# White Coat Hypertension in Primary Care: A Narrative Review

## TL;DR

White coat hypertension, where blood pressure is high in clinics but normal elsewhere, may not be harmless and needs careful monitoring and management to avoid over-treatment and reduce risks.

## Contribution

This paper reviews the challenges in diagnosing and managing white coat hypertension in primary care and suggests strategies to improve its identification and treatment.

## Key findings

- White coat hypertension is linked to increased risks of cardiovascular events and mortality.
- There is no universal definition or treatment approach for white coat hypertension.
- Barriers to diagnosis include cost, access to monitoring, and provider knowledge gaps.

## Abstract

White coat hypertension (WCH) is the presence of elevated blood pressure (BP) in clinical settings, despite normal readings outside of the office, measured through ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM), in untreated individuals. WCH is associated with increased risk of sustained hypertension (SH), target organ damage (TOD), metabolic syndrome, and cardiovascular (CV) events. The prevalence of WCH is not consistent across studies due to different BP cut-offs used and varies depending on the definition of WCH and the cohort studied. There is no universally defined approach to its definition, with variability among the American College of Cardiology (ACC)/American Heart Association (AHA), European Society of Hypertension (ESH), and National Institute for Health and Care Excellence (NICE) guidelines.

There is insufficient evidence from randomized controlled trials on whether WCH requires treatment. Current guidelines suggest lifestyle interventions and monitoring for patients with no additional CV risk factors, and lifestyle interventions along with drug treatment for those patients with increased CV risk or with hypertension-mediated organ damage. Annual ABPM or HBPM is advised to track progression to SH. Studies have shown that WCH may not be benign, with some evidence linking it to an increased risk of CV events and total mortality.

Several barriers hinder effective diagnosis in primary care, including cost, limited access to ABPM, provider knowledge gaps, and patient non-compliance with HBPM protocols. Improvement strategies include health provider training, patient education, enhanced physician-patient communication, and potential use of telemedicine for remote BP monitoring. Strengthening the patient-physician relationship may also reduce anxiety-driven BP elevations during clinic visits.

Addressing these barriers through policy changes and behavioral interventions can enhance the identification and management of WCH, prevent overtreatment, and reduce healthcare costs.