masked hypertension, masked uncontrolled hypertension, risk factors, office and out-of-office blood pressure


Despite significant advances in the diagnosis and treatment of arterial hypertension (AH), the problem of insufficient blood pressure (BP) control in hypertensive patients is quite acute. According to current guidelines, the effectiveness of antihypertensive therapy is mainly assessed by reaching the target levels of office BP, while masked uncontrolled hypertension (MUCH), which is diagnosed on the basis of insufficient control of out-of-office BP, increases the risk of cardiovascular events. Patients with insufficient out-of-office BP control have an increased risk of cardiovascular events compared to patients with both office and out-of-office BP control, therefore MUCH requires timely diagnosis and correction.

This mini-review summarizes the understanding of the nature of MUCH. A particular attention is paid to risk factors and ways of influencing the out-of-office BP control. The article also assessed the important contribution of ABPM to the control of out-of-office BP and to determining the overall risk of MUCH.



Agarwal R., Pappas M. K. Delayed systolic blood pressure recovery following exercise as a mechanism of masked uncontrolled hypertension in chronic kidney disease // Nephrol. Dial Transplant. — 2017. — 32. — P. 1710 — 1717. doi: 10.1093/ndt/gfw266

Ben-Dov IZ, Kark JD, Mekler J, Shaked E, Bursztyn M. The white coat phenomenon is benign in referred treated patients: a 14-year ambulatory blood pressure mortality study. J Hypertens 2008;26:699–705.

Booth JN, 3rd, Diaz KM, Seals SR, Sims M, Ravenell J, Muntner P, Shimbo D. Masked hypertension and cardiovascular disease events in a prospective cohort of blacks: The Jackson Heart Study. Hypertension 2016;68:501–10.

Bromfield S. G., Ngameni C. A., Colantonio L. D. et al. Blood pressure, antihypertensive polypharmacy, frailty, and risk for serious fall injuries among older treated adults with hypertension // Hypertension. — 2017. — 70. — P. 259 — 66. doi: 10.1161/hypertensionaha.116.09390

Cai A., Zhong Q., Liu C. et al. Associations of systolic and diastolic blood pressure night-to-day ratios with atherosclerotic cardiovascular diseases // Hypertens Res. — 2016. — 39. — P. 874 — 8. doi: 10.1038/hr.2016.82.

Cha R. H., Lee H., Lee J. P. et al. Changes of blood pressure patterns and target organ damage in patients with chronic kidney disease: results of the APrODiTe-2 study // J. Hypertens. — 2017. — 35. — P. 593 — 601. doi: 10.1097/HJH.0000000000001185

Coccina F., Pierdomenico A.M., Cuccurullo C., Pizzicannella J. et al. Prognostic Value of Masked Uncontrolled Hypertension Defined by Different Ambulatory Blood Pressure Criteria // American Journal of Hypertension 33(8) August 2020. – P.726-733.

Cohena L.P, Schwartza J.E, Pugliesea D.N., Anstey D.E. et al. The Short-Term Reproducibility of Masked Hypertension among Adults without Office Hypertension // Hypertension. 2020 October; 76(4): 1169–1175. doi:10.1161/hypertensionaha.120.15287.

Dart AM, Du XJ, Kingwell BA. Gender, sex hormones and autonomic nervous control of the cardiovascular system. Cardiovasc Res 2002; 53 (3):678–687.

De la Sierra A., Banegas J. R., Vinyoles E. et al. Prevalence of masked hypertension in untreated and treated patients with office blood pressure below 130/80 mm Hg // Circulation. — 2018. — 137. — P. 2651 — 2653. doi: 10.1161/circulationaha.118.034619

Diaz KM, Veerabhadrappa P, Brown MD, Whited MC, Dubber PM, Hickson DA. Prevalence, determinants, and clinical significance of masked hypertension in a population-based sample of Africans Americans: the Jackson Heart Study. Am J Hypertens 2015;28:900–908.

Erdem F., Cakır U., Yıldırım O. et al. A new diagnostic tool for masked hypertension: impaired sleep quality // Arch Med. Sci. — 2016. — 12. — P. 1207 — 1213. doi: 10.5114/aoms.2015.51177

Franklin S. S., O’Brien E., Staessen J. A. Masked hypertension: understanding its complexity // Eur. Heart J. — 2017. — 38 (15). — P. 1112 — 1118. doi:10.1093/eurheartj/ehw502

Franklin SS, Thijs L, Hansen TW, et al.; International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators. Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population. Hypertension 2012;59:564–571.

Franklin SS, Thijs L, Li Y, et al.; International Database on Ambulatory blood pressure in Relation to Cardiovascular Outcomes Investigators. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Hypertension 2013;61:964–971

Ghazi L., Cohen L.P., Muntner P., Shimbo D., Drawz P.E.. Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study // Hypertension. 2020 October; 76(4): 1090–1096. doi:10.1161/hypertensionaha.120.15300

Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure monitoring and risk of cardiovascular disease: a population based study. Am J Hypertens 2006;19:243–250 [PubMed: 16500508] 13. Ingelsson E, Bjorklund K, Lind L, Arnlov J, Sundstrom J. Diurnal blood pressure pattern and risk of congestive heart failure. JAMA. 2006;295:2859–2866

Hering D., Trzebski A., Narkiewicz K. Recent advances in the pathophysiology of arterial hypertension: potential implications for clinical practice. Pol // Arch. Intern. Med. — 2017. — 127 (3). — P. 195 — 204. doi: 10.20452/pamw.3971

Hung Ming-Hui, Shih Ling-Chieh, Wang Yu-Ching, Leu Hsin-Bang et al. Prediction of Masked Hypertension and Masked Uncontrolled Hypertension Using Machine Learning // Front. Cardiovasc. Med., 19 November 2021

Huang Q.-F., Yang W.-Y., Asayama K., Zhang Z.-Y. et al. Ambulatory Blood Pressure Monitoring to Diagnose and Manage Hypertension // Hypertension. 2021;77:254–264. DOI: 10.1161/hypertensionaha.120.14591

Jafar Tazeen H,Gandhi Mihir,Jehan Imtiaz,Naheed Aliya,Asita de Silva H,Shahab Hunaina,Alam Dewan, Luke Nathasha,Lim Ching Wee,COBRA-BPS Study Group. Determinants of Uncontrolled Hypertension in Rural Communities in South Asia—Bangladesh, Pakistan, and Sri Lanka. American Journal of Hypertension, hpy071, 10.1093/ajh/hpy071.

Koenig J, Thayer JF. Sex differences in healthy human heart rate variability: A meta-analysis. Neurosci Biobehav Rev 2016; 64:288–310.

Kushiro T., Kario K., Saito I. et al. Increased cardiovascular risk of treated white coat and masked hypertension in patients with diabetes and chronic kidney disease: the HONEST Study // Hypertens Res. — 2017. — 40. — P. 87 — 95. doi: 10.1038/hr.2016.87

Lambert E, Straznicky N, Eikelis N, Esler M, Dawood T, Masuo K, et al. Gender differences in sympathetic nervous activity: influence of body mass and blood pressure. Journal of hypertension 2007; 25 (7):1411–1419.

Lee SH, Kim JH, Kang MJ, Lee YA, Yang SW, Shin CH. Implications of nocturnal hypertension in children and adolescents with type 1 diabetes. Diabetes Care 2011;34:2180–2185.

Leitao CB, Canani LH, Kramer CK, Boza JC, Pinotti A, Gross JL. Masked hypertension, urinary albumin excretion rate, and echocardiographic parameters in putatively normotensive type 2 diabetic patients. Diabetes Care 2007;30:1255–1260.

Lopatowska P., Mlodawska E., Tomaszuk-Kazberuk A. et al. Adhering to the principles of clinical pharmacology — the correct fixed combinations of antihypertensive drugs // Exp. Rev. Clin. Pharmacol. — 2018. — 11. — P. 165 — 170. doi: 10.1080/17512433.2018.1412826

Lu J., Lu Y., Wang X. et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1.7 million adults in a population-based screening study (China PEACE Million Persons Project) // Lancet. — 2017. — 390. — P. 2549 — 58. doi: 10.1016/S0140-6736(17)32478-9

Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure. Hypertension 2006;47:846–853.

Melgarejo J. D., Maestre G. E., Thijs L. et al. Prevalence, treatment, and control rates of conventional and ambulatory hypertension across 10 populations in 3 continents // Hypertension. — 2017. — 70. — P. 50 — 58. doi: 10.1161/hypertensionaha.117.09188.

Minutolo R, Gabbai FB, Agarwal R, Chiodini P, Borrelli S, Bellizzi V, Nappi F, Stanzione G, Conte G, De Nicola L. Assessment of achieved clinic and ambulatory blood pressure recordings and outcomes during treatment in hypertensive patients with CKD: a multicenter prospective cohort study. Am J Kidney Dis 2014;64:744–752.

Morris J. H., Bisognano J. D. Masked hypertension: finding trouble under the disguise // Circ Cardiovasc. Qual Outcomes. — 2017. — 10. — P. pii: e003945. doi: 10.1161/circoutcomes.117.003945

Muntner P., Shimbo D., Carey R. M. et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association // Hypertension. — 2019. — 73. — P. e35–e66. doi: 10.1161/HYP.0000000000000087

Naito Y, Hosokawa M, Sawada H, Oboshi M, Hirotani S, Iwasaku T, Okuhara Y, Morisawa D, Eguchi A, Nishimura K, Soyama Y, Fujii K, Mano T, Ishihara M, Tsujino T, Masuyama T. Transferrin Receptor 1 in Chronic Hypoxia-Induced Pulmonary Vascular Remodeling. Am J Hypertens. 2016 6;29(6):713–8.

Ogedebe G, Spruill TM, Sarpong DF, Agyemang C, Chaplin W, Pastva A, Martins D, Ravenell J, Pickering TG. Correlates of isolated nocturnal hypertension and target organ damage in a population-based cohort of African Americans: the Jackson Heart Study. Am J Hypertens 2013;26:1011–1016.

Palla M., Saber H., Konda S., Briasoulis A. Masked hypertension and cardiovascular outcomes: an updated systematic review and meta-analysis // Integrated Blood Pressure Control 2018:11 11–24

Parati G, Agabiti- 48 Rosei E, Bakris GL, et al. MASked-unconTrolled hypERtension management based on office BP or on ambulatory blood pressure measurement (MASTER) Study: a randomised controlled trial protocol. BMJ Open 2018;8:e021038. doi:10.1136/ bmjopen-2017-021038.

Penmatsa K.R., Vishakhapatnam, Biyani I.M., Gupta A. Masked Hypertension: Lessons for the Future Ulster Med J 2020;89(2):77-82

Pierdomenico SD, Lapenna D, Bucci A, Di Tommaso R, Di Mascio R, Manente BM, Caldarella MP, Neri M, Cuccurullo F, Mezzetti A. Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension. Am J Hypertens 2005;18:1422–1428.

Pierdomenico SD, Pierdomenico AM, Coccina F, Porreca E. Prognosis of masked and white coat uncontrolled hypertension detected by ambulatory blood pressure monitoring in elderly treated hypertensive patients. Am J Hypertens 2017;30:1106–1111.

Pierdomenico S. D., Pierdomenico A. M., Coccina F. et al. Prognostic Value of masked uncontrolled hypertension // Hypertension. — 2018. — 72. — P. 862 — 869. doi: 10.1161/hypertensionaha.118.11499

Pogue V, Rahman M, Lipkowitz Toto R, Miller E, Faulkner M, Rostand S, Hiremath L, Sika M, Kendrick C, Hu BO, Greene T, Appal L. Phillips RA for the African American Study of Kidney disease and Hypertension Collaborative Research Group. Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension 2009;53:20–27.

Pothineni NV, Shirazi LF, Mehta JL. Gender Differences in Autonomic Control of the Cardiovascular System. Curr Pharm Design 2016; 22 (25):3829–3834.

Prejbisz A, Klocek M, Gąsowski J, Topór-Mądry R, Leśniak W, Kabat M, Czarnecka D, KaweckaJaszcz K, Narkiewicz K, Januszewicz A. Factors associated with resistant hypertension in a large cohort of hypertensive patients: the Pol-Fokus study. Pol Arch Med Wewn. 2015;125(4):249–59. Epub 2015 Feb 27.

Pugliese D.N., Booth J.N., Deng L., Anstey D.E. et al. Sex Differences in Masked Hypertension: The Coronary Artery Risk Development in Young Adults (CARDIA) Study // J Hypertens. 2019 December; 37(12): 2380–2388. doi:10.1097/HJH.0000000000002175.

Rhodes CJ, Howard LS, Busbridge M, Ashby D, Kondili E, Gibbs JS, Wharton J, Wilkins MR. Iron deficiency and raised hepcidin in idiopathic pulmonary arterial hypertension: clinical prevalence, outcomes, and mechanistic insights. J Am CollCardiol 2011; 58:300–309.

Ruiter G, Lankhorst S, Boonstra A, Postmus PE, Zweegman S, Westerhof N, van der Laarse WJ, Vonk-Noordegraaf A. Iron deficiency is common in idiopathic pulmonary arterial hypertension. EurRespir J 2011; 37:1386–1391.

Salles GF, Reboldi G, Fagard RH, Claudia RI, Cardoso SD, Pierdomenico SD, Verdecchia P, Eguchi K, Kario S, Hoshide S, Polonia J, del la Sierra A, Hermida RC, Dolan E, O’brien E, Roush GC. For the ABC-H Investigators. Prognostic effect of the nocturnal blood pressure fall in hypertensive patients. The Ambulatory Blood Pressure Collaboration in Patients with Hypertension (ABCH) meta-analyis. Hypertension 2016;67:693–700.

Satoh M, Asayama K, Kikuya M, et al. Long-term stroke risk due to partial white-coat or masked hypertension based on home and ambulatory blood pressure measurements: The Ohasama Study. Hypertension 2016;67:48–55.

Schwartz J. E., Burg M. M., Shimbo D. et al. Clinic blood pressure underestimates ambulatory blood pressure in an untreated employer-based us population: results from the masked hypertension study // Circulation. — 2016. — 134. — P. 1794 — 807. doi: 10.1161/CIRCULATIONAHA.116.023404

Soon E, Treacy CM, Toshner MR, MacKenzie-Ross R, Manglam V, Busbridge M, SinclairMcGarvie M, Arnold J, Sheares KK, Morrell NW, Pepke-Zaba J. Unexplained iron deficiency in idiopathic and heritable pulmonary arterial hypertension. Thorax 2011; 66:326–332.

Shalimova A., J. Wolf. Masked uncontrolled hypertension: risk factors and ways of influence // Ukrainian Therapuatical Journal. – 2021. – 2. – H.14–20.

Shimada K, Fujita T, Ito S, Naritomi H, Ogihara T, Shimamoto K, Tanaka H, Yoshiike N. The importance of home blood pressure measurement for preventing stroke and cardiovascular disease in hypertensive patients: a sub-analysis of the Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH) study, a prospective nationwide observational study. Hypertens Res 2008;31:1903–1911.

Shi X., Zhang K., Wang P. et al. Association of masked uncontrolled hypertension and cardiovascular diseases in treated hypertensive patients. Arch Med Sci. 2020. — 16 (3). — P. 538 — 544. doi: 10.5114/aoms.2019.89218

Siddiqui M., Judd E. K., Dudenbostel T. et al. Masked uncontrolled hypertension is not attributable to medication nonadherence // Hypertension. — 2019. — 74. — P. 652 — 659. doi: 10.1161/hypertensionaha.119.13258

Siddiqui M, Judd EK, Jaeger BC, Bhatt H, Dudenbostel T, Zhang B, et al. Out-of-Clinic Sympathetic Activity Is Increased in Patients With Masked Uncontrolled Hypertension. Hypertension (Dallas, Tex : 1979) 2019; 73 (1):132–141.

Siddiqui M., Judd E. K., Zhang B. et al. Masked uncontrolled hypertension is accompanied by increased out-of-clinic aldosterone secretion // Hypertension. — 2021. — 77 (2). — P. 435 — 444.

Stergiou G. S., Palatini P., Parati G. et al. 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement // J.Hypertens. — 2021, 39. — P. 000 — 000. doi: 10.1097/HJH.0000000000002843

Sung J.H., Lee J.E., Lee J.-Y. Biomarker Differences between Controlled and Uncontrolled Hypertension among US Adults: National Health and Nutrition Examination Survey 2005-2010 // Int J Adv Res Sci Eng Technol. 2018 September ; 5(9): 6790–6797

Thakkar H. V., Pope A., Anpalahan M. Masked Hypertension: A Systematic Review. Heart Lung Circ. 2020. — 29 (1). — P. 102 — 111. doi: 10.1016/j.hlc.2019.08.006

Tientcheu D, Ayers C, Das SR, McGuire DK, de Lemos JA, Khera A, Kaplan N, Victor R, Vongpatanasin W. Target organ complications and cardiovascular events associated with masked hypertension and white-coat hypertension: analysis from the Dallas Heart Study. J Am Coll Cardiol 2015;66:2159–2169.

Unger T., Borghi C., Charchar F. et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines // Hypertension. — 2020. — 75. — P. 1334 — 1357. doi: 10.1161/hypertensionaha.120.15026.

Verdalles U, Goicoechea M, Garcia de Vinuesa S, Quiroga B, Galan I, Verde E, Perez de Jose A, Luno J. Prevalence and characteristics of patients with resistant hypertension and chronic kidney disease. Nefrologia (English Edition). 2016 Volume 36, Issue 5:523–529.

Wang C, Zhang J, Li Y, Ma X, Ye Z, Peng H, Lou T. Masked hypertension, rather than white-coat hypertension, has a prognostic role in patients with non-dialysis chronic kidney disease. Int J Cardiol 2017;230:33–39.

Ware LJ, Rennie KL, Gatane LF, Nell TM, Thompson JE, Van Rooyen JM, Schutte R, Schutte AE. Masked hypertension in low-income South African adults. J Clin Hypertens 2016;18:396–404.

Whelton P.K., Carey R.M., Arono W.S. et al. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines // Hypertension. 2018;71:e13–e115.

Williams B., Mancia G., Spiering W. et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension // Eur. Heart J. — 2018. — 39 (33). — P. 3021 — 3104. doi/10.1093/eurheartj/ehy339

Youssef G., Nagy S., El-gengehe A., Aal al. Masked uncontrolled hypertension: Prevalence and predictors // The Egyptian Heart Journal 70 (2018) 369–37.

Copyright for articles published in the journal is regulated by the License Agreement for the use of a scientific article in the journal, which is concluded between the author of the article (Licensor) and Kharkov National Medical University (Licensee, publisher of the journal "Inter Collegas"). The licensor grants to the Licensee a non-exclusive non-exclusive license for the use of the article (a license that does not exclude the use of the article by the Licensor and the issuance of licenses to others for use of this article) on the terms and for the period specified in the contract. The licensor (the author of the article) grants the Licensee the right to reproduce the article (publication in the journal "Inter Collegas", publication, duplication, duplication or other reproduction of the article without limiting the circulation of copies, each copy of the article must contain the name of the Licensor; Of general information, including the publication of the article in full or in part on the Internet on the journal page, the right to use the metadata of the article (titles, full names of authors, annotations, bibliography eskih materials) through the dissemination and communication to the public, processing and systematization, as well as inclusion in various databases and in-formational system).

The licensor grants the licensee the right to transfer, store and process his personal data (full name, scientific degree, academic title, place of work and position, contact information of the authors) with the purpose of including them in the database in accordance with the Law of Ukraine No. 2297 - VI "on protection of personal data" from 01.06.2010.

Personal data and metadata of the article are provided for their storage and processing in various databases and information systems, including them in analytical and statistical reporting, creating sound relationships between the objects of works of science, literature and art with personal data, etc. on unlimited territory. The licensee has the right to transfer the specified data for processing and storage to third parties provided that such a fact is notified with the provision of information about the third party (name and address) to the Licensor.