CHAPTER 62
WHITE COAT HYPERTENSION
AND WHITE COAT WORSE
HYPERTENSION
STEVEN G. CHRYSANT, MD, PhD
The introduction of ambulatory blood pressure (ABP)
monitoring several years ago demonstrated that the clinic
blood pressure of a subject may not be the true blood
pressure. Many such subjects demonstrate an elevated
blood pressure during the clinic visit and a normal blood
pressure away from the clinic environment, either by
ABP monitoring (see Chapter 67, “Ambulatory Blood
Pressure Monitoring: Its Use in Clinical Practice and
Implications for Therapy”) or by home blood pressure
monitoring (see Chapter 68, “The Role of Self-Measured
Home Blood Pressure”). The difference between the
mean clinic blood pressure and the mean daytime ABP
has been called white coat hypertension (WCH) by
several investigators. 1–5 This phenomenon is quite
common; it has been reported to occur between 20 and
45%1,6–8 in persons with WCH and has a higher preva-
lence in women, the elderly, and mildly hypertensive
subjects.9–12 WCH should not be confused with the white
coat effect (WCE), which represents an increase in blood
pressure during the clinic visit compared with the mean
daytime ABP and occurs in patients with sustained
hypertension, treated or untreated.4,8,10,13–15 Another
phenomenon that was recently observed is a normal
clinic blood pressure and an elevated ABP, the opposite
of WCH. This phenomenon, which is also quite
common, has been called by different names, such as
“inverse white coat hypertension,”16 “reverse white coat
hypertension,”17,18 and “white coat normotension.”19,20
Because these terms are confusing, in this chapter, I use
the term white coat worse hypertension (WCWH), which
is more descriptive of the situation. The significance,
prognostic implications, and management of WCH,
WCE, and WCWH are discussed in this chapter.
537
White Coat Hypertension
DEFINITION
WCH has been defined as a “persistently elevated clinic or
office blood pressure in the presence of normal daytime
ambulatory blood pressure.”1–5 This has been ascribed to a
defense or alarm reaction against the doctor or nurse
measuring the blood pressure by conventional means in the
clinic and is usually associated with an increase in heart rate
besides blood pressure.21 Elevated blood pressure in the
office or clinic has been defined by both the Seventh Joint
National Committee Report (JNC-7) and the 2003
European Society of Hypertension and the European
Society of Cardiology as blood pressure
139/89 mm
Hg.22,23 The same societies have defined daytime ABP of
 134/84 mm Hg as normal. The mean nighttime ABP has
been defined as < 120/75 mm Hg.22 Despite these cutoff
levels for the normal ABP, some investigators have used
higher blood pressure levels (< 140/90 mm Hg), whereas
others have used lower (< 130/80 mm Hg) ABP
levels.7,24–26 Other investigators have proposed the follow-
ing cutoff levels for a normal ABP:  130/80 mm Hg for
the 24-hour mean,  135/85 mm Hg for the daytime
mean, and  120/70 mm Hg for the nighttime mean.3,27 In
addition, Verdecchia and colleagues suggested using sepa-
rate ABP levels for normal blood pressure of  131/86 mm
Hg for women and  136/87 mm Hg for men.28 However,
this distinction is not warranted because treatment deci-
sions are the same for both sexes. On the contrary, the
suggestion by Bindlingmeyer and colleagues to use differ-
ent cutoff levels for normal ABP in younger and older
patients, such as < 134/90 mm Hg for persons younger
538 / Advanced Therapy in Hypertension and Vascular Disease

than 65 years of age and < 142/90 mm Hg for persons older
than 65 years of age, does not seem appropriate under the
current thinking because initiation of treatment for high
blood pressure does not take into account the age of the
patient.29 All of these suggestions, although they may be
useful, create confusion with respect to decision making
regarding treatment of hypertension, and the physician
should adhere to the guidelines of JNC-7 and the European
Society of Hypertension and the European Society of
Cardiology.22,23
PREVALENCE
WCH is common, but its actual prevalence depends on
the definition of normal office blood pressure and ABP.
According to cutoffs of 139/89 mm Hg for normal office
blood pressure and 134/84 mm Hg for normal daytime
ABP, the prevalence of WCH varies between 20 and
45%,1,6–8 and it is more prevalent in women, the elderly,
and mildly hypertensive patients. 9–12 Verdecchia and
colleagues reported an overall prevalence of 19% in a
population of 1,333 hypertensive patients, with the preva-
lence being even higher among subjects with the mildest
form of hypertension.13 A similar incidence (19.2%) was
reported among 1,187 adult subjects in the PIUMA
(Progetto Ipertensione Umbria Monitoraggio
Ambulatoriale) study.30 Martinez and colleagues reported
a prevalence of WCH of 39% among 345 subjects using a
cutoff level of ABP 135/85 mm Hg.31 In a meta-analysis of
large ABP data, Staessen and colleagues reported that
among 7,069 patients, the overall incidence of WCH was
24%.32 They also found that female sex, old age, mild
hypertension, and infrequent visits accounted for a higher
incidence of WCH. The importance of the frequency of
screening visits on the prevalence of WCH has been
emphasized by other investigators who found that the
prevalence of WCH decreased from 25.8% from the first
clinic and first ABP to 13.6% after the fifth visit.33 In
addition, the incidence of WCH increases if the doctor,
instead of the nurse, takes the patient’s blood pressure,
and it has been proposed that physicians should not be
measuring blood pressures.34
TARGET ORGAN DAMAGE
The currently held view by most investigators is that
WCH is a fairly benign condition and is not associated
with target organ damage. This view is strengthened by
the fact that there is no difference in the left ventricular
mass index (LVMI) between normotensive individuals
and those with WCH.7,12,13,30,33,35,36 In contrast, others
have found that the LVMI was higher in subjects with
WCH compared with normotensive persons,25,26,37–41
although the LVMI values were within normal ranges for
both groups (Table 62-1). The effect of blood pressure or
left ventricular thickness is quantitative, and as blood
pressure increases, so does the left ventricular thickness
(Figure 62-1). This figure also shows that ABP is better
correlated with left ventricular thickness than with clinic
blood pressure.
Another measure of target organ damage is carotid inti-
mal medial thickness measured by ultrasonography. In a
study of subjects with normal blood pressures, WCH, and
sustained hypertension, the carotid intimal medial thickness
was 0.76 mm for those with normal blood pressure and
0.84 mm for those with WCH but was significantly higher,
0.98 mm, for those with sustained hypertension.35 In a simi-
lar study of normotensive, WCH, and sustained hyperten-
sive persons matched for age and sex, the left ventricular
mass, carotid intimal medial thickness, forearm vascular
resistance, and urinary albumin excretion were similar for
the normotensive and WCH subjects and much higher for
those with sustained hypertension.42 Similar findings were
also reported by Hoegholm and colleagues in 420 subjects

Table 62-1 Ambulatory Daytime Blood Pressure and Left Ventricular Mass Index in Normotensive Persons and Patients with
White Coat Hypertension
Blood Pressure, mm Hg LVMI, g/m2
Study Normotensive Group WCH Group Normotensive Group WCH Group
Cavallini et al35 126/77 130/79 78 82
Palatini et al36 120/74 121/74 82 88
Pierdomenico et al42 126/78 128/78 94 98
Verdecchia et al13 125/81 124/79 87 93
White et al37 120/78 126/79 91 97
Cerasola et al38 119/76 130/82* 81 93*
Cardillo et al40 113/78 126/88* 82 103*
Kuwajima et al41 129/69 138/78* 91 119*
Pose-Reino et al39 114/69 125/75* 106 132*
Grandi et al25 125/74 126/74 85 103*

LVMI = left ventricular mass index; WCH = white coat hypertension.

*Values significantly higher than those in normotensive persons.

150
r = 0.64
140 p < 0.003
n = 20
130
LVMI, g/m2
120
110
100
90
80
70
100 110 120 130 140 150 160
A Clinic systolic BP, mm Hg
Figure 62-1 The figure depicts data from six published studies relating clinic systolic blood pressure (SBP) to left ventricular mass index (LVMI).
A, Clinic SBP. B, Daytime mean ambulatory SBP. Each point represents the average value for one group of subjects (subjects with white coat
hypertension or patients with sustained hypertension). The blood pressure effect is continuous and is more closely correlated with the daytime
ambulatory than clinic blood pressure. Adapted from Chrysant SG.8
with normotension, WCH, and established hypertension.33
With respect to cardiovascular event rate (fatal, nonfatal
cardiovascular events), Verdecchia and colleagues reported
an incidence of 0.47 in 100 patient-years for normotensive
subjects, 0.49 in 100 patient-years for subjects with WCH,
and 1.79 in 100 patient-years for patients with sustained
hypertension among 1,187 patients from the PIUMA
study.30 The cardiovascular event rate was even higher: 4.9
in 100 patient-years for nondippers compared with 1.79 in
100 patient-years for dippers. Complementary to these find-
ings are those reported by Kario and colleagues regarding
the incidence of silent and clinically overt strokes in older
Japanese subjects with normal blood pressure, WCH, and
sustained hypertension.24 After a follow-up period of 42
months, they found no difference in the incidence of strokes
between the normotensive and WCH subjects in contrast to
sustained hypertensive subjects who had a significant inci-
dence of strokes. In most cases, the differences in outcomes
are due to different cutoff levels for normal ABP used by the
different investigators. Those using higher cutoff levels (ABP
> 135/80 mm Hg) had higher target organ damage than
those using lower levels (ABP  135/80 mm Hg). It is
hoped that future studies using the standardized normal
levels for ABP from the JNC-722 and the European Society
of Hypertension and the European Society of Cardiology23
will define whether WCH is a benign condition.
White Coat Effect
DEFINITION
WCE is defined as the difference between the average clinic
blood pressure and daytime ABP or home blood pres-
White Coat Hypertension and White Coat Worse Hypertension / 539
150
r = 0.74
140 p < 0.0002
n = 20
130
120
LVMI, g/m2
110
100
90
80
70
170 110 120 130 140 150 160
B Daytime systolic BP, mm Hg
sure.8,10,13–15 The WCE should not be confused with WCH
because it occurs in subjects with sustained hypertension,
treated or untreated, in whom the ABP is lower than the
office blood pressure. The WCE is conceived as the increase
in blood pressure that occurs at the time of the clinic visit
and dissipates soon thereafter. Therefore, the WCE is a
measure of blood pressure change, whereas WCH is a
measure of blood pressure level. The difference in blood
pressure between the clinic and the outside setting is quite
variable and depends on whether low-normal or high-
normal clinic blood pressure levels are used (eg, 140/90 mm
Hg or less) and the activity of the patient while wearing the
ABP monitor. Inactivity tends to increase the difference,
whereas activity, cigarette smoking, or alcohol drinking will
tend to decrease the difference by increasing the ABP. The
mechanisms underlying the WCE are not well defined but
may include anxiety or a hyperalerting response to the clinic
setting and can vary from 14/9 to 27/14 mm Hg for systolic
and diastolic blood pressure, respectively,13,15 especially
during the first few minutes of the visit. Stergiou and
colleagues reported that treatment of hypertension
decreases the WCE but does not abolish it.14 Also, the differ-
ence in WCE is smaller between self-measurement and
clinic blood pressure than between ABP and clinic pressure.
PREVALENCE
The prevalence of WCE varies from study to study.
Pickering and colleagues stated that WCE is a universal
phenomenon and is seen to a greater or lesser extent in
most, if not all, hypertensive patients. 15 In contrast,
Stergiou and colleagues found it in 27% of untreated
versus 20% of treated hypertensive patients.14 The WCE
540 / Advanced Therapy in Hypertension and Vascular Disease
is more common in women, the elderly, patients with
severe hypertension, and obese subjects.4,10,13
TARGET ORGAN DAMAGE
Most investigators believe that the WCE is a fairly benign
phenomenon and does not exert any additional harmful
effects over and above the blood pressure outside the
clinic.43,44 However, other investigators have found a
significant correlation with WCE and target organ
damage, especially in those patients who demonstrate
higher values for this effect.45 Besides these different
reports, the consensus of opinion is that this is a very
temporary phenomenon occurring during the clinic visit
and should not have any adverse clinical conse-
quences.13,15 Future studies might clarify this issue.
White Coat Worse Hypertension
DEFINITION
WCWH has recently been described with different defin-
itions, such as “inverse white coat hypertension,” 16
“reverse white coat hypertension,”17,18 or “white coat
normotension.” 19,20 In this chapter, I use the term
WCWH, which is more descriptive of the condition and
causes less confusion. This phenomenon refers to higher
mean daily ABP than office blood pressure and is the
opposite of WCH. Numerically, WCWH is defined as
office blood pressure < 140/90 mm Hg and home or
daytime ABP > 135/85 mm Hg.
PREVALENCE
The prevalence of WCWH has been estimated to be
between 14 and 24%16,18 and up to 45% of patients with
high daytime ambulatory systolic or diastolic blood pres-
sure.19,20 This depends on the definition of normal clinic
blood pressure. Hernandez Del-Rey and colleagues
reported an incidence of WCWH of 14% among 211
patients with grade 1 to 2 clinic hypertension,16 whereas
Liu and colleagues found an incidence of WCWH of 20%
among 295 clinically normotensive subjects.20 Similar
results were reported by Selenta and colleagues, who
found an incidence of 23% and 24% for WCWH for
systolic and diastolic blood pressure, respectively, among
319 subjects.19 On the other hand, Wing and colleagues
found an incidence of WCWH of 21% when the systolic
blood pressure was considered and 45% when the dias-
tolic blood pressure was taken into account.18 These data
were extracted from a sample of 713 elderly hypertensive
patients whose ABP was measured, of a total cohort of
6,085 patients, who participated in the Second Australian
National Blood Pressure Study (ANBP2). All of these
studies found that WCWH is more common in males,
the elderly, cigarette smokers, and alcohol drinkers.
However, it should be stressed that the true incidence of
WCWH is difficult to identify because most, if not all,
hypertensive patients are diagnosed with clinic blood
pressure measurements and it is difficult to justify ABP
measurements in such individuals. Easier to identify are
treated hypertensive individuals, who present to the
clinic with uncontrolled hypertension. However, if
patients with normal clinic blood pressure show target
organ damage, WCWH should be suspected.
TARGET ORGAN DAMAGE
WCWH is more serious with respect to target organ
damage than isolated clinic hypertension. Many studies
have shown that target organ damage is correlated more
with ABP than clinic blood pressure.30,46 Recent studies
have shown that the LVMI and the carotid intimal medial
thickness are higher in subjects with WCWH than in
those with WCH or sustained normotension.16,20 The
true prevalence and significance of WCWH are not
known at present. Most investigators believe that it is not
a true pathologic condition but is mostly due to different
stimuli, such as cigarette smoking, alcohol drinking, and
physical activity. However, the true physical prognostic
significance of WCWH must be defined in prospective
observational studies and randomized clinical trials that
use actual morbid event rates.
Management
WHITE COAT HYPERTENSION
The diagnosis of WCH must be established before any
treatment is initiated. The diagnosis should be based on
the criteria discussed earlier, and after the patient has had
three visits to the doctor’s office and has a normal ABP,
then the course of treatment should be decided. The use
of antihypertensive drugs in subjects with WCH is
controversial because several large studies have shown
that this condition is fairly benign and that antihyperten-
sive drugs seem to have a negligible effect on ABP in these
subjects.47,48 In the Hypertension And Lipid Trial (HALT)
study, Pickering and colleagues reported that the adminis-
tration of doxazosin, an 1 receptor blocker, decreased the
ABP in patients with sustained hypertension but not in
those with WCH, although it was equally effective in
reducing the clinic blood pressure in both groups.48 Other
investigators have also shown that the ABP is not affected
by antihypertensive treatment in contrast to clinic blood
pressure, when the decision to treat is based on clinic
blood pressures.49,50 These studies suggest that the inef-
 White Coat Hypertension and White Coat Worse Hypertension / 541
fectiveness of antihypertensive treatment in WCH is
mostly due to the level of ABP because patients with low-
normal ABP were most resistant to treatment. Fagard and
colleagues also showed that a daytime ABP of 128/88 mm
Hg was resistant to treatment with isradipine and lisino-
pril.47 Given the evidence today regarding the ineffective-
ness of antihypertensive treatment in subjects with WCH
and the results of the Hypertension Optimal Treatment
(HOT) study, that there was no cardiovascular benefit
with reducing the blood pressure to less than
138.5/86.5 mm Hg, except in diabetic patients,51 pharma-
cologic treatment of WCH is not advisable. Instead, a
nonpharmacologic approach to management of WCH
should be instituted. Nonpharmacologic management
should include modification of the subject’s lifestyle,
moderate salt restriction, weight loss if the subject is
obese, regular aerobic exercise, cessation of cigarette
smoking, moderation of alcohol consumption, correction
of blood glucose and lipid abnormalities, and regular
follow-ups by ABP monitoring every 6 to 12 months. This
will result in early detection of those subjects who will
develop sustained hypertension because WCH has been
considered by some as a prehypertensive condition. It has
been estimated that approximately 37% of those subjects
with WCH will eventually develop sustained hypertension
after 2 to 3 years.52 The cost-effectiveness of ABP moni-
toring as an adjunct to conventional clinic blood pressure
measurement is a matter of debate, although ABP moni-
toring is now funded by Medicare with a meager compen-
sation and great restrictions to its use.5 However, ABP
monitoring has certain advantages over office blood pres-
sure monitoring because it provides better information
on blood pressure levels over a 24-hour period instead of
a single office blood pressure measurement. This informa-
tion has significant bearing on the continued effectiveness
of antihypertensive drugs and the blood pressure load,
which is better correlated with target organ damage.53
The suggestion by some investigators that physicians
should stop measuring blood pressures at the office and
be replaced by qualified nurses34 could lead to a great
reduction or even elimination of WCH.
WHITE COAT EFFECT
As discussed previously, the WCE is a benign condition,
occurring only temporarily during the office visit and
dissipating soon thereafter. There is no substantial
evidence at present from large studies in hypertensive
subjects with long-term follow-up that the presence of the
WCE is associated with target organ damage or increased
morbidity and mortality. 13 Therefore, no additional
medical therapy is needed over and above that required
for good blood pressure control outside the clinic envi-
ronment, despite the current view that blood pressure
management should be based on clinic blood pressures.
The WCE can be significantly ameliorated, besides good
blood pressure control, by weight loss and having nurses
check the blood pressure at the clinic instead of doctors.34
WHITE COAT WORSE HYPERTENSION
WCWH can be very elusive in its detection and treat-
ment because in the great majority of cases, the diagnosis
of hypertension is based on clinic blood pressures. In
addition, treatment decisions regarding hypertension are
still based on clinic blood pressure measurements; there-
fore, justification to treat these patients with office
normal blood pressure levels is difficult. The presence of
WCWH should be suspected in patients with high
normal clinic blood pressure (140/90 mm Hg), the
elderly, smokers, and drinkers. The actual daytime ABP
should be verified by instructing patients to avoid exces-
sive physical activity, cigarette smoking, and alcohol
drinking while wearing the ABP monitor. Also, when
they return to the clinic, they should not be allowed to
rest but should have their blood pressure checked manu-
ally while wearing the monitor. This provides a clearer
picture regarding the influence of the clinic environment
on blood pressure. Those patients who consistently
present with higher ABP readings than clinic readings
should be treated accordingly because ABP is better
correlated with target organ damage and cardiovascular
morbidity and mortality than isolated clinic blood pres-
sure.46,53 However, more studies are needed to under-
stand the prognostic significance of WCWH.
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