What is masked hypertension and why is it particularly dangerous?

Masked hypertension is defined as blood pressure that is normal in a clinical setting (below 130/80 mmHg in clinic) but elevated on home or ambulatory monitoring (above 130/80 mmHg on home readings or above 135/85 mmHg on 24-hour average), it is present in approximately 15–20% of men told their blood pressure is "fine," and carries equivalent or higher cardiovascular risk than sustained clinical hypertension, precisely because it goes untreated (Fagard & Cornelissen, J Hypertens, 2007).

In my clinical practice, I have seen men with in-office blood pressure of 118/76, textbook normal, whose 24-hour ambulatory monitoring showed average daytime pressures of 138/88 and nocturnal readings above 130/80. The mechanism is sympathetic nervous system activation in clinic (white coat response) that suppresses blood pressure in the office while the chronic stress burden of a high-pressure career re-emerges at home. The man who is told his blood pressure is fine in clinic but wakes with headaches, works in a high-cognitive-demand role, and carries excess visceral fat may have masked hypertension that is not being treated.

Honesty Scale: Solid (1) for masked hypertension's cardiovascular risk. Solid (1) for its prevalence in men with clinic-normal readings.

What to do: If you are a high-stress, high-achieving man over 40 who has only had blood pressure checked in clinic, ask your physician about home blood pressure monitoring for 1 week. Better: request a 24-hour ambulatory blood pressure monitor (ABPM), which captures nocturnal dipping and true average blood pressure including during your work day. This is the gold standard for blood pressure characterization.

For the full picture, read The Blood Pressure Deep Dive