Very high central aortic systolic pressures in a young hypertensive patient on telmisartan: Is central aortic systolic pressure associated with white coat hypertension?

Central aortic systolic pressure (CASP) is a very well-recognized tool to assess the end organ damage in patients with hypertension. It is known that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers reduce CASP more than some antihypertensives such as beta-blockers. White coat hypertension with CASP has not been described and validated. The present report describes a very anxious 24-year-old patient on telmisartan (an angiotensin receptor blocker), with a very high CASP compared with his peripheral blood pressure (BP). He had a strong family history of hypertension, and was fairly well controlled on 80 mg/day telmisartan, with his BP ranging from 125/80 mmHg to 130/85 mmHg (home BP monitoring). In May 2009, he underwent routine CASP at Tan Tock Seng Hospital (Singapore), and ambulatory BP measurements using a BPro watch (HealthSTATS, Singapore). The patient had a CASP of 132 mmHg at the hospital, but his calculated CASP by ambulatory BP measurement at 1 pm was 120 mmHg. His ambulatory pressures were 137/94 mmHg; thus, hydrochlorothiazide was added for further control. He was advised to repeat CASP measurements on follow-up in six weeks. He followed up on June 18, 2009, and July 30, 2009, and his CASPs were 139 mmHg and 137 mmHg, respectively. He underwent a magnetic resonance aortogram to exclude any obstructive cause for very high CASPs. His magnetic resonance aortogram revealed no evidence of coarctation of the aorta. CASP may have significant variations due to white coat phenomenon. Further 24 h CASP studies are needed to observe whether CASP is subject to white coat phenomenon.