False versus true resistant hypertension

Research output: Chapter in Book/Report/Conference proceedingChapter


While in interventional studies and in clinical practice much attention has been given to the issues related to the treatment of resistant hypertension, only marginal attention has been devoted to the methodological aspects related to BP measurement that should be considered for a proper identification of resistant hypertension. Current definition of resistant hypertension (i.e., failure to control BP by a treatment based on adequate doses of a diuretic and two additional antihypertensive drugs) is still based on office blood pressure (BP) measurements obtained in the medical office, which are characterized by important acknowledged limitations among which the frequent interference by the "white-coat" effect. Following the introduction of ABPM and HBPM in clinical practice, several studies have repeatedly reported substantial disagreements between in-office and out-of-office BP measurement techniques, leading to identification of two new forms of hypertension, previously unknown when BP measurements were limited to the clinical setting: (1) the so-called white-coat hypertension (elevated in-office but normal out-of-office BP levels) and (2) "masked" hypertension (normal in-office but elevated out-of-office BP levels) [1, 2]. Although these terms were initially defined referring to subjects not yet receiving antihypertensive treatment during the initial diagnostic approach of hypertension, equivalent phenomena have been described among treated hypertensive subjects and are known as false resistant/ uncontrolled hypertension (white-coat resistant/uncontrolled hypertension, WCRH) and false BP control (masked resistant/uncontrolled hypertension (masked resistant/uncontrolled hypertension, MRH). Remarkably, observational and interventional studies implementing both in-office and out-of-office BP measurements for assessment of BP control have shown a substantial and sometimes higher-than-expected frequency of WCRH and MRH among treated hypertensive patients [3-5], indicating that OBP alone is insufficient to reliably assess BP control. Detection of these conditions with out-of-office BP monitoring is thus an essential step in the diagnostic approach to resistant hypertension. While identification of WCRH may avoid performing unnecessary and costly diagnostic tests, or exposing subjects to the adverse effects associated with multidrug therapy, detection of MRH would allow early implementation of adequate BP-lowering strategies to achieve daily-life BP control, thus preventing the adverse cardiovascular consequences associated with this condition. The present chapter is aimed at addressing the initial diagnostic approach to the patient who presents with resistant hypertension in the medical office focusing on the role of ABPM and HBPM in defining whether the failure to achieve OBP control actually corresponds to true resistant hypertension. A general outlook to the advantages of implementing out-of-office BP measuring techniques for assessment of BP control in treated hypertensive patients is also provided.

Original languageEnglish
Title of host publicationResistant Hypertension: Epidemiology, Pathophysiology, Diagnosis and Treatment
PublisherSpringer-Verlag Italia s.r.l.
Number of pages17
ISBN (Print)9788847054158, 8847054141, 9788847054141
Publication statusPublished - Nov 1 2013

ASJC Scopus subject areas

  • Medicine(all)


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