Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension

Abstract

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic-daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future.

Fig. 1

Changes in blood pressure with age in a population survey. BP, blood pressure. Adapted from [12].

Fig. 2

Classification of blood pressure status.

Fig. 3

Measurement of clinic–ambulatory blood pressure differences. BP, blood pressure; HT, sustained hypertension; MH, masked hypertension; NT, true normotension; WC, white coat hypertension.

Fig. 4

Blood pressure status and self-rated anxiety during physician measurement. BP, blood pressure; HT, sustained hypertension; MH, masked hypertension; MD, physician; NT, true normotension; WC, white coat hypertension.

Fig. 5

Relationships of clinic and ambulatory blood pressure with age in people who have been previously told (labeled) or not told (not labeled) that they have hypertension. BP, blood pressure.