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................................................................................ When hypertension is suspected, the diagnosis of hypertension should be confirmed, either by repeated office BP measurements over a number of visits, or by 24-h ABPM or HBPM (Figure 14).

4.7.3.1 White-coat and masked hypertension White-coat hypertension refers to BP that is elevated in the office but is normal when measured by ABPM or HBPM. It occurs in up to 3040% of patients. The risk associated with white-coat hypertension is lower than sustained hypertension but may be higher than normotension. People with white-coat hypertension should receive lifestyle advice to reduce their CV risk and be offered BP measurement at least every 2 years by ABPM or HBPM because of high rates of transition to sustained hypertension. Routine drug treatment for white-coat hypertension is not indicated. Masked hypertension refers to patients with a normal office BP but an elevated BP on ABPM or HBPM. These patients often have HMOD and are at a CV risk level at least equivalent to sustained hypertension. It is more common in younger people and in those with high-normal office BP. In masked hypertension, lifestyle changes are recommended, and drug treatment should be considered to control ‘out-of-office’ BP, with periodic monitoring of BP, usually with HBPM.

4.7.4. Clinical evaluation and risk stratification in hypertensive patients The routine work-up for hypertensive patients is shown in Table 16. Alongside clinical examination, this is designed to:

Table 15 Indications for home blood pressure monitoring or ambulatory blood pressure monitoring

Conditions in which white-coat hypertension is more common, for example: • Grade 1 hypertension on office BP measurement • Marked office BP elevation without HMOD Conditions in which masked hypertension is more common, for example: • High-normal office BP • Normal office BP in individuals with HMOD or at high total CV risk Postural and post-prandial hypotension in untreated and treated patients Evaluation of resistant hypertension Evaluation of BP control, especially in treated higher-risk patients Exaggerated BP response to exercise When there is considerable variability in the office BP Evaluating symptoms consistent with hypotension during treatment

Specific indications for ABPM rather than HBPM: • Assessment of nocturnal BP values and dipping status (e.g. suspicion

of nocturnal hypertension, such as in sleep apnoea, CKD, DM, endocrine hypertension, or autonomic dysfunction) ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; DM = diabetes mellitus; HBPM = home blood pressure monitoring; HMOD = hypertension-mediated organ damage.

Screening and diagnosis of hypertension

Repeat visits for office BP measurement

OR Out-of-office BP measurement (ABPM or HBPM)

Repeat BP measurement a least annually

Repeat BP measurement a least every 5 years Repeat BP measurement at least every 3 years Blood pressure measurement Indications

for ABPM or HBPM

Out-of-office BP measurement (ABPM or HBPM)

High-normal 130–139 mmHg / 85–89 mmHg

Optimal <120/80 mmHg Normal 120–129 mmHg / 80–84 mmHg Hypertension ≥140/90 mmHg

Consider masked hypertension

Figure 14 Screening and diagnosis of hypertension. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.

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