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An Updated Meta-analysis of White Coat Hypertension and Mortality

Journal of Human Hypertension volume 39, pages 595–597 (2025)Cite this article

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In 1983, Perloff et al. found that among 1,076 patients with hypertension, there was a significant difference in the incidence of fatal and nonfatal cardiovascular events between patients with higher and lower 24-hour ambulatory BP ( < 160 mm Hg versus ≥160 mm Hg), regardless of baseline office BP. This was the first study to highlight the stronger association of 24-hour ambulatory BP compared to office BP with cardiovascular complications [1]. In 1984, Kleinert et al. coined the term “white coat hypertension” (WCH), referring to elevated office BP in the setting of normal out-of-office BP [2]. WCH has been further distinguished to represent individuals who are not yet on antihypertensive medication, while white coat effect (WCE) refers to those already treated with antihypertensive medication [3]. Because of this potential for discordance between out-of-office and office BPs and the greater prognostic value of out-of-office BPs, guidelines now strongly recommend out-of-office BP monitoring for the diagnosis and treatment of hypertension [4, 5]. Nonetheless, out-of-office BP monitoring has not been widely adopted in clinical practice [6].

The association between WCH and all-cause mortality has historically differed across studies, leading to controversy regarding the prognostic significance and actionability of WCH. Accordingly, we conducted a systematic review and meta-analysis, published in Annals of Internal Medicine in 2018 [7], which demonstrated that untreated WCH was associated with a modestly higher risk of all-cause (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.07-1.67) and cardiovascular (HR 2.09, 95% CI 1.23-4.48) mortality, which we concluded was likely driven by missed transition of patients with WCH to sustained hypertension over time [7]. Alternatively, WCE was not associated with all-cause (HR 1.11, 95% CI 0.89-1.46) or cardiovascular mortality (HR 1.04, 95% CI 0.65-1.66).

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Fig. 1: Mortality risk in white coat hypertension and white coat effect.

Data availability

Data from this study are entirely composed of pooled results from previously published studies and will be made available upon request from the corresponding author.

Code availability

Code from this study will be made available upon request from the corresponding author.

References

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Authors and Affiliations

  1. Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Alavi Hossain, Raymond R. Townsend & Jordana B. Cohen

  2. Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Jordana B. Cohen

Authors
  1. Alavi Hossain
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  2. Raymond R. Townsend
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  3. Jordana B. Cohen
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Contributions

JC and AH were responsible for all aspects of the study including study concept, study design, data acquisition, data analysis and manuscript drafting and revision. RT was involved in the study design, data interpretation as well as critical revision of the paper. All authors provided final approval.

Corresponding author

Correspondence to Jordana B. Cohen.

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Competing interests

There are no competing interests for any of the authors. JC is supported by the National Institutes of Health R01-HL153646, R01-HL157108, R01-HL155599, R01-HL157264, U01-HL160277, U24-DK060990, and R01-AG074989, and an American Heart Association Bugher Award.

Ethical approval

Due to a lack of patient-specific data, the study was exempt from institutional review board approval at the University of Pennsylvania. Participants provided informed consent as appropriate per the design and implementation of the individual studies included in this study-level meta-analysis.

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Hossain, A., Townsend, R.R. & Cohen, J.B. An Updated Meta-analysis of White Coat Hypertension and Mortality. J Hum Hypertens 39, 595–597 (2025). https://doi.org/10.1038/s41371-025-01041-5

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