CLINICAL STUDY
Silent and clinically overt stroke in older Japanese subjects with white-coat and sustained hypertension
Kazuomi Kario, MD, PhD, FACC*  ,
Kazuyuki Shimada, MD, PhD*,
Joseph E. Schwartz, PhD ,
Takefumi Matsuo, MD, PhD ,
Satoshi Hoshide, MD* and
Thomas G. Pickering, MD, DPhil
* Department of Cardiology, Jichi Medical School, Tochigi, Japan
The Zena and Michael A. Weiner Cardiovascular Center, Mount Sinai School of Medicine, New York, New York, USA
Department of Psychiatry and Behavioral Science, State University of New York at Stony Brook, Stony Brook, New York, USA
Department of Internal Medicine, Hyogo Prefectural Awaji Hospital, Hyogo, Japan
Manuscript received November 8, 2000;
revised manuscript received March 15, 2001,
accepted March 29, 2001.
Reprint requests and correspondence: Dr. Kazuomi Kario, Department of Cardiology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Kawachi, Tochigi, 329-0498, Japan
kkario{at}jichi.ac.jp
OBJECTIVES
We investigated whether white-coat hypertension is a risk factor for stroke in relation to silent cerebral infarct (SCI) in an older Japanese population.
BACKGROUND
It remains uncertain whether white-coat hypertension in older subjects is a benign condition or is associated with an increased risk of stroke.
METHODS
We studied the prognosis for stroke in 958 older Japanese subjects (147 normotensives [NT], 236 white-coat hypertensives [WCHT] and 575 sustained hypertensives [SHT]) in whom ambulatory blood pressure monitoring was performed in the absence of antihypertensive treatment. In 585 subjects (61%), we also assessed SCI using brain magnetic resonance imaging.
RESULTS
Silent cerebral infarcts were found in 36% of NT (n = 70), 42% of WCHT (n = 154), and 53% of SHT (n = 361); multiple SCIs (the presence of  2 SCIs) were found in 24% of NT, 25% of WCHT and 39% of SHT. During a mean 42-month follow-up period, clinically overt strokes occurred in 62 subjects (NT: three [2.0%]; WCHT: five [2.1%]; SHT: 54 [9.4%]), with 14 fatal cases (NT: one [0.7%]; WCHT: 0 [0%]; SHT: 13 [2.3%]). A Cox regression analysis showed that age (p = 0.0001) and SHT (relative risk, [RR] [95% confidence interval, CI]: 4.3 [1.3–14.2], p = 0.018) were independent stroke predictors, whereas WCHT was not significant. When we added presence/absence of SCI at baseline into this model, the RR (95% CI) for SCI was 4.6 (2.0–10.5) (p = 0.003) and that of SHT was 5.5 (1.8–18.9) versus WCHT (p = 0.004) and 3.8 (0.88–16.7) versus NT (p = 0.07).
CONCLUSIONS
In older subjects the incidence of stroke in WCHT is similar to that of NT and one-fourth the risk in SHT. Although SCI is a strong predictor of stroke, the difference in stroke prognosis between SHT and WCHT was independent of SCI. It is clinically important to distinguish WCHT from SHT even after assessment of target organ damage in the elderly.
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Abbreviations and Acronyms
| | ABPM | = ambulatory blood pressure monitoring | | BMI | = body mass index | | BP | = blood pressure | | MRI | = magnetic resonance imaging | | NT | = normotension | | RR | = relative risk | | SCI | = silent cerebral infarct | | SHT | = sustained hypertension | | WCHT | = white-coat hypertension |
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