Research Article
White coat hypertension in children: not rare and not benign?

https://doi.org/10.1016/j.jash.2009.10.002Get rights and content

Abstract

The clinical significance of white coat hypertension (WCH) remains uncertain. We aimed to evaluate the target organ damage (TOD) in children with essential hypertension (HTN) and WCH. We retrospectively analyzed the body mass index (BMI) and ambulatory blood pressure monitoring (ABPM) in 183 untreated children aged 5 to 19 years who were referred for assessment of hypertension and had secondary hypertension ruled out. Left ventricular mass index (LVMi) and carotid intima media thickness (CIMT) were analyzed in a subset of 106 children. WCH was found in 54/183 children (29.5%) who had normal mean arterial pressure (MAP), MAP load, and MAP day/night ratio. However, the mean ± SD LVMi (g/m2.7) was identical in HTN and WCH patients (38.2 ± 10.9 vs. 37.0 ± 11.3, P = .59); it exceeded the 95th percentile in 40% HTN and 36% WCH patients (NS). The mean CIMT was significantly higher compared with normal, but not different between HTN and WCH; it exceeded the 95th percentile in 26% HTN and 29% WCH patients. WCH was found in up to 30% of children referred for HTN. Patients with WCH have TOD comparable to that found in HTN patients despite similar BMI, significantly lower average BP and BP load and a well-preserved BP dipping pattern.

Introduction

White coat hypertension (WCH) has been defined by elevated blood pressure (BP) readings in the office, but normal BP on ambulatory blood pressure monitoring (ABPM).1, 2 Its prevalence in pediatric studies ranges from 10% to 60% depending on the methods and the threshold limits used for office and ABPM and the characteristics of the study population.3

Clinical significance of WCH in children is a matter of debate.3 Because several earlier studies did not show significant target organ damage (TOD) associated with WCH,4, 5, 6 it has been believed that WCH represents a rather benign condition in children that does not require therapeutic intervention and monitoring.7, 8 Even in adults, the clinical significance remains uncertain9 and most studies indicate that the incidence of cardiovascular events is not significantly different between WCH and true normotension.10

The availability of normative values for ABPM in children11 has improved the classification and detection of WCH. In addition, increased availability of echocardiography for the assessment of the left ventricular mass index (LVMi) and pediatric reference values for ultrasound assessment of carotid intima media thickness (CIMT)12 have allowed for a more specific evaluation of presence of HTN-related TOD. Indeed, three recent studies in children and adolescents with WCH showed impaired arterial elasticity13 and increased LVMi,14, 15 suggesting that WCH is not a benign condition.

Our study had two major goals: to analyze the prevalence of WCH in children with office hypertension (HTN) and to compare the prevalence of hypertrophy of the left ventricle and carotid intima media thickness in children with WCH and true HTN.

Section snippets

Subjects

Our study population consisted of consecutively referred children to two tertiary university centers (Warsaw and Ottawa) for evaluation of HTN based on the elevated office BP readings between January 2004 and December 2007. HTN was confirmed by an elevated BP above the 95th percentile for age and gender on three separate occasions per current guidelines.16 According to these guidelines, all patients underwent the same workup for secondary causes of HTN, which included determination of the body

Results

In the study period, a total of 183 untreated children diagnosed with essential HTN based on office BP measurements underwent ABPM. Using results of ABPM and office BP measurements, WCH was detected in 54 patients (29.5%). The demographic and BP data in patients with true HTN and WCH are shown in Table 1. Age and BMI were not significantly different between HTN and WCH patients.

Discussion

Our study has two major findings: WCH is highly prevalent (about 30%) in children with essential HTN diagnosed on the basis of office BP measurements and WCH is associated with TOD at a similar frequency and extent as in children with confirmed sustained HTN.

Acknowledgment

We thank Stephanie Barnes, administrative assistant in the Division of Pediatric Nephrology in Ottawa, for her kind assistance in the preparation of the manuscript.

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    Conflicts of interest: None

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