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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e132

Synopsis

The availability of out-of-office BP monitoring provides differentiation of hypertension into several clinically relevant categories based on the concordance or dis­ cordance of office BP and out-of-office BP, including white-coat hypertension and masked hypertension for individuals not taking antihypertensive medication and white-coat effect and masked uncontrolled hyperten­ sion for those taking antihypertensive medication (Table 9).16,17 ABPM has been the reference standard for outof-office BP monitoring, as there are more studies that have examined the association between ABPM and CVD outcomes than studies that have examined the associa­ tion between HBPM and CVD outcomes.18,19 However, there are scarce data demonstrating that ABPM is su­ perior to HBPM or vice versa for CVD risk prediction.20,21 ABPM is preferred for excluding white-coat hyperten­ sion and masked hypertension among individuals not taking antihypertensive medication. However, HBPM is preferred for excluding a white-coat effect and masked uncontrolled hypertension among individuals taking an­ tihypertensive medication as ABPM is more difficult to conduct repeatedly in clinical practice. In RCTs demon­ strating a reduction in CVD events with the lowering of BP with antihypertensive medication, office BP has been used as a target for titration instead of out-of-office BP.22 There are scarce data on the cardiovascular risks of not treating white-coat hypertension and not intensifying treatment for white-coat effect and the benefits of treat­ ing masked hypertension and intensifying treatment for masked uncontrolled hypertension.

Recommendation-Specific Supportive Text

1 Systematic reviews and meta-analyses of observa­

tional studies have demonstrated that compared with sustained normotension, white-coat hypertension is associated with no risk to a moderately increased risk of CVD.1–5 The risk of CVD associated with whitecoat hypertension may only be increased among older adults who have high baseline CVD risk.1,23 Nonetheless, the risk of CVD is higher in sustained hypertension than in white-coat hypertension among adults with high office BP.24 Therefore, it is reason­ able to exclude white-coat hypertension using outof-office BP monitoring for adults with high office BP (ie, SBP/DBP ≥130/80 mm Hg). One caveat is that adults with office SBP/DBP ≥160/100 mm Hg should be promptly treated and antihypertensive medication dose titrated as necessary to control BP (Section 5.2, “Medical Management”). The prevalence of white-coat hypertension is low among those with office BP levels in this range.25,26

2 Studies have demonstrated that compared with

individuals with sustained normotension, a higher proportion of individuals with white-coat hyperten­ sion or masked hypertension have sustained hyper­ tension during follow-up.6–8 An additional study27 demonstrated that compared with individuals with sustained normotension, a higher proportion of individuals with white-coat hypertension had high out-of-office BP during follow-up. Therefore, it is reasonable to conduct out-of-office BP monitoring to exclude sustained hypertension among those initially identified with white-coat hypertension or masked hypertension. The frequency of follow-up monitoring is unclear as only a single visit was con­ ducted at follow-up in these studies (ie, approxi­ mately 7 to 11 years after the baseline visit).6–8,27

3 Studies have consistently demonstrated that com­

pared with controlled hypertension, white-coat effect is not associated with an increased risk of CVD events and mortality.9,11 Evidence also sug­ gests that higher out-of-office BP is associated with an increased risk of CVD events, indepen­ dent of office BP, among individuals with apparent resistant hypertension.10,12 Out-of-office BP moni­ toring is a central component of the initial work-up of apparent resistant hypertension (Section 5.6, “Resistant Hypertension and Renal Denervation”). Therefore, it is reasonable to exclude a white-coat effect using out-of-office BP monitoring for indi­ viduals with apparent resistant hypertension. 4.	 Systematic reviews and meta-analyses have

demonstrated that compared with controlled

Table 9.  BP Categories Based on Office and Out-of-Office BP Measurements

BP Category High BP in the Office Setting? High BP Outside of the Office Setting?* Among individuals not taking antihypertensive medication Sustained normotension No No Sustained hypertension Yes Yes Masked hypertension No Yes White-coat hypertension Yes No Among individuals taking antihypertensive medication Controlled hypertension No No Uncontrolled hypertension Yes Yes Masked uncontrolled hypertension No Yes White-coat effect Yes No *Please refer to Table 7 for office BP and out-of-office BP thresholds used to define high BP. High out-of-office BP is defined as SBP ≥130 mm Hg or DBP ≥80 mm Hg when using awake BP and SBP ≥125 mm Hg or DBP ≥75 mm Hg when using 24-hour BP. These BP thresholds correspond to an office SBP ≥130 mm Hg or DBP ≥80 mm Hg. Out-of-office BP is primarily based on mean awake BP or mean 24-hour BP. It remains unclear whether asleep BP should be used to determine high out-of-office BP as the prevalence and reproducibility of isolated nocturnal hypertension (high asleep BP without high awake BP) are both low.36,37 Further, there is no high-quality randomized controlled trial evidence to indicate that lowering asleep BP reduces CVD risk.38,39 Modified with permission from Whelton et al.40 Copyright 2018 American College of Cardiology Foundation and American Heart Association, Inc.

BP indicates blood pressure.

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