Jordana B. Cohen, MD, MSCE; Michael J. Lotito; Usha K. Trivedi, BS; Matthew G. Denker, MD, MSCE; Debbie L. Cohen, MD; Raymond R. Townsend, MD
Disclaimer: The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the National Institutes of Health (NIH).
Grant Support: By NIH grant K23-HL133843 to Dr. J.B. Cohen.
Disclosures: Dr. J.B. Cohen reports grants from the NIH, National Heart, Lung, and Blood Institute, during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0223.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement:Study protocol: See the Supplement. Statistical code: Available from Dr. J.B. Cohen (e-mail, email@example.com). Data set: See Supplement Tables 1 to 6. Additional data are available from Dr. J.B. Cohen (e-mail, firstname.lastname@example.org).
Corresponding Author: Jordana B. Cohen, MD, MSCE, 423 Guardian Drive, Blockley 831, University of Pennsylvania, Philadelphia, PA 19104; e-mail, email@example.com.
Current Author Addresses: Dr. J.B. Cohen: 423 Guardian Drive, Blockley 831, University of Pennsylvania, Philadelphia, PA 19104.
Mr. Lotito: 0696 Frist Center, Princeton University, Princeton, NJ 08544.
Drs. Denker, D.L. Cohen, and Townsend: 3400 Spruce Street, 1 Founders, Hospital of the University of Pennsylvania, Philadelphia, PA 19104.
Author Contributions: Conception and design: J.B. Cohen, D.L. Cohen, R.R. Townsend.
Analysis and interpretation of the data: J.B. Cohen, R.R. Townsend.
Drafting of the article: J.B. Cohen, M.J. Lotito, M.G. Denker.
Critical revision for important intellectual content: J.B. Cohen, U.K. Trivedi, M.G. Denker, D.L. Cohen, R.R. Townsend.
Final approval of the article: J.B. Cohen, M.J. Lotito, U.K. Trivedi, M.G. Denker, D.L. Cohen, R.R. Townsend.
Obtaining of funding: J.B. Cohen.
Collection and assembly of data: J.B. Cohen, M.J. Lotito, U.K. Trivedi.
The long-term cardiovascular risk of isolated elevated office blood pressure (BP) is unclear.
To summarize the risk for cardiovascular events and all-cause mortality associated with untreated white coat hypertension (WCH) and treated white coat effect (WCE).
PubMed and EMBASE, without language restriction, from inception to December 2018.
Observational studies with at least 3 years of follow-up evaluating the cardiovascular risk of WCH or WCE compared with normotension.
2 investigators independently extracted study data and assessed study quality.
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.
Paucity of studies evaluating isolated cardiac outcomes or reporting participant race/ethnicity.
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.
National Institutes of Health.
Cohen JB, Lotito MJ, Trivedi UK, et al. Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis. Ann Intern Med. 2019;170:853–862. [Epub ahead of print 11 June 2019]. doi: https://doi.org/10.7326/M19-0223
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Published: Ann Intern Med. 2019;170(12):853-862.
Published at www.annals.org on 11 June 2019
Cardiology, Coronary Risk Factors, Hypertension, Nephrology.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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