Faculty Bibliography

The diagnosis of masked hypertension has been made easier with the widespread availability of home blood pressure monitoring devices with levels of accuracy comparable to ambulatory blood pressure monitoring. The negative impact of masked hypertension on cardiovascular morbidity and mortality is evidenced by numerous well-designed clinic-based and population-based studies. The relationship of masked hypertension and target organ damage is also well documented. These two factors, combined with the robust evidence of reduced cardiovascular morbidity and mortality achieved with blood pressure treatment, makes the argument for actively identifying patients with masked hypertension and prescribing treatment similar to that for patients with sustained hypertension. In this paper, we review the evidence for the cardiovascular prognosis of masked hypertension compared with sustained hypertension, we review its impact on target organ damage, we propose an algorithm for the treatment of patients with masked hypertension, and we point out the pitfalls in adopting such an approach

The contribution of Dr Thomas Pickering's study to the measurement of blood pressure (BP) is the defining aspect of his academic career and achievement - narrowly defined. In this regard, two important areas characterized his study as it relates to masked hypertension. First, he introduced the term, masked hypertension, to replace the rather inappropriate term 'reverse white-coat hypertension' and 'white-coat normotension'; thus drawing attention to the fact that these patients are genuinely hypertensive by ambulatory BP but were missed by normal office BP. More importantly, he rightly maintained that masked hypertension is a true continuum of sustained hypertension rather than an aberrant measurement artifact. Second, is his pivotal study on the important role of psychosocial factors as a potential mechanism for the development of masked hypertension. In this regard, he explained masked hypertension as a conditioned response to anxiety in office settings, and highlighted the role that diagnostic labeling plays in its development. His view of masked hypertension is that of a continuum from prehypertension (based on office BP measurement) to masked hypertension (based on ambulatory BP) and finally to sustained hypertension (based on both office and ambulatory BP). He strongly believes that it is the prehypertensive patients who progress to masked hypertension. Subsequently, patients who are prehypertensive should be screened for masked hypertension and treated. In this manuscript, we summarize his study as it relates to the definition of masked hypertension, the psychosocial characteristics, mechanisms and its clinical relevance