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Meta-Analysis
. 2019 Jun 18;170(12):853-862.
doi: 10.7326/M19-0223. Epub 2019 Jun 11.

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

Jordana B Cohen  1 , Michael J Lotito  2 , Usha K Trivedi  3 , Matthew G Denker  1 , Debbie L Cohen  1 , Raymond R Townsend  1
Affiliations
Meta-Analysis

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis

Jordana B Cohen et al. Ann Intern Med. .

Abstract

Background: The long-term cardiovascular risk of isolated elevated office blood pressure (BP) is unclear.

Purpose: To summarize the risk for cardiovascular events and all-cause mortality associated with untreated white coat hypertension (WCH) and treated white coat effect (WCE).

Data sources: PubMed and EMBASE, without language restriction, from inception to December 2018.

Study selection: Observational studies with at least 3 years of follow-up evaluating the cardiovascular risk of WCH or WCE compared with normotension.

Data extraction: 2 investigators independently extracted study data and assessed study quality.

Data synthesis: 27 studies were included, comprising 25 786 participants with untreated WCH or treated WCE and 38 487 with normal BP followed for a mean of 3 to 19 years. Compared with normotension, untreated WCH was associated with an increased risk for cardiovascular events (hazard ratio [HR], 1.36 [95% CI, 1.03 to 2.00]), all-cause mortality (HR, 1.33 [CI, 1.07 to 1.67]), and cardiovascular mortality (HR, 2.09 [CI, 1.23 to 4.48]); the risk for WCH was attenuated in studies that included stroke in the definition of cardiovascular events (HR, 1.26 [CI, 1.00 to 1.54]). No significant association was found between treated WCE and cardiovascular events (HR, 1.12 [CI, 0.91 to 1.39]), all-cause mortality (HR, 1.11 [CI, 0.89 to 1.46]), or cardiovascular mortality (HR, 1.04 [CI, 0.65 to 1.66]). The findings persisted across several sensitivity analyses.

Limitation: Paucity of studies evaluating isolated cardiac outcomes or reporting participant race/ethnicity.

Conclusion: Untreated WCH, but not treated WCE, is associated with an increased risk for cardiovascular events and all-cause mortality. Out-of-office BP monitoring is critical in the diagnosis and management of hypertension.

Primary funding source: National Institutes of Health.

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Figures

Figure 1.
Figure 1.. Evidence search and selection
Abbreviations: CVD = Cardiovascular disease
Figure 2.
Figure 2.. Cardiovascular event risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
Figure 2.
Figure 2.. Cardiovascular event risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
Figure 2.
Figure 2.. Cardiovascular event risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
Figure 3.
Figure 3.. All-cause mortality risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
Figure 3.
Figure 3.. All-cause mortality risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
Figure 3.
Figure 3.. All-cause mortality risk in white coat hypertension and white coat effect
A) Untreated white coat hypertension B) Treated white coat effect C) Results not stratified by antihypertensive treatment
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