Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?
Open accessAbstract
Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m 2 , P <0.001; and 4.9 [2.1] g/m 2 , P =0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], −1.9 [4.8] g/m 2 , P =0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.
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In about half of patients diagnosed with masked hypertension, the phenomenon is present with both ABPM and HBPM, whereas in the remainder the diagnosis is documented with only one of the two methods.
“in about half of the patients diagnosed with masked hypertension, this phenomenon is present with both ABPM and HBPM (dual masked hypertension), whereas in the remainder, the diagnosis is only documented with one of the two BP measurement methods [22–25].”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [23]
The Discussion reports that prior studies found dual detection in 36%–45% of people with masked hypertension, which broadly supports the ‘about half’ description. But this paper’s own Results (Prevalence of MHT on ABPM and MHT on HBPM) found 29.5% with masked hypertension on both methods; the claim does not distinguish the prior studies from this study’s finding. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIndividuals with masked hypertension identified by only HBPM or ABPM have an intermediate cardiovascular disease risk between those identified by both methods as normotensives and those as sustained hypertensive patients.
“In outcome studies, individuals with masked hypertension identified by only HBPM or ABPM have an intermediate level of cardiovascular disease (CVD) risk between those identified by both methods as normotensives and those as sustained hypertensive patients.”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [23]
The Discussion (page unavailable) reports a prior outcome study in which people with masked hypertension detected by only ABPM or only HBPM had higher stroke risk than those with sustained normotension. It does not establish that their risk was lower than that of sustained hypertensive patients. The paper also says its own findings leave increased CVD risk for the HBPM-only group unclear. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMasked hypertension diagnosed by ABPM and not by HBPM, or the reverse, is not uncommon.
“masked hypertension diagnosed by ABPM and not by HBPM, or the reverse, is not uncommon”
Isolated ambulatory masked hypertension is more common in younger participants.
“with the former being more common in younger participants”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [23]
The Results section reports how often masked hypertension was detected only by ambulatory monitoring, but does not compare its prevalence by age. The Discussion says the study could not conduct subgroup analyses by age; searches for younger participants and age-specific prevalence found no supporting passage in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredIsolated home masked hypertension is more common in older participants.
“and the latter in older ones [23].”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [23]
The Results report how often masked hypertension occurred only on home monitoring, but do not relate that finding to participants’ ages. The Discussion says the study could not conduct subgroup analyses by age; searches for older participants and age comparisons found no supporting passage in our copy. (LLM, conf=0.73)
Experimental — accuracy not yet measured
Age is the most important determinant of isolated ambulatory or home masked hypertension.
“with age being the most important determinant of isolated ambulatory or home masked hypertension”
From Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension (2021) · cites this paper as [23]
The Results (Baseline Characteristics; page unavailable) give the cohort’s mean age but do not assess age as a determinant of isolated ambulatory or home masked hypertension. The Discussion (page unavailable) says the authors could not conduct subgroup analyses by age. Searches for age-related determinants of ABPM-only and HBPM-only masked hypertension found no supporting passage. (LLM, conf=0.75)
Experimental — accuracy not yet measured
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“For this study, we included participants with at least 14 readings during the self-defined daytime and at least 5 readings during the self-defined night-time [22,23].”
MethodCohen, J., Hsu, C.-Y., Glidden, D., Linke, L., Palad, F., Larson, H., Mehrotra, R., Townsend, R., & Bansal, N. (2021) · Kidney Medicine · doi:10.1016/j.xkme.2020.12.013 · Cited by 8 · see citing works
Left ventricular hypertrophy in isolated and dual masked hypertension
Cuspidi, C., Facchetti, R., Quarti-Trevano, F., Dell'Oro, R., Tadic, M., Grassi, G., & Mancia, G. (2020) · The Journal of Clinical Hypertension · doi:10.1111/jch.13808 · Cited by 8 · see citing works
Pugliese, D., Booth, J., Deng, L., Anstey, D. E., Bello, N., Jaeger, B., Shikany, J., Lloyd-Jones, D., Lewis, C., Schwartz, J. E., et al. (2019) · Journal of Hypertension · doi:10.1097/hjh.0000000000002175 · Cited by 8 · see citing works
Self-citationBerman, A., Hidrue, M., Ginder, C. R., Shirkey, L. B., Kwatra, J., O'Kelly, A. C., Murphy, S. P., Como, J. M. S., Daly, D., Sun, Y.-P., et al. (2025) · JAMA cardiology · doi:10.1016/s0735-1097(25)00799-5 · Cited by 7
Data-Driven Guided Attention for Analysis of Physiological Waveforms With Deep Learning
Martinez, J., Nowroozilarki, Z., Jafari, R., & Mortazavi, B. J. (2022) · IEEE Journal of Biomedical and Health Informatics · doi:10.1109/jbhi.2022.3199199 · Cited by 8 · see citing works
Blood pressure estimation based on pulse rate variation in a certain period
Hayase, T. (2020) · Scientific Reports · doi:10.1038/s41598-020-58367-y · Cited by 6 · see citing works
Berman, A. N., Ginder, C. R., Wang, X., Borden, L. R., Hidrue, M. K., Como, J. S., Daly, D., Sun, Y., Curry, W. T., Carmen, M. G. D., et al. (2023) · American Heart Journal · doi:10.1016/j.ahj.2023.06.014 · Cited by 5 · see citing works
Hypertension-Mediated Organ Damage in Masked Hypertension
Hinderliter, A., Lin, F.-C., Viera, L., Olsson, E., Klein, J. L., & Viera, A. (2022) · Journal of Hypertension · doi:10.1097/hjh.0000000000003084 · Cited by 5 · see citing works
Diagnostic Value of Home Blood Pressure
Kario, K., Imai, Y., Kollias, A., Niiranen, T. J., Ohkubo, T., McManus, R. J., & Stergiou, G. S. (2020) · Updates in Hypertension and Cardiovascular Protection · doi:10.1007/978-3-030-23065-4_5 · Cited by 5 · see citing works
Bersaoui, M., Bisai, A., Baldew, S., Toelsie, J., Goessler, K., & Cornelissen, V. (2023) · Journal of Human Hypertension · doi:10.1038/s41371-023-00844-8 · Cited by 4 · see citing works
“Also, ambulatory BP monitoring has been classi fi ed as the golden standard for the diagnosis and management of hypertension, characterized by increased 24-h, daytime, and nighttime BP even if of fi ce BP is well controlled [39, 40].”
MacDonald, A. S., Robertson, M., Dickie, D. A., Bath, P., Forbes, K., Quinn, T. J., Broomfield, N., Dani, K., Doney, A., Muir, K., et al. (2023) · Journal of Human Hypertension · doi:10.1038/s41371-024-00906-5 · Cited by 4
“Measures of short-term BPV were only calculated if the ABPM recording included ≥ 10 daytime and ≥ 5 night-time readings [27, 28].”
MethodHypothesis Scoring for Confidence-Aware Blood Pressure Estimation With Particle Filters
Martinez, J., Passage, B., Mortazavi, B. J., & Jafari, R. (2023) · IEEE Journal of Biomedical and Health Informatics · doi:10.1109/jbhi.2023.3289192 · Cited by 6 · see citing works
“XGBoost hyperparameters set for CAPF were optimized for the max tree depth and number of estimators – where the range of values were [2, 3, 4, 5, 6, 7, 8, 9, 10] and [25, 50, 75, 100] respectively.”
Egbe, A., Miranda, W., Shaik, L., Katta, R., Sakr, A., Devara, J., & Connolly, H. (2021) · Blood Pressure Monitoring · doi:10.1097/mbp.0000000000000573 · Cited by 4 · see citing works
Algorithm for diagnosing hypertension using out‐of‐office blood pressure measurements
Kim, J. S., Rhee, M., Kim, C. H., Kim, Y., Do, U., Kim, J.-H., Kim, Y. K., Lee, H. J., Park, J.-Y., Namgung, J., et al. (2021) · The Journal of Clinical Hypertension · doi:10.1111/jch.14382 · Cited by 4 · see citing works
Prevalence and Determinants of Masked Hypertension in Nigeria: The REMAH Study.
Odili, A., Danladi, B., Chori, B., Oshaju, H., Nwakile, P. C., Okoye, I., Abdullahi, U., Nwegbu, M. M., Zawaya, K., Essien, I., et al. (2020) · American Journal of Hypertension · doi:10.1093/ajh/hpaa211 · Cited by 4 · see citing works
Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review
Cesario, V., Presta, V., Figliuzzi, I., Citoni, B., Battistoni, A., Miceli, F., Volpe, M., & Tocci, G. (2020) · High Blood Pressure & Cardiovascular Prevention · doi:10.1007/s40292-020-00382-1 · Cited by 4 · see citing works
Morning blood pressure surge and diastolic dysfunction in patients with masked hypertension
Yılmaz, S., Nar, G., Til, A., & Kaftan, A. (2020) · Blood Pressure Monitoring · doi:10.1097/mbp.0000000000000440 · Cited by 4 · see citing works
Chen, B.-H., Chen, G., Jiang, H., Ya, S., Chen, J., Wang, D., Chen, M., Shi, J., Peng, Y., Cheng, Y., et al. (2025) · Blood Pressure · doi:10.1080/08037051.2025.2469264 · Cited by 3
“Home BP monitoring has been widely recommended for hypertension management, as it not only provides more accurate BP readings but also helps identify masked hypertension (MHT) outside the clinical setting [4–6].”
Abdalla, M., Juraschek, S. P., Biaggioni, I., Bowling, C., Balijepalli, R. C., Brady, T. M., Bress, A., Brook, R. D., Cohen, J. B., Commodore-Mensah, Y., et al. (2026) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2026.02.5124 · Cited by 2 · see citing works
Self-citationHome Blood Pressure Phenotypes and Cardiovascular Remodeling in Hemodialysis
Chen, M.-K., Dai, L.-P., Hsu, R.-Y., Hsieh, M.-Y., Cheng, H.-M., & Wu, C.-C. (2026) · Kidney International Reports · doi:10.1016/j.ekir.2026.106375 · Cited by 2 · see citing works
Obi, Y., Zhang, Y.-X., Tio, M., Yen, T. E., Wells, C. C., Hall, M., Dossabhoy, N., Chandra, S., & Shafi, T. (2025) · Kidney Medicine · doi:10.1016/j.xkme.2025.101192 · Cited by 2 · see citing works
“Participants were instructed to measure BP early in the morning before having coffee or breakfast and then at night before going to sleep, at least once each, and were encouraged to recheck BP if they had symptoms potentially associated with high or low BP. UMMC CfT also provided initial and quarterly home medication…”
InfluentialGeneral Principles, Etiologies, Evaluation, and Management in Older Adults
Egan, B. M., Rich, M. W., Sutherland, S. E., Wright, J. T., & Kjeldsen, S. E. (2024) · Clinics in Geriatric Medicine · doi:10.1016/j.cger.2024.04.008 · Cited by 2 · see citing works
Novel Pulse Waveform Index by Ambulatory Blood Pressure Monitoring and Cardiac Function
Narita, K., Yuan, Z., Yasui, N., Hoshide, S., & Kario, K. (2023) · JACC: Advances · doi:10.1016/j.jacadv.2023.100737 · Cited by 2 · see citing works
Okumura, K., Obayashi, K., Tai, Y., Yamagami, Y., Kurumatani, N., & Saeki, K. (2022) · Journal of Hypertension · doi:10.1097/hjh.0000000000003221 · Cited by 4 · see citing works
Cohen, J., & Townsend, R. (2020) · Nephrology Self-Assessment Program · doi:10.1681/nsap.2020.19.1.2 · Cited by 2 · see citing works
Bhatia, R., Haldar, P., Longkumer, I., Srivastava, M. P., Misra, P., Sharma, G., Singh, M., Kumar, R., & Salve, H. (2026) · The Lancet Primary Care · doi:10.1016/j.lanprc.2026.100174 · Cited by 1 · see citing works
Machine learning model for detecting masked hypertension in young adults
Miller, B., Coeyman, S. J., Wentzel, A., Mels, C., & Richardson, W. J. (2025) · Frontiers in Physiology · doi:10.3389/fphys.2025.1684693 · Cited by 1 · see citing works
Home Versus Ambulatory Blood Pressure Monitoring
O'Brien, E., de la Sierra, Á., McManus, R., Mihailidou, A., Muntner, P., Myers, M., Stergiou, G., Parati, G., & Manios, E. (2019) · Updates in Hypertension and Cardiovascular Protection · doi:10.1007/978-3-030-23065-4_15 · Cited by 1 · see citing works
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Govo, V., Jessen, N., Novela, C., Amarcy, S., Chemane, J., Lunet, N., & Damasceno, A. (2026) · The Journal of Clinical Hypertension · doi:10.1111/jch.70356
“[ 47 ].”
Response to Letter to the Editor entitled "2017 ACC/AHA BP Thresholds for Masked HTN Detection".
Shimbo, D., Walsh, S., & Choi, E. (2025) · American Journal of Hypertension · doi:10.1093/ajh/hpaf151
Self-citationdu Toit, W. L., Kruger, R., Gafane-Matemane, L., Schutte, A., Louw, R., & Mels, C. (2024) · Amino Acids · doi:10.1007/s00726-024-03412-7
Correlation of diabetes complications with blood pressure variability
Shakya, S., Verma, P., Karoli, R., & Meena, P. (2023) · Heart India · doi:10.4103/heartindia.heartindia_19_23
Shin, J.-H., Lee, Y.-G., Ihm, S., Shin, J.-H., Kim, H.-J., Kim, B., Park, H.-C., Lim, Y., Park, J., Heo, R., et al. (2021) · Scientific Reports · doi:10.1038/s41598-022-04913-9
Cohen, J. (2021) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2021.06.010
Goudswaard, L., Harrison, S., Klee, D. V. D., Chaturvedi, N., Lawlor, D., Smith, G. D., Hughes, A., & Howe, L. (2020) · medRxiv · doi:10.1101/2020.11.20.20235473
Galloo, X., Robberechts, T., & der Niepen, P. V. (2020) · Arterial Hypertension · doi:10.5603/ah.a2020.0010
Phenotyping of masked hypertension based on the clustering of 24-hour blood pressure monitoring data
Geltser, B., Shakhgeldyan, K. I., Kotelnikov, V. N., Vetrova, O. O., Orlova-Ilyinskaya, V. V., & Karpov, R. (2020) · Russian Journal of Cardiology · doi:10.15829/1560-4071-2020-3-3286
Die unbeaufsichtigte Blutdruckmessung in der Praxis
Middeke, M., & Westhoff, T. (2020) · CardioVasc · doi:10.1007/s15027-019-0007-9
“Umso erstaunlicher sind die Ergebnisse aus SPRINT, und umso mehr müssen die Schlussfolgerungen der amerikanischen Fachgesellschaft hinterfragt werden [3].”
Background
- Authors
- Anstey, D. E., Muntner, P., Bello, N. A., Pugliese, D. N., Yano, Y., Kronish, I. M., Reynolds, K., Schwartz, J. E., & Shimbo, D.
- Affiliations
- Columbia University Irving Medical Center (US)
- University of Alabama at Birmingham (US)
- Duke University (US)
- Kaiser Permanente (US)
- ORCID
- Venue
- Hypertension
- Published
- 2018-11
- Volume
- 72
- Issue
- 5
- Pages
- 1200-1207
- ISSN
- 0194-911X (ISSN-L)
- 1524-4563
- PMC
- PMC6207212
- OpenAlex
- W2890266312
- Cited by
- 85
- References
- 39
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 6 · 2023: 17 · 2022: 11 · 2021: 11 · 2020: 14 · 2019: 13 · 2018: 1
- FWCI
- 7.38
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Hypertension (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- European Society of Cardiology
- European Association of Cardiovascular Imaging
- National Institutes of Health (and K24, HL007854, KL2TR001874)
- Agency for Healthcare Research and Quality (R01HS024262)
- National Heart, Lung, and Blood Institute (K23HL136853, P01HL047540, HL047540, HL007854, R01HL117323, K24HL125704, T32HL007854)
- National Center for Advancing Translational Sciences (TR001874)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Keywords
- masked hypertension, ambulatory blood pressure monitoring, home blood pressure monitoring, hypertension detection, left ventricular mass, cardiovascular risk, community-dwelling adults, nocturnal blood pressure
- MeSH terms
- Adult, Blood Pressure, Blood Pressure Determination, Female, Humans, Male, Middle Aged, Prevalence, Blood Pressure Monitoring, Ambulatory, Masked Hypertension
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