Continued clinical follow-up is appropriate for this patient with white coat hypertension. He has high blood pressure readings in the clinic; however, his ambulatory blood pressure monitor (ABPM) readings do not meet the definition of hypertension. The diagnosis of white coat hypertension is applied to patients with average blood pressure readings ≥140/90 mm Hg in the office and average readings <135/85 mm Hg as determined by ABPM. Daytime (awake) average above 140/90 mm Hg and nighttime (asleep) average above 125/75 mm Hg are also used to diagnose hypertension on ABPM. Analysis of nocturnal readings compared to daytime reading is also helpful. Compared with daytime readings, nocturnal readings are approximately 15% lower (“dipping”). A non-dipping status (failure to drop nocturnal blood pressure by <10%) is associated with more cardiovascular events compared with dipping. This patient dips appropriately at night. Patients with white coat hypertension may have an elevated cardiovascular risk compared with normotensive patients. Moreover, such patients are also at a higher risk for sustained hypertension. Therefore, close observation for sustained hypertension and end-organ damage is recommended in patients with white coat hypertension.

Echocardiography is more sensitive than electrocardiography in detecting evidence of left ventricular hypertrophy. However, it is not used for the diagnosis of hypertension unless there is evidence of end-organ damage or if the information would help guide subsequent treatment. In this patient with a normal ABPM study without evidence of cardiac disease, echocardiography is not indicated.

Evaluation for secondary causes of hypertension such as primary hyperaldosteronism is not indicated in this patient without evidence of sustained hypertension and a normal serum potassium level.

Drug therapy is not recommended unless sustained hypertension or evidence of end-organ damage is present.