-blood pressure monitoring for diagnosing white coat hypertension amongst pregnant women

Background: White coat hypertension (WCH) is a common and well recognized phenomenon. It is also very prevalent amongst pregnant women and is often diagnosed as chronic/ gestational hypertension leading to unnecessary medications during pregnancy. ABPM is the gold standard for diagnosis of WCH. SBPM is an easy effective and reliable method to measure blood pressure but its efficacy needs to be tested and compared with ABPM in cases of WCH. It is important to compare the two methods in assessing WCH so SBPM can be utilized in cases of WCH, if found useful and efficacious.Methods: All pregnant women who presented to the ANC were screened for hypertension. Those who were diagnosed to be hypertensive in antenatal clinic and these patients were then admitted for ambulatory blood pressure monitoring (ABPM) for 24 hours and SBPM on 6 hourly bases for 5 days.Results: The ABPM and SBPB readings were noted, tabulated and compared. It was found that the prevalence of ‘WCH’ in this study using ABPM and SBPM were 47.368% (27/54) and 45.614% (26/54) respectively.Conclusions: The results in diagnosing WCH using ABPM and SBPM were comparable.

Office blood pressure combined with ambulatory blood pressure monitoring in hypertension diagnosis / 预防医学

Objective@#To evaluate the effects of office blood pressure(OBP)combined with ambulatory blood pressure monitoring(ABPM)on the diagnosis of hypertension.@*Methods@#The residents aged 35-79 years without hypertension history,whose casual OBP were 120~159 mm Hg/80~99 mm Hg,were enrolled from 4 communities of Hangzhou and Zhuji from 2015 to 2018. They were performed OBP measurements on other two days in 4 weeks and ABPM in a week. There were 2 criteria of OBP as elevated OBP on the first day or in 3 different days,and 4 criteria of ABPM as elevated mean BP in 24 hours, daytime, nighttime and either of the above time. Receiver operating characteristic(ROC)curve was employed to evaluate the effects of different OBP criteria combined with ABPM criteria on the diagnosis of masked hypertension(MH)and white-coat hypertension(WCH).@* Results@#Taking 3-day-OBP as a golden standard,the 1-day-OBP with 4 ABPM criteria had the areas under the ROC curve(AUC)of 0.79-0.81,sensitivity of 57.58%-62.77% and specificity of 100.00% in MH;had the AUC of 0.95-0.98,sensitivity of 100.00% and specificity of 88.96%-96.80% in WCH. The Kappa values were all less than 0.6,known as low consistency. Taking either time of ABPM as a golden standard,24 hours,daytime and nighttime ABPM criteria with OBP had the AUC of 0.90-0.92,sensitivity of 79.17%-83.90% and specificity of 100.00% in MH(all Kappa>0.6),when with 1-day-OBP,the Kappa values were all more than 0.8,known as high consistency;had the AUC of 0.95-1.00,sensitivity of 100.00% and specificity of 89.54%-99.37% in WCH,the Kappa values of daytime ABPM were all more than 0.6,known as high consistency. @* Conclusions @# If limited by options, 1-day-OBP could be used instead of 3-day-OBP for detection of WCH or exclusion of MH yet with less accuracy; 24 hours or daytime ABPM instead of either time of ABPM was reliable.

Prevalence of white coat hypertension amongst pregnant women admitted with high BP recordings in ante-natal clinic

Background: White coat hypertension (WCH) is a common and well recognized phenomenon with significant prevalence amongst all age groups. This is also quite prevalent in the pregnant women with an intermediate long term prognosis between hypertensive and normo-tensive individuals. It is important to assess the true prevalence WCH in pregnant women and to prevent unnecessary medications to them during pregnancy but at the same time to keep a timely follow up and a watchful eye on these patients to identify complications at the earliest. Study was conducted at a peripheral secondary level hospital with a small obstetrics and gynecology OPD and ward. 54 patients were diagnosed to be hypertensive in Antenatal Clinic.Methods: All pregnant women who presented to the ANC were screened for hypertension. Those who were diagnosed to be hypertensive in antenatal clinic and these patients were then admitted for Ambulatory Blood Pressure Monitoring (ABPM) for 24 hours.Results: The ABPM tracings were checked and tabulated to arrive at the final diagnosis after 24 hrs. The prevalence of ‘WCH’ in this study was 48.15% as 26/54 patients were found to have their average BP < 140/90 mmHg after measurement by ABPM over 24 hours so they were diagnosed as ‘White Coat Hypertension’ patients.Conclusions: Many women who come to ANC in the early pregnancy are diagnosed to have hypertension. WCH is a well known phenomenon in pregnancy. WCH must be ruled out prior to starting these patients on anti-hypertensive medications.

Prevalence of Masked and White-Coat Hypertension in Pre-Hypertensive and Stage 1 Hypertensive patients with the use of TeleMRPA / Prevalência de Hipertensão Mascarada e do Avental Branco em Pré-Hipertensos e Hipertensos Estágio 1 com o uso da TeleMRPA

Abstract Background: The diagnosis of arterial hypertension based on measurements of blood pressure in the office has low accuracy. Objective: To evaluate the prevalence of masked hypertension (MH) and white-coat hypertension through home blood pressure monitoring (HBPM) in pre-hypertensive and stage 1 hypertensive patients. Method: Retrospective study, of which sample consisted of individuals with BP ≥ 120/80 mmHg and < 160/100 mmHg at the medical office without the use of antihypertensive medication and who underwent exams on the HBPM platform by telemedicine (TeleMRPA) between May 2017 and September 2018. The four-day MRPA protocol was used, with 24 measurements, using automated, validated, calibrated equipment with a memory function. Results: The sample consisted of 1,273 participants, of which 739 (58.1%) were women. The mean age was 52.4 ± 14.9 years, mean body mass index (BMI) 28.4 ± 5.1 kg/m2. The casual BP was higher than the HBPM in 7.6 mmHg for systolic blood pressure (SBP) and 5.2 mmHg for diastolic blood pressure (DBP), both with statistical significance (p < 0.001). There were 558 (43.8%) normotensive individuals; 291 (22.9%) with sustained hypertension; 145 (11.4%) with MH and 279 (21.9%) with white-coat hypertension (WCH), with a diagnostic error by casual BP in the total sample in 424 (33.3%) patients. In stage 1 hypertensive individuals, the prevalence of WCH was 48.9%; in prehypertensive patients, the prevalence of MH was 20.6%. Conclusion: MH and WCH have a high prevalence rate in the adult population; however, in prehypertensive or stage 1 hypertensive patients, the prevalence is higher. Out-of-office BP measurements in these subgroups should be performed whenever possible to prevent misdiagnosis.

Resumo Fundamento: O diagnóstico de hipertensão arterial baseado nas medidas do consultório tem baixa acurácia. Objetivo: Avaliar a prevalência de hipertensão mascarada (HM) e do avental branco pela monitorização residencial da pressão arterial (MRPA) em pacientes pré-hipertensos e hipertensos estágio. Método: Estudo retrospectivo com amostra constituída de indivíduos com pressão arterial (PA) na clínica ≥ 120/80 mmHg e < 160/100 mmHg sem uso de medicação anti-hipertensiva e que realizaram exames na plataforma de MRPA por telemedicina (TeleMRPA) entre maio de 2017 e setembro de 2018. Foi utilizado o protocolo MRPA de quatro dias, com 24 medidas, com equipamentos automáticos, validados, calibrados e com memória. Resultados: A amostra foi constituída de 1.273 participantes, sendo 739 (58,1%) mulheres. A idade média foi 52,4 ± 14,9 anos, índice de massa corporal (IMC) médio 28,4 ± 5,1 kg/m2. A PA casual foi maior que a MRPA em 7,6 mmHg para pressão arterial sistólica (PAS) e 5,2 mmHg para a pressão arterial diastólica (PAD), ambas com significância estatística (p < 0,001). Foram diagnosticados 558 (43,8%) normotensos; 291 (22,9%) hipertensos sustentados; 145 (11,4%) com HM e 279 (21,9%) com hipertensão do avental branco (HAB), com erro diagnóstico pela PA casual na amostra total em 424 (33,3%) pacientes. Em hipertensos estágio 1, a prevalência de HAB foi de 48,9%; nos pré-hipertensos a prevalência de HM foi de 20,6%. Conclusão: HM e HAB têm elevada prevalência na população adulta; entretanto, na população de pré-hipertensos ou hipertensos estágio 1 a prevalência é maior. Medidas da PA fora do consultório, nestes subgrupos, devem ser realizadas sempre que possível para evitar erro diagnóstico.

Hipertensão arterial resistente (HAR) / Resistant arterial hypertension (RAH)

A hipertensão arterial resistente (HAR) é definida quando a pressão arterial (PA) permanece acima das metas recomendadas com o uso de três anti-hipertensivos de diferentes classes, incluindo um bloqueador do sistema renina- angiotensina (inibidor da enzima conversora da angiotensina [IECA] ou bloqueador do receptor de angiotensina [BRA]), um bloqueador dos canais de cálcio (BCC) de ação prolongada e um diurético tiazídico (DT) de longa ação em doses máximas preconizadas e toleradas, administradas com frequência, dosagem apropriada e comprovada adesão. Nesta definição está incluído o subgrupo de pacientes hipertensos resistentes, cuja PA é controlada com quatro ou mais medicamentos anti-hipertensivos, chamada de HAR controlada (HAR-C). A classificação da doença em HAR-C e HAR não controlada (HAR-NC), incluindo a HAR refratária (HAR-Ref), um fenótipo extremo de HAR-NC em uso de cinco ou mais anti-hipertensivos, é uma proposta que ganha espaço na literatura. Diante da suspeita clínica de HAR, é necessário verificar a confirmação diagnóstica, e a primeira etapa na investigação é a exclusão das causas de pseudorresistência, tais como falta de adesão ao tratamento (farmacológico e não farmacológico), posologia inadequada, técnica imprópria de aferição da PA e efeito do avental branco. O MAPA e o monitoramento residencial da pressão arterial (MRPA) são os exames para confirmação do controle inadequado da PA. Uma vez afastada a pseudorresistência, confirma-se a existência da HAR e inicia-se uma investigação diagnóstica com exames específicos, conforme a orientação das Diretrizes de Hipertensão em relação ao comprometimento de lesões em órgãos-alvo e hipertensão secundária. A ocorrência de comorbidades associadas deve ser detectada com exames especializados de acordo com a suspeita clínica. O objetivo do tratamento medicamentoso na HAR é detectar as causas do não controle e encontrar a melhor combinação de fármacos, visando o alcance das metas pressóricas com menor ocorrência de efeitos adversos e maior adesão. Em geral, busca-se otimizar o tratamento tríplice com os fármacos preferenciais, que são: IECA ou BRA, BCC di-hidropiridínico e DT.

Resistant hypertension (RHTN) is defined as blood pressure (BP) persistently above the recommended target values despite the use of three antihypertensive agents of different classes, including one blocker of the renin- angiotensin system (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin receptor blocker [ARB]), one long- acting calcium channel blocker (CCB), and one long-acting thiazide diuretic (TD) at maximum recommended and tolerated doses, administered with appropriate frequency and doses and with proven adherence. The definition above includes a subgroup of patients with RHTN whose BP is controlled with four or more antihypertensive medications, known as controlled RHTN (C-RHTN). On clinical suspicion of RHTN, diagnostic confirmation is required, and the first step in the investigation is the exclusion of causes of pseudoresistance, such as lack of treatment adherence (pharmacological and non-pharmacological), inadequate dosing, improper BP measurement technique, and white-coat effect. Lack of BP control should be confirmed by ABPM and home blood pressure monitoring (HBPM). Secondary hypertension (SecH) is defined as increased BP due to an identifiable cause. Patients with RH should be investigated for the most prevalent causes of "non-endocrine" and "endocrine" SecH after exclusion of use of medications that may interfere with BP values: antiinflammatory drugs, glucocorticoids, nasal decongestants, appetite suppressants, antidepressants, immunosuppressants, erythropoietin, contraceptives, and illicit drugs. The objective of pharmacological treatment in RHTN is to identify the causes of lack of control and find the best combination of drugs, aiming at achieving the target BP with few adverse effects and greater adherence. In general, triple treatment optimization is attempted with preferred drugs, namely, ACEIs or ARBs, dihydropyridine CCBs, and TDs

Ambulatory blood pressure monitoring in clinical practice

Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.

1. White Coat Ceremony Description of a White Coat Ceremony at Aichi Medical University School of Medicine / 医学教育

Abstract:　The first White Coat Ceremony was officially conducted by prof. Arnold P. Gold at Columbia University in 1993. The professor felt that medical students needed more humanism and professionalism. Therefore, he established the Gold Foundation, the sponsoring organization for the White Coat Ceremony. Since then, it has spread across the country. The aim of the White Coat Ceremony is for medical students to understand the meaning of the responsibility associated with wearing the white coats, and to be aware of humanism and professionalism. Although it has been recently introduced in many medical departments in Japan, implementation methods of the White Coat Ceremony.

Tecidos de poliéster e suas implicações para confecção de jalecos / Polyester cloths and their implications for making white coats

A literatura científica reporta a contaminação microbiana dos jalecos utilizados por profissionais da saúde, no entanto não há consenso relacionando seu uso com a redução da exposição microbiana por risco ocupacional. O objetivo desta pesquisa foi avaliar tecidos de poliéster (oxford e microfibra) utilizados na confecção de jalecos, quanto à função de barreira física contra fluido e bactérias, nas perspectivas e desafios do controle de infecção na área da saúde. Trata-se de um estudo do tipo experimental / laboratorial in vitro realizado em três etapas. Na primeira etapa, os tempos de passagem do fluido através dos tecidos foram cronometrados e registrados em segundos desde o início do escoamento do fluido até as formações e quedas das últimas gotas. Na segunda etapa (microbiológica), inóculos padronizados das bactérias padrão de Staphylococcus aureus (ATCC 25923) e Pseudomonas aeruginosa (ATCC 27853) foram adicionadas ao fluido. Decorrida a passagem do fluido através dos tecidos, alíquotas de 50µL in natura e diluídas (10-1 a 10-5) foram semeadas na superfície de placas de Petri (60x15mm) com meios de cultura seletivos, incubadas a 37°C por 24h e o número de unidades formadoras de colônia das bactérias expresso por mililitro do fluido (UFC/mL). Na terceira etapa, as características estruturais dos tecidos e a retenção bacteriana foram analisadas por meio de microscopia eletrônica de varredura (MEV). Os dados obtidos foram submetidos aos testes de normalidade (Kolmogorov-Smirnov e Shapiro-Wilk) e, posteriormente, ao teste de U de Mann-Whitney por meio do software IBM SPSS Statistics (versão 25) e nível de significância ?=5%. A comparação entre as medianas dos tempos de passagem do fluido através dos tecidos de oxford e microfibra demonstrou diferença estatisticamente significante (p<0,001) independente das variáveis envolvidas (tecidos limpo ou limpo e passado, e tecidos autoclavado ou não autoclavado). Na etapa microbiológica, não foi observada diferença entre as medianas das cargas bacterianas dos tecidos de oxford e microfibra após a passagem do fluido com S. aureus (p=0,056) e P. aeruginosa (p=0,320). As análises por MEV permitiram evidenciar estruturas com formas irregulares e de cristal, bem como espaços (macroporos) entre os fios dos tecidos de oxford, que permitiram um menor tempo de passagem do fluido através do tecido. No entanto, não foi constatada a presença bacteriana na superfície dos tecidos. Em conclusão, diante dos dois tipos de tecidos utilizados na confecção de jalecos, o de microfibra apresentou maior tempo de passagem do fluido comparado ao de oxford, em decorrência das diferenças estruturais desses tecidos. Entretanto, a função de barreira física bacteriana após a passagem do fluido através dos tecidos não foi observada, o que reforça a necessidade de substituição do jaleco quando esse entra em contato com fluidos biológicos, visando à biossegurança: controle de contaminação/infecção na área da saúde

Scientific literature reports contamination of white coats used by health professionals, but there is not a consensus relating its usage to reduction of microbial exposure by occupational risk. The objective of this study was to evaluate Oxford and microfiber cloths used for making white coats, regarding its function as physical barrier to fluid and bacteria, in perspectives and challenges of infection control in health field. It is an in vitro experimental / laboratory study carried out in three stages. In the first stage, fluid passage times through the pieces of cloths were measured and registered in seconds since the beginning of fluid flow until formations and falls of the last drops. In the second stage (microbiological), standardized inocula of standard bacteria of Staphylococcus aureus (ATCC 25923) and Pseudomonas aeruginosa (ATCC 27853) were added to the fluid. After the passage of fluid through the pieces of cloths, in natura and diluted 50µL aliquots (10-1 to 10-5) were seeded on the surface of Petri dishes (60x15mm) with selective culture mediums, incubated at 37°C for 24h and the number of colony forming units of bacteria expressed by milliliter of fluid (CFU/mL). In the third stage, structural characteristics of cloths and bacterial retention were analyzed through scanning electron microscopy (SEM). The obtained data were submitted to normality tests (Kolmogorov-Smirnov and Shapiro-Wilk) and, later, to Mann-Whitney U test through IBM SPSS Statistics (version 25) software and ?=5% significance level. Comparison between medians of the fluid passage time through oxford and microfiber cloths showed statistically significant difference (p<0.001) independent of the involved variables (clean or clean and ironed cloths, and autoclaved or non-autoclaved cloths). In the microbiological stage, difference was not observed between medians of bacterial loads of Oxford and microfiber cloths after the passage of the fluid with S. aureus (p=0.056) and P. aeruginosa (p=0.320). The analyses by SEM allowed evidence structures with irregular and crystal shapes as well as gaps (macropores) between the threads of pieces of Oxford cloth, that allowed a shorter fluid passage time through the cloth. However, bacterial presence on the surface of cloths were not noticed. In conclusion, before the two types of cloths used for making white coats, the microfiber one presented longer fluid passage time compared to the Oxford one, due to the structural differences of these cloths. However, the functionality as bacterial physical barrier after fluid passage through the pieces of cloths were not observed, which reinforces the need to replace the white coat when it comes in contact with biological fluids, aiming at biosafety: contamination/infection control in health field

Does resting heart rate measured by the physician reflect the patient’s true resting heart rate? White-coat heart rate

Objectives In cardiology, resting heart rate (HR) and blood pressure (BP) are key elements and are used to adapt treatment. However HR measured in consultation may not reflect true resting HR. We hypothesize that there may be a “white-coat” effect like with BP and that there may be an association between HR variations and BP variations. Methods This prospective, monocentric, observational, pilot study (January-April 2016) included 57 consecutive ambulatory patients at Poitiers University Hospital, France (58% male, mean age 64 years). Patients’ resting HR and BP were recorded with the same automated blood pressure sphygmomanometer in consultation by the physician then with self-measurement at home. Results In the overall cohort, we found that HR was significantly higher in consultation (70.5bpm ± 12.6 vs. 68.1bpm ± 10.1, p = 0.034). HR also correlated with diastolic BP (r = 0.45, p = 0.001). Patients were divided into three groups to look for associations with BP: masked HR, (higher HR at home, 38.6%), white-coat HR, (lower HR at home 52.6%) and iso HR, (no change between HR at home and consultation, 8.8%). Although there was no difference between groups in diastolic BP measured in consultation, home diastolic BP was lower in the white-coat HR group (74.3 mmHg ± 9.8 vs. 77.9 mmHg ± 7.5, p = 0.016). Conclusions Our study brings to light an exciting idea that could have a major therapeutic and maybe prognostic impact in cardiology: resting HR measured by the physician in consultation does not reflect true resting HR. This must be taken into account to adapt treatment.

Does the attire of a primary care physician affect patients’ perceptions and their levels of trust in the doctor?

@#Introduction: With increasing evidence of disease transmission through doctors’ white coats, many countries have discouraged doctors from wearing their white coats during consultations. However, there have been limited studies about patients’ preferences concerning doctors’ attire in Malaysia. This study, therefore, aimed to investigate patients’ perceptions of doctors’ attire before and after the disclosure of information about the infection risk associated with white coats. Method: This cross-sectional study was conducted from 1st June 2015 to 31st July 2015 at three different primary care settings (government, private, and university primary care clinics) using a self-administered questionnaire. A 1:5 systematic random sampling method was employed to select the participants. The respondents were shown photographs of male and female doctors in four different types of attire and asked to rate their level of confidence and trust in and ease with doctors in each type of attire. Subsequently, the respondents were informed of the risk of white coat-carried infections, and their responses were reevaluated. Data analysis was completed using SPSS Version 24.0. Associations of categorical data were assessed using the Chi-Square test, while the overall change in perceptions after the disclosure of additional information was examined using the McNemar test. Results with p-values < 0.05 were considered statistically significant. Results: A total of 299 respondents completed the questionnaire. Most of the respondents had more confidence and trust in the male (62.5%) and female (59.2%) doctors wearing white coats. A high proportion of the respondents from the government clinic (70.5%) felt more confidence in male doctors dressed in white coats (p-value = 0.018). In terms of ethnicity, male doctors in white coats were highly favored by Malays (61.0%), followed by the Chinese (41.2%) and Indians (38%) (p = 0.005). A similar preference was observed for the female doctors, whereby the highest number of Malays (60.3%), followed by the Chinese (41.2%) and Indians (40.0%) (p = 0.006), had a preference for female doctors wearing white coats. Only 21.9% of the initial 71.9% of patients who preferred white coats maintained their preference (p < 0.001) after learning of the risk of microbial contamination associated with white coats. Conclusion: Most patients preferred that primary care doctors wear white coats. Nevertheless, that perception changed after they were informed about the infection risk associated with white coats.

Discussion on using ambulatory blood pressure monitoring in the diagnostic criteria of white coat and masked hypertension / 上海交通大学学报（医学版）

Objective • To investigate different methods on the diagnosis of white coat and masked phenomena in ambulatory blood pressure monitoring (ABPM). Methods • Information of clinical characteristics and laboratory data were collected, and measurements of office blood pressure (OBP) and ambulatory blood pressure (ABP) in 274 subjects were performed, including 46 persons with high normal OBP (SBP/DBP 130-139/85-89 mmHg) (1 mmHg=0.133 kPa), 187 untreated patients with grade 1 and grade 2 hypertension (SBP/DBP 140-179/90-109 mmHg), and 41 treated hypertensive patients. Differences of 95th and 5th percentile between OBP and daytime ABP, were respectively taken as the cutoff for the definition of white coat phenomenon and masked phenomenon. Results • If white coat and masked phenomenon were diagnosed according to the current hypertension guidelines, the prevalence of white coat phenomenon did not differ between untreated and treated hypertensive patients (11.2% vs 7.3%, P=0.460). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than in grade 1 hypertension (20.0% vs 8.5%, P=0.033), whereas the prevalence of white coat hypertension did not differ (2.2% vs 7.0%, P=0.230). The prevalence of masked hypertension was 73.9% in high normal blood pressure group. The prevalence of masked uncontrolled hypertension was 4.9%. If the difference of 95th percentile (≥20.50/20.50 mmHg) and 5th percentile (≤-18.67/-6.00 mmHg) between OBP and daytime ABP were, respectively, used as the cutoff for the definition of white coat and masked phenomenon, the prevalence of white coat phenomenon did not differ between treated and untreated groups (12.2% vs 9.1%，P=0.543). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than in grade 1 hypertension (24.4% vs 4.2%, P=0.000). The prevalence of masked phenomenon did not differ between persons with high normal OBP (15.2%) and untreated (5.9%) as well as treated hypertensive patients (12.2%) (P>0.05). Conclusion • The percentile methods may be useful for the diagnosis of white coat and masked phenomena.

White-Coat Hypertension: the Neglected Subgroup in Hypertension

The clinical prognostic importance of white coat hypertension (WCH), that is, the clinical condition characterized by an increase of office but a normal ambulatory or home blood pressure (BP) is since a long time matter of considerable debate. WCH accounts for a consistent portion of hypertensive patients (up to 30–40%), particularly when hypertension is mild or age is more advanced. Although scanty and inconsistent information is available on the response of office and out-office BP to antihypertensive treatment and the cardiovascular (CV) protection provided by treatment, an increasing body of evidence focusing on the association of WCH with CV risk factors, subclinical cardiac and extra-cardiac organ damage and, more importantly, with CV events indicates that the risk entailed by this condition is intermediate between true normotension and sustained hypertension. This review will address a number of issues concerning WCH with particular attention to prevalence and clinical correlates, relation with subclinical target organ damage and CV morbidity/mortality, therapeutic perspectives. Several topics covered in this review are based on data acquired over the past 20 years by the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study, a longitudinal survey performed by our group on the general population living in the surroundings of Milan area in the north part of Italy.

Changes of serum cortisol and IL-6 levels before and after exercise stress test and their relationship with white coat hypertension / 国际检验医学杂志

Objective To investigate the changes of serum cortisol and IL-6 levels before and after exercise stress test and their relationship with white coat hypertension .Methods A total of 48 patients with white coat hypertension in Liwan Hospital of Tra-ditional Chinese Medicine from January 2014 to August 2016 were selected as the study group ,30 cases of patients with common hypertension in the same period were selected as common group ,30 cases of healthy volunteers in the same period were selected as control group .All the objects in the three groups completed exercise stress test on an empty stomach ,sat on the power bicycle and pedaling 2 min with 200 W ,and after intermittent 5 min repeated exercise until extreme fatigue .Serum cortisol and IL-6 levels ,mean arterial pressure(MAP) of 3 groups before exercise ,immediately after exercise and 3 h after exercise were detected and compared . Value of serum cortisol and IL-6 on diagnosing white coat hypertension and its relationship with MAP were analyzed .Results Compared with the control group ,serum cortisol ,IL-6 levels and MAP of the study group and common group before and after exer-cise were increased .Compared with the common group ,serum cortisol and IL-6 levels and MAP of the study group were significant-ly increased immediately after exercise and 3 h after exercise (P<0 .05) .Compared with before exercise ,serum cortisol and IL-6 levels and MAP of the study group immediately after exercise and 3 h after exercise were increased(P<0 .05) .ROC curve analysis showed that it′s value to detecting serum cortisol and IL-6 levels before and after exercise stress test for diagnosing white coat hy-pertension ,in which the value of combined detection of serum cortisol and IL-6 immediately after exercise for diagnosing white coat hypertension was the best .Pearson linear correlation analysis showed that serum cortisol and IL-6 levels before and after exercise stress test were positively correlated with MAP of patients with white coat hypertension (r=0 .844 ,0 .802 ,P<0 .05) .Conclusion It′s value to detecting serum cortisol and IL-6 levels before and after exercise stress test for diagnosing white coat hypertension , which are related with blood pressure ,and could be used as reference indexes for the diagnosis and illness severity evaluation of white coat hypertension .

Changes of serum cortisol and IL-6 levels before and after exercise stress test and their relationship with white coat hypertension / 国际检验医学杂志

Objective To investigate the changes of serum cortisol and IL-6 levels before and after exercise stress test and their relationship with white coat hypertension .Methods A total of 48 patients with white coat hypertension in Liwan Hospital of Tra-ditional Chinese Medicine from January 2014 to August 2016 were selected as the study group ,30 cases of patients with common hypertension in the same period were selected as common group ,30 cases of healthy volunteers in the same period were selected as control group .All the objects in the three groups completed exercise stress test on an empty stomach ,sat on the power bicycle and pedaling 2 min with 200 W ,and after intermittent 5 min repeated exercise until extreme fatigue .Serum cortisol and IL-6 levels ,mean arterial pressure(MAP) of 3 groups before exercise ,immediately after exercise and 3 h after exercise were detected and compared . Value of serum cortisol and IL-6 on diagnosing white coat hypertension and its relationship with MAP were analyzed .Results Compared with the control group ,serum cortisol ,IL-6 levels and MAP of the study group and common group before and after exer-cise were increased .Compared with the common group ,serum cortisol and IL-6 levels and MAP of the study group were significant-ly increased immediately after exercise and 3 h after exercise (P<0 .05) .Compared with before exercise ,serum cortisol and IL-6 levels and MAP of the study group immediately after exercise and 3 h after exercise were increased(P<0 .05) .ROC curve analysis showed that it′s value to detecting serum cortisol and IL-6 levels before and after exercise stress test for diagnosing white coat hy-pertension ,in which the value of combined detection of serum cortisol and IL-6 immediately after exercise for diagnosing white coat hypertension was the best .Pearson linear correlation analysis showed that serum cortisol and IL-6 levels before and after exercise stress test were positively correlated with MAP of patients with white coat hypertension (r=0 .844 ,0 .802 ,P<0 .05) .Conclusion It′s value to detecting serum cortisol and IL-6 levels before and after exercise stress test for diagnosing white coat hypertension , which are related with blood pressure ,and could be used as reference indexes for the diagnosis and illness severity evaluation of white coat hypertension .

The significance of blood pressure variation and metabolic risk factors in patients with different stages of hypertension / 고신대학교의과대학학술지

OBJECTIVES: Blood pressure variation (BPV) and metabolic syndrome is an independent risk factor for cardiovascular events. Ambulatory blood Pressure (ABP) has been shown to be more closely related to cardiovascular events in hypertensive patients than conventional office BP (OBP). Using both OBP and ABP, 4 groups of patients were identified: (1) normotensive patients (NT); (2) white coat hypertensives (WCHT); (3) masked hypertensives (MHT); and (4) sustainedhypertensives (SHT). We investigated the significance of BPV and metabolic risks of these 4 groups. METHODS: This study is a retrospective analysis of patients between January 2008 and May 2013. Echocardiography and 24 hour ABP monitoring were performed. RESULTS: BMI was significantly higher in the MHT compared with the NT. There were progressive increases in fasting glucose level from NT to WCHT, MHT, and SHT.MHT and SHT had higher 24h and nighttime BPV than NT.MHT was significantly related with BMI (r = 0.139, P = 0.010), creatinine (r = 0.144, P = 0.018), fasting glucose (r = 0.128, P = 0.046), daytime systolic BPV (r = 0.130, P = 0.017), and daytime diastolic BPV (r = 0.130, P = 0.017). Dyslipidemia (r = 0.110, P = 0.043), nighttime systolic BPV (r = 0.241, P < 0.001) and nighttime diastolic BPV (r = 0.143, P = 0.009) shown correlation with SHT. In multivariate logistic regression, MHT was independently associated with Body mass index (OR 1.086, 95% CI 1.005–1.174, P = 0.038) and creatinine (OR 1.005, 95% CI 1.001–1.010, P = 0.045). CONCLUSIONS: BPV and metabolic risk factors were found to be greater in MHT and SHT compared with NT and WCHT. This suggests that BPV and metabolic risks may contribute to the elevated cardiovascular risk observed in patients with MHT and SHT.

The 'auxiliary' white coat effect in hospitals: perceptions of patients and doctors

A doctor's attire is important in making a positive first impression and enhancing the overall healthcare experience for patients. We conducted a study to examine the perceptions and preferences of patients and doctors regarding six types of dress codes used by doctors in different scenarios and locations. A total of 87 patients and 46 doctors participated in the study. Separate sets of questionnaires containing four demographic questions and 14 survey questions were distributed to the two groups. Most patients preferred doctors to dress formally in white coats regardless of the scenario or location, whereas the majority of doctors preferred formal attire without white coats. Both groups preferred operating theatre attire in the emergency department. Our findings confirmed that patients perceived doctors in white coats to be more trustworthy, responsible, authoritative, confident, knowledgeable and caring. There is a need to educate the public about the reasons for changes in doctors' traditional dress codes.

Discrepancies in Clinic and Ambulatory Blood Pressure in Korean Chronic Kidney Disease Patients

Blood pressure (BP) control is considered the most important treatment for preventing chronic kidney disease (CKD) progression and associated cardiovascular complications. However, clinic BP is insufficient to diagnose hypertension (HT) and to monitor overall BP control because it does not correlate well with ambulatory blood pressure monitoring (ABPM). We enrolled 387 hypertensive CKD patients (stages G1–G4, 58.4% male with median age 61 years) from 3 hospitals in Korea. HT of clinic BP and ABPM was classified as ≥ 140/90 and ≥ 130/80 mmHg, respectively. Clinic BP control rate was 60.2%. The median 24-hour systolic blood pressures (SBPs) of CKD G3b and CKD G4 were significantly higher than those of CKD G1–2 and CKD G3a. However, the median 24-hour SBPs were not different between CKD G1–2 and CKD G3a or between CKD G3b and CKD G4. Of all patients, 5.7%, 38.0%. 42.3%, and 14.0% were extreme-dippers, dippers, non-dippers, and reverse-dippers, respectively. Non-/reverse-dippers independently correlated with higher Ca × P product, higher intact parathyroid hormone (iPTH), and lower albumin. Normal BP was 33.3%, and sustained, masked, and white-coat HT were 29.7%, 26.9%, and 10.1%, respectively. White-coat HT independently correlated with age ≥ 61 years and masked HT independently correlated with CKD G3b/G4. In conclusion, ABPM revealed a high prevalence of non-/reverse-dippers and sustained/masked HT in Korean CKD patients. Clinicians should try to obtain a CKD patient's ABPM, especially among those who are older or who have advanced CKD as well as those with abnormal Ca × P product, iPTH, and albumin.