Management of Blood Pressure Discrepancy in Patients with Heart Failure

Assessment and Diagnosis

The American Heart Association suggests that a significant difference between office BP and home BP strongly suggests white coat hypertension, which is common in 10-30% of patients attending clinics due to high BP 1, 2
White coat hypertension is defined as elevated BP only in the office (≥140/90 mmHg) with normal home or ambulatory BP (<135/85 mmHg) 2, 3
The European Society of Cardiology recommends confirmation with repeated office and out-of-office BP measurements before making treatment decisions 1, 4

The American College of Cardiology recommends verifying the accuracy of home BP measurements by ensuring the patient uses a validated device with an appropriate cuff size 4, 5
Proper measurement technique is crucial, including a quiet room, comfortable temperature, empty bladder, no smoking/coffee/exercise for 30 min before, relaxed for 3-5 min, and taking 3 measurements at 1-min intervals 5
The European Heart Journal suggests verifying readings are taken at consistent times of day 3

The European Society of Cardiology recommends that patients with HFrEF be on optimal heart failure therapy, including an ACE inhibitor/ARB/ARNI, beta-blocker, and diuretic if required, with a target BP of <130/80 mmHg 6
Carvedilol (Coreg) is a beta-blocker that is part of guideline-directed medical therapy for HFrEF 6
If white coat hypertension is confirmed, no immediate medication changes are needed, but regular follow-up with continued home BP monitoring is recommended 1, 3

In patients with HFrEF, BP-lowering treatment should include an ACE inhibitor/ARB/ARNI, beta-blocker, and diuretic if required, according to the European Society of Cardiology 6
The American Heart Association suggests that lifestyle modifications are important even in patients with white coat hypertension, as they may develop sustained hypertension requiring treatment 2

The American College of Physicians recommends repeating office BP measurements on at least two separate occasions, using proper technique 8
Continued home BP monitoring with a standardized protocol is recommended by the European Society of Hypertension 4
Follow-up within 3 months to reassess BP control is suggested by the American Heart Association 1