ORIGINAL ARTICLE White Coat Hypertension May be an Initial Sign of the Metabolic Syndrome Mehmet R. Helvaci1, Hasan Kaya1, Mehmet Gundogdu2 1 Medical Faculty of the Mustafa Kemal University. 31100, Serinyol, Antakya, Hatay, Turkey. Correspondence mail: [email protected] 2 Professor of Internal Medicine, Medical Faculty of the Ataturk University, Erzurum, Turkey. ABSTRAK Tujuan: untuk memahami peran dan pentingnya WCH dalam sindrom metabolik. Metode: Penelitian ini dilakukan di Poliklinik Bagian Ilmu Penyakit Dalam Universitas Dumlupinar pada Agustus 2005 hingga Maret 2007. Kami mengambil pasien yang berusia 20 tahun ke atas. Kriteria yang disertakan memiliki kebiasaan merokok, DM, dislipidemia, mempelajari obat-obatan yang digunakan, dan rutin periksa laboratorium glukosa plasma puasa (FPG), trigliserida (TG), density lipoprotein kolesterol tinggi (HDL-C), low density lipoprotein kolesterol (LDL-C), dan elektrokardiografi. Perbandingan proporsi digunakan sebagai metode analisis statistik. Hasil: Penelitian ini menyertakan 1.068 kasus. Prevalensi berat badan berlebih meningkat secara bertahap mulai dari dekade ketiga (28,7%) hingga dekade ketujuh (87,0%) (p<0,05 hampir pada seluruh tahapan), dan kemudian menurun pada dekade kedelapan kehidupan (78,5%, p<0,05). Peningkatan paling bermakna terlihat pada peralihan dekade ketiga ke dekade keempat (28,7% vs 63,6%, p<0,001) yang juga serupa untuk kebiasaan merokok. Hiperbetalipoproteinemia, hipertrigliserida, dislipidemia dan toleransi glukosa terganggu /impaired glucose tolerance (IGT), dan WCH mempunyai karakteristik serupa terhadap berat badan berlebih, yakni terus meningkat hingga dekade ketujuh dan kemudian menurun pada dekade selanjutnya (p<0,05 hampir pada semua tahapan). Sedangkan hipertensi (HT), diabetes mellitus tipe 2 (DM), dan penyakit jantung koroner / coronary heart disease (CHD ) selalu meningkat tanpa adanya penurunan prevalensi seiring dengan bertambahnya dekade (p<0,05 hampir pada semua tahapan), yang menunjukkan sifatnya yang ireversibel. Kesimpulan: WCH dapat merupakan tanda awal dari proses aterosklerosis sitemik yang dapat dideteksi dengan mudah dan dicegah dengan kecenderungan menurunkan berat badan. Kata kunci: hipertensi kerah putih, sindroma metabolik, aterosklerosis. ABSTRACT Aim: to understand the role and significance of WCH in definition of the metabolic syndrome. Methods: the study was performed in the Internal Medicine Polyclinic of the Dumlupinar University between August 2005 and March 2007. We took consecutive patients at and above the age of 20 years. Their medical histories including smoking habit, DM, dyslipidemia, and already used medications were learnt, and a routine check up procedure including fasting plasma glucose (FPG), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and an electrocardiography was performed. Comparison of proportions was used as the method of statistical analysis. Results: the study included 1,068 cases. Prevalences of excess weight increased from the third (28.7%) up to the seventh decades (87.0%), gradually (p<0.05 nearly in all steps), and then decreased in the eighth (78.5%, p<0.05) decade of life. The most significant increase was seen during the passage from the third to the fourth decades (28.7% versus 63.6%, p<0.001) with a similar fashion to smoking. Hyperbetalipoproteinemia, hypertriglyceridemia, dyslipidemia, impaired glucose tolerance (IGT), and WCH had a similar fashion with excess weight by increasing until the seventh decade and decreasing afterwards (p<0.05 nearly in all steps). Whereas hypertension (HT), type 2 222 Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine Vol 44 • Number 3 • July 2012 White Coat Hypertension May be an Initial Sign of the Metabolic Syndrome diabetes mellitus (DM), and coronary heart disease (CHD) always increased without any decrease by decades (p<0.05 nearly in all steps), indicating their irreversible natures. Conclusion: WCH may be an initial sign of the systemic atherosclerotic process that can be detected easily and prevented by a trend towards weight loss. Key words: white coat hypertension, metabolic syndrome, atherosclerosis. INTRODUCTION METHODS A causative relationship between excess The study was performed at the Internal weight and systemic atherosclerosis is known Medicine Polyclinic of the Dumlupinar University for many years under the title of metabolic between August 2005 and March 2007. We took syndrome.1,2 The syndrome is characterized consecutive patients at and above the age of 20 by a low-grade chronic inflammatory process, years. Their medical histories including smoking probably initiated in early life3, and it can habit, DM, dyslipidemia, and already used probably be slowed down during the early phases medications were learnt, and a routine check with appropriate nonpharmaceutical approaches up procedure including fasting plasma glucose including lifestyle changes, diet, and exercise (FPG), triglyceride (TG), high density lipoprotein to prevent excess weight.4 But probably the cholesterol (HDL-C), low density lipoprotein syndrome can not be prevented completely, cholesterol (LDL-C), and an electrocardiography since aging alone may be one of the significant was performed. Current smokers with six pack- facilitator factor of the systemic atherosclerotic months and cases with a history of five pack-years process. The metabolic syndrome may contain were accepted as smokers, and cigar or pipe early reversible indicators such as white coat smokers were excluded. Patients with devastating hypertension (WCH), impaired fasting glucose illnesses including type 1 DM, malignancies, (IFG), impaired glucose tolerance (IGT), acute and chronic renal failure, chronic liver hypertriglyceridemia, hyperbetalipoproteinemia, diseases, hyper- or hypothyroidism, and heart dyslipidemia, overweight, and smoking for the failure were excluded to avoid their possible development of irreversible diseases including effects on weight. Body mass index (BMI) of obesity, hypertension (HT), type 2 diabetes each case was calculated by the measurements of mellitus (DM), peripheric artery disease (PAD), the Same Physician instead of verbal expressions. coronary heart disease (CHD), chronic obstructive Weight in kilograms is divided by height in pulmonary disease (COPD), cirrhosis, and meters squared, and underweight is defined as stroke.5 In another view, the syndrome induced a BMI of lower than 18.5, normal weight as systemic atherosclerosis is probably the leading 18.5-24.9, overweight as 25–29.9, and obesity cause of death for both sexes. On the other hand, as a BMI of 30.0 kg/m2 or greater.8 Cases with WCH is a well-known clinical entity defined an overnight FPG level of 126 mg/dL or greater as the persistently elevated blood pressure on two occasions or already using antidiabetic (BP) in doctor's office whereas normal in other medications were defined as diabetics. An oral conditions. It was reported in Ohasama study glucose tolerance test with 75-gram glucose that WCH is a risk factor for development of was performed in cases with a FPG level home HT.6 Similarly, intima-media thickness between 110 and 126 mg/dL, and diagnosis of and cross-sectional area of carotid artery were cases with a 2-hour plasma glucose level 200 found as similar in patients with WCH and HT, mg/dL or higher is DM and 140-199 mg/dL is which were significantly higher than cases with IGT. Additionally, patients with dyslipidemia sustained normotension (NT).7 Additionally, were detected, and we used the National plasma homocysteine levels were higher, and Cholesterol Education Program Expert Panel’s left ventricle mass index was greater in WCH recommendations for defining dyslipidemic group compared to NT cases (p<0.001 in both). subgroups.8 Dyslipidemia is diagnosed when We tried to understand the role and significance LDL-C is 160 or higher and/or TG is 200 or of WCH in definition of the metabolic syndrome higher and/or HDL-C is lower than 40 mg/dL. in the present study. 223 Mehmet R. Helvaci Acta Med Indones-Indones J Intern Med A stress electrocardiography was performed mmHg.9 Eventually, prevalences of smoking, in suspected cases via the electrocardiography excess weight, hyperbetalipoproteinemia, or any history about angina pectoris, and a hypertriglyceridemia, dyslipidemia, IGT, WCH, coronary angiography was obtained just for the DM, HT, and CHD were detected in decades and stress electrocardiography positive cases. So compared in between. Comparison of proportions CHD was diagnosed either angiographically was used as the method of statistical analysis. or with a history of coronary artery stenting and/or coronary artery bypass graft surgery. RESULTS Office blood pressure (OBP) was checked after The study included 1,068 cases (628 females a 5-minute of rest in seated position with a and 440 males). Due to the just 20 cases in the mercury sphygmomanometer on three visits, and ninth decade, they were not included for the no smoking was permitted during the previous statistical comparison. There were only 1.7% 2-hour. A 10-day twice daily measurement of (19) of cases with underweight and 28.7% (307) blood pressure at home (HBP) was obtained in with normal weight, so as a very high prevalence, all cases, even in normotensives in the office due 69.4% (742) of cases at and above the age of to the risk of masked HT after a brief education 20 years had excess weight. The prevalence 9 about proper BP measurement techniques.