Q: Many of my patients appear to have white-coat
hypertension: their pressure is elevated when
measured in my office—but normal when measured at
home. Am I ignoring significant hypertension if I do not
treat these patients? Or am I overtreating if I do treat?
A: Most patients have lower blood pressure (BP) at
home than in the physician's office. Measurements
taken with ambulatory BP instruments are lower than office
readings by about 10 mm Hg. My recommendation is
to target treatment to office BP measurements. Office readings
should be below 140/90 mm Hg in healthy adults, and
below 135/85 to 130/80 mm Hg in adults with diabetes.
Take time to measure BP correctly: for example, measurement
should be done after the patient has been sitting for 5
minutes—not after he or she has just bolted up the steps.
A significant discrepancy (that is, 8 to 10 mm Hg) between
office and home BPs is cause for concern. But the office
measurement is what counts for most patients: all clinical
trials, therapy benefits, epidemiologic reports, and risk calculations
are based on those numbers. Newer studies show that
ambulatory BP may better reflect target organ damage; however,
we do not have a significant number of studies in which
ambulatory BP was tied to clinical outcomes such as stroke.
In rare cases, there is a dramatic difference between office
and home BPs (for example, systolic pressure of 170 mm Hg in
the office and 110 or 120 mm Hg at home). For such a patient,
ambulatory BP measurement is particularly useful. Home BP
instruments are not uniformly reliable, however. If a patient
needs or wants to take BP measurements at home, have him
bring the machine to the office so it can be calibrated.
Q: Should I treat a patient whose office BP is only
mildly elevated, say 144 or 148 mm Hg over 70 or
80 mm Hg, if his home systolic pressure is 130 mm Hg?
A: The treatment of patients with hypertension should
be based on global risk rather than BP level alone.
The goal of antihypertensive therapy is not simply to lower
BP but to prevent morbidity and mortality. When a patient
has what appears to be mildly elevated BP, consider ambulatory
BP monitoring or look for evidence of target organ
damage. If echocardiography shows left ventricular hypertrophy
or if the patient has microalbuminuria, I would recommend
antihypertensive therapy. If the patient has no comorbidities,
I would be less inclined to treat.
It is unlikely that we will ever have hard clinical data that
clearly show the benefits of treating patients with mildly elevated
pressures. I don't foresee a clinical trial that compares outcomes
in normotensive patients with those who have mild hypertension
and no other risk factors. However, a growing body
of evidence indicates the need to treat patients with mildly elevated
BP who have an additional risk factor, such as diabetes.
Q: For which patients with elevated BP should
I consider a trial of diet and exercise—and for
A: The most important nonpharmacologic measures are
weight loss and sodium reduction. A low-fat, low-sodium
diet such as the DASH diet is beneficial.1 However, if
systolic pressure is high—for example, 160 or 170 mm
Hg—it is unlikely that nondrug therapy alone will make the
patient normotensive. In this setting, a recommendation
that a patient lose weight and return to your office in 6
months is not advisable.
On the other hand, if a patient has stage 1 isolated systolic
hypertension—that is, pressures of 140 to 150 mm
Hg—a 3- to 6-month nondrug therapy trial may be appropriate,
just as it would be for a patient with diastolic hypertension.
In this situation, however, the patient needs to be
closely followed. If you don't see the patient for several
months, his BP may have risen significantly. Furthermore,
adherence to nonpharmacologic therapy programs depends
in large measure on frequent contact between the patient
Q: Many of my patients have a hard time complying
with nonpharmacologic strategies. What do you
A: Compliance success—or failure—depends on the
particular patient and on how the strategy is implemented.
In general, long-term weightloss
programs are more successful if
dietary change is associated with an
exercise program and with social support
and encouragement. The Trial of
Nonpharmacologic Interventions in
the Elderly (TONE) investigators
found that after BP had been controlled
for 1 year, antihypertensive
medication could be safely withdrawn
in persons aged 60 to 80 years whose
BP was 150/90 mm Hg or lower and
who had no clinical evidence of cardiovascular
good BP control could be maintained
with nonpharmacologic therapy.2 Patients
were very compliant. Moreover,
patients in the combined weight
loss/sodium reduction group had a 53% lower chance of remaining
free of a trial end point (sustained BP of 150/90
mm Hg or higher, a clinical cardiovascular event, or a decision
to resume BP medication) for the duration of the study
compared with patients in the usual-care group.
However, this study was unusual in that patients met
with dietitians frequently. These dietitians went shopping
with patients, taught them how to buy the right food, how
to read lists of ingredients, and even how to cook.
Q:Is there an age beyond which patients no longer
benefit from antihypertensive therapy?
A: Current guidelines advise against an age-specific cutoff
and recommend continuing to treat even very elderly
hypertensive patients.3 Some epidemiologic data show
that in persons 90 years or older who are not being treated
there is no absolute proof of incremental risk of stroke, heart
disease, and mortality with increasing BP. This issue is being
investigated in the Hypertension in the Very Elderly Trial
(HYVET)—an international study now under way that is
evaluating the effect of antihypertensive therapy on incidence
of stroke and cognitive function in patients 80 years
On the other hand, in clinical trials such as the Systolic
Hypertension in the Elderly Program (SHEP)—where we
enrolled persons 60 years and older, with no upper age
limit—there was no decrease in benefit for older people.5
Q: Many of my colleagues are turning to angiotensinconverting
enzyme (ACE) inhibitors as first-line
therapy for elderly patients with isolated systolic hypertension.
Is there convincing evidence
for such a practice?
A: ACE inhibitors have been shown
to decrease cardiovascular events
among patients at high risk with and
without hypertension. However, these
agents are not recommended as firstline
therapy for isolated systolic hypertension
in the Sixth Report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of
High Blood Pressure (JNC VI). This is
because in controlled clinical trials of
older persons with this condition, only
2 classes of drugs were more effective
than placebo: diuretics—such as
chlorthalidone—and long-acting calcium
channel blockers (CCBs)—such as nitrendipine.5,6 The
JNC VI guidelines therefore recommend diuretics ("preferred"
agents) or long-acting dihydropyridines.3
A low-dose diuretic—a thiazide or thiazidelike agent—at
a dosage of 12.5 to 25 mg/d is an easy and cost-effective way to
initiate antihypertensive therapy. Elderly patients may need additional
pharmacotherapy related or unrelated to their BP—
such as an ACE inhibitor for heart failure or a β-blocker or
CCB for angina.
The results of trials such as this argue against an agespecific
1. Sacks FM, Svetkey LP, Vollmer WM, et al, for the DASH-Sodium Collaborative
Research Group. Effects on blood pressure of reduced dietary sodium and
the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med. 2001;
2. Kostis JB, Espeland MA, Appel L, et al, for the Trial of Nonpharmacologic Interventions
in the Elderly (TONE) Cooperative Research Group. Does withdrawal
of antihypertensive medication increase the risk of cardiovascular events? Am J
3. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Rockville, Md: National Institutes of
Health; 1997. NIH publication 98-4080.
4. Bulpitt C, Fletcher A, Beckett N, et al. Hypertension in the Very Elderly Trial
(HYVET): protocol for the main trial. Drugs Aging. 2001;18:151-164.
5. Kostis JB, Berge KG, Davis BR, et al. Effect of atenolol and reserpine on selected
events in the systolic hypertension in the elderly program (SHEP). Am J Hypertens.
6. Fagard RH, Staessen JA, for the Systolic Hypertension in Europe (Syst-Eur)
Trial Investigators. Treatment of isolated hypertension in the elderly: the Syst-
Eur trial. Clin Exp Hypertens. 1999;21:491-497.
7. Sica DA, Bakris GL. Type 2 diabetes: RENAAL and IDNT—the emergence of
new treatment options. J Clin Hypertens (Greenwich). 2002;4:52-57.
8. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and
cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl
J Med. 2001;345:861-869.
9. American Diabetes Association: clinical practice recommendations 2002.
Diabetes Care. 2002;25(suppl 1):S1-S147.