Causal mechanisms of masked hypertension: socio-psychological aspects

The contribution of Dr Thomas Pickering's study to the measurement of blood pressure (BP) is the defining aspect of his academic career and achievement - narrowly defined. In this regard, two important areas characterized his study as it relates to masked hypertension. First, he introduced the term, masked hypertension, to replace the rather inappropriate term 'reverse white-coat hypertension' and 'white-coat normotension'; thus drawing attention to the fact that these patients are genuinely hypertensive by ambulatory BP but were missed by normal office BP. More importantly, he rightly maintained that masked hypertension is a true continuum of sustained hypertension rather than an aberrant measurement artifact. Second, is his pivotal study on the important role of psychosocial factors as a potential mechanism for the development of masked hypertension. In this regard, he explained masked hypertension as a conditioned response to anxiety in office settings, and highlighted the role that diagnostic labeling plays in its development. His view of masked hypertension is that of a continuum from prehypertension (based on office BP measurement) to masked hypertension (based on ambulatory BP) and finally to sustained hypertension (based on both office and ambulatory BP). He strongly believes that it is the prehypertensive patients who progress to masked hypertension. Subsequently, patients who are prehypertensive should be screened for masked hypertension and treated. In this manuscript, we summarize his study as it relates to the definition of masked hypertension, the psychosocial characteristics, mechanisms and its clinical relevance.