Masked stress-induced arterial hypertension

Background: Patients who suffer from masked stress-induced arterial hypertension have normal blood pressure values, when measured in the doctor's office, but show elevated values in their everyday life or at work. The two cases, described here, underline the importance of optimal blood pressure measurement and the use of state-of-the-art methods as the basis for recognition and correct classification of this kind of hypertension and for characterization of individual blood pressure profile. This diagnostics is necessary for every therapeutic decision. History: Case 1: A now 53-year-old patient first came in six years ago with incidental cardiac dysrhythmia. He stated to suffer from substantial stress at work. Three years previously, an ambulatory blood pressure monitoring (ABPM) showed normal blood pressure levels: daytime mean of 122/78 mmHg (<135/85). Case 2: A 42-year-old patient reported to have had elevated blood pressure for a year and a half, as seen during occasional self-measurements. He, too, suffers from substantial stress at work and, in addition, has a family predisposition for hypertension. Investigations: Case 1: Investigations showed paroxysmal atrial fibrillation with hypertensive heart disease. Repeated blood pressure measures (brachial and aortal) in the clinic showed normal values when the patient was under standardized exercise testing or at rest. Ambulatory blood pressure monitoring (ABPM) revealed a moderate systolic and a mild diastolic hypertension. Case 2: Both measurements during exercise and at rest showed normal blood pressure values. ABPM showed moderate systolic and severe diastolic hypertension (daytime mean of 150/103 mmHg). Central/aortal blood pressure was also normal (118 mmHg) when measured in the clinic, but severely elevated during ABPM (145 mmHg < 130). There was no hypertension-induced organ damage yet. Treatment: Case 1: Under antihypertensive medication blood pressure has been stabilized at the normal level (ABPM). Atrial fibrillation was permanently removed by catheter ablation. Case 2: According to the patient's wishes, no antihypertensive drug therapy has been initiated yet. The current aim is to normalize the blood pressure by general measures (i.a. stress management). Conclusion: Masked stress-induced arterial hypertension can lead to hypertension-induced organ damage. It has to be revealed via ABPM and therapy must be initiated, despite normal blood pressure levels measured in the clinic. Exact characterization of this kind of hypertension with optimal measuring methods is the prerequisite for individual treatment strategies. This applies particularly to masked hypertension, which is often stress-induced and results in high blood pressure under daily routine.