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Ann Intern Med. 2019 Jun 18;170(12):853-862. doi: 10.7326/M19-0223. Epub 2019 Jun 11.

Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis.

Author information

University of Pennsylvania, Philadelphia, Pennsylvania (J.B.C., M.G.D., D.L.C., R.R.T.).
Princeton University, Princeton, New Jersey (M.J.L.).
Rutgers New Jersey Medical School, Newark, New Jersey (U.K.T.).



The long-term cardiovascular risk of isolated elevated office blood pressure (BP) is unclear.


To summarize the risk for cardiovascular events and all-cause mortality associated with untreated white coat hypertension (WCH) and treated white coat effect (WCE).

Data Sources:

PubMed and EMBASE, without language restriction, from inception to December 2018.

Study Selection:

Observational studies with at least 3 years of follow-up evaluating the cardiovascular risk of WCH or WCE compared with normotension.

Data Extraction:

2 investigators independently extracted study data and assessed study quality.

Data Synthesis:

27 studies were included, comprising 25 786 participants with untreated WCH or treated WCE and 38 487 with normal BP followed for a mean of 3 to 19 years. Compared with normotension, untreated WCH was associated with an increased risk for cardiovascular events (hazard ratio [HR], 1.36 [95% CI, 1.03 to 2.00]), all-cause mortality (HR, 1.33 [CI, 1.07 to 1.67]), and cardiovascular mortality (HR, 2.09 [CI, 1.23 to 4.48]); the risk for WCH was attenuated in studies that included stroke in the definition of cardiovascular events (HR, 1.26 [CI, 1.00 to 1.54]). No significant association was found between treated WCE and cardiovascular events (HR, 1.12 [CI, 0.91 to 1.39]), all-cause mortality (HR, 1.11 [CI, 0.89 to 1.46]), or cardiovascular mortality (HR, 1.04 [CI, 0.65 to 1.66]). The findings persisted across several sensitivity analyses.


Paucity of studies evaluating isolated cardiac outcomes or reporting participant race/ethnicity.


Untreated WCH, but not treated WCE, is associated with an increased risk for cardiovascular events and all-cause mortality. Out-of-office BP monitoring is critical in the diagnosis and management of hypertension.

Primary Funding Source:

National Institutes of Health.

[Available on 2019-12-18]

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