White Coat Hypertension & Masked Hypertension

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white coat hypertension functional cardiovascular medicineWhite coat hypertension is a condition where your blood pressure is elevated when you are at the doctor’s office but nowhere else.

I would argue that most of the patients in our Tulsa, OK Functional Medicine clinic have blood pressure greater than 120/80. If you haven’t read my post on hypertension then you should definitely check it out. That post will talk about the ranges for blood pressure and why >120/80 is a problem.

Regardless, when I review their blood pressure with them many of these patients will simply reply “oh, its no big deal. I just have white coat hypertension.” I guess they think it isn’t a problem.

Reality tells a different story.

First, the only real way to know if you have white coat hypertension is to get a 24-hour ambulatory blood pressure monitor (ABPM).

Next, white coat hypertension definitely DOES increase your risk of cardiovascular disease!

A meta-analysis of 7382 patients in 25 studies evaluated white coat hypertension. 2493 patients were normotensive and 3184 were hypertensive. The authors concluded that “alterations in cardiac structure and function in white coat hypertension patients, as defined by ambulatory blood pressure monitoring, are intermediate between sustained hypertensive patients and normotensive controls. The study supports the view that white coat hypertension should not be further considered a fully benign entity.”1

This meta-analysis looked at left ventricular mass and left atrial diameter. Patients in this study with white coat hypertension had alterations in these measurements indicating that white coat hypertension has a detrimental effect on the cardiovascular system. That is not a good thing.

Another study reviewed 14 studies with 29,100 patients. 13,538 of these patients had normal blood pressure while 4806 had white coat hypertension and 10,756 had sustained hypertension. They followed these patients for 8 years. They noticed that the patients with white coat hypertension had an increased rate of cardiovascular disease morbidity and mortality compared with normotensive patients. Patients with sustained hypertension had even higher risks, significantly so, than those with white coat hypertension.2

The point here is that white coat hypertension is NOT completely benign. It IS associated with an increased risk of cardiovascular disease events and deaths.

When you consider that cardiovascular disease is the #1 killer of men and women we need to do everything we can to lower every patients’ risks. White coat hypertension is associated with increased risk and should be optimized through a comprehensive functional cardiovascular medicine program.

Masked Hypertension

Masked hypertension is basically the opposite of white coat hypertension. It is characterized by normal blood pressure in the clinic but elevated everywhere else. The scary thing about this one is that it is harder to pick up, at least by traditional methods (when your doctor measures your blood pressure in the office).

The incidence of masked hypertension is about 10-15%. Masked hypertension is associated with an increased risk of cardiovascular disease and target organ damage.4,5

Risk factors for masked hypertension include: male gender, relatively young age, high stress, increased physical activity, and smoking/drinking. If you notice sporadically elevated blood pressures but your blood pressure is normal in the doctor’s office then you need an ambulatory blood pressure monitor.

“The high prevalence of masked hypertension would suggest the necessity for measuring out-of-office BP in persons with apparently normal or well-controlled office BP.”5

Patients at high risk should have an ambulatory blood pressure monitor. Those with kidney disease, diabetes, smoking history, and any number of other conditions that increase risk for hypertension should have an ambulatory blood pressure monitor.

Masked hypertension comes with an increased risk of left ventricular hypertrophy, increased CIMT, increased pulse wave velocity, and impaired endothelial function. The increased risk of cardiovascular disease in patients with masked hypertension approaches the risk in those with chronic hypertension.5


White coat hypertension and masked hypertension are both associated with problems in and of themselves. However, they both also suggest an increased risk of sustained hypertension. In fact, their risk is increased 300-400%. These patients should be monitored and followed closely.6

Our goal is to reduce the risk of cardiovascular disease as much as possible. We should seek to identify patients with white coat hypertension and masked hypertension before they progress to sustained hypertension.

When we identify these patients we can begin to work on the “3 finite responses” the ultimately cause vascular damage and hypertension. The earlier we intervene the greater our chances for success.

Everyone should have a 24-hour ambulatory blood pressure monitor done at least once as this is the best way to identify white coat hypertension and masked hypertension.

The ‘3 finite responses’

There are numerous (over 400) different risk factors for cardiovascular disease. However, the body only responds in 3 different ways. These responses are quite normal but become maladaptive over time and exacerbate the problem.

  1. Inflammation
  2. Oxidation
  3. Vascular Immune Dysfunction

Each of these 3 responses are trying to protect your body from these 400 different risk factors but they eventually increase the problem itself.

There are a number of ways to address these 3 Finite Responses including lifestyle changes, nutritional supplements, and medications. Optimizing your health requires identifying and treating all 3 of these.

We highly recommend our Executive Cardiovascular Evaluation Program. There isn’t another program like it anywhere in the state. This evaluation includes complete risk factor analysis, labs, and comprehensive tests to accurately and completely evaluate your risk for cardiovascular disease.



  1. Cuspidi C, Rescaldani M, Tadic M, Sala C, Grassi G, Mancia G. White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis. J Hypertens. 2015 Jan;33(1):24-32.
  2. Briasoulis A, Androulakis E, Palla M, Papageorgiou N, Tousoulis D. White-coat hypertension and cardiovascular events: a meta-analysis. J Hypertens. 2016 Apr;34(4):593-9.
  3. Michael A. Weber M, Schiffrin E, White W, Mann S, Lindholm L, Kenerson J, Flack J, Carter B. Clinical Practice Guidelines for the Management of Hypertension in the Community. J of Clinical Hypertension 2013;15:681.
  4. Papadopoulos DP, Makris TK. Masked hypertension definition, impact, outcomes: a critical review. J Clin Hypertens (Greenwich). 2007 Dec;9(12):956-63.
  5. Pickering TG, Equchi K, Kario K. Masked Hypertension: A Review. Hypertension Research volume30pages479–488 (2007).
  6. Sivén SS, Niiranen TJ, Kantola IM, Jula AM. White-coat and masked hypertension as risk factors for progression to sustained hypertension: the Finn-Home study. J Hypertens. 2016 Jan;34(1):54-60.