How should we manage a patient with masked hypertension?

A number of studies have shown that masked hypertension (MH) confers an increased risk of target organ damage and of cardiovascular events suggesting that patients with MH would benefit from antihypertensive treatment. However, there is no general agreement about how this condition should be diagnosed. Although ambulatory blood pressure monitoring (ABPM) and self blood pressure measurement (SBPM) provide different and complementary clinical information, the recently published ESH/ESC guidelines for the management of arterial hypertension suggest that for initial assessment of the patient, SBPM may be more suitable in primary care and ABPM in specialist care. If SBPM provides borderline values it is advisable to confirm the diagnosis of MH with ABPM. As the prevalence of MH declines with repeated ABPMs the diagnosis of MH should be based on at least two ABPMs. Patients with MH should undergo a careful diagnostic work-up to assess the existence of additional risk factors including a worsened metabolic profile and the presence of target organ involvement. Treatment of the patient with MH should initially be addressed to improve the patient's lifestyle in order to decrease out-of-office blood pressure and to ameliorate metabolic data. If non-pharmacological measures are insufficient to normalize blood pressure, MH may benefit from pharmacological treatment but no clinical trial has been implemented as yet with the specific purpose of testing this hypothesis. Despite this lack of evidence, the 2013 ESH/ESC guidelines have recommended that in patients with MH also drug treatment should be considered because in patients with MH the risk of adverse outcome is very close to that in sustained hypertension. When ambulatory blood pressure is measured, pharmacological treatment may be modulated according to whether blood pressure is elevated during daytime hours or during sleep.