When can the practicing physician suspect white coat hypertension? Statement from the Working Group on Blood Pressure Monitoring of the European Society of Hypertension.

T he Centers for Medicare and Medicaid Services (CMS) in the United States have recently approved ambulatory blood pressure measurement (ABPM) for reimbursement, but only for “patients with suspected WCH (white coat hypertension)” in whom the CMS believes the information deriving from the technique “is necessary in order to determine the appropriate management of the patient.” This decision, which is likely to change the clinical management of hypertension in the United States, makes white coat hypertension a condition of major importance. The decision by the CMS begs the question as to how the practicing physician can select patients with white coat hypertension. It might indeed be argued that all patients with an elevated clinic blood pressure (BP) are candidates for ABPM. However, the CMS decision carries a few other stipulations. First, white coat hypertension should be defined as “office BP 140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit.” Second, in addition “there should be at least two BP measurements taken outside the office which are 140/90 mm Hg.” Third, “there should be no evidence of endorgan damage.” Fourth and last, patients selected for ABPM on the foregoing criteria who have” an ambulatory BP 135/85 (presumably average daytime pressure, although this is not stated) with no evidence of end-organ damage” are likely to be at normal risk, whereas those patients whose pressures are above this level “may be at increased cardiovascular risk, and a physician may wish to consider antihypertensive therapies.” In anticipation of a considerable increase in the use of ABPM in clinical practice in the United States, it is timely to examine the CMS recommendations in the light of recent evidence from a number of studies on WCH.