Magnitude of the Difference Between Clinic and Ambulatory Blood Pressures and Risk of Adverse Outcomes in Patients With Chronic Kidney Disease

BACKGROUND: Obtaining 24‐hour ambulatory blood pressure (BP) is recommended for the detection of masked or white‐coat hypertension. Our objective was to determine whether the magnitude of the difference between ambulatory and clinic BPs has prognostic implications. METHODS AND RESULTS: We included 610 participants of the AASK (African American Study of Kidney Disease and Hypertension) Cohort Study who had clinic and ambulatory BPs performed in close proximity in time. We used Cox models to determine the association between the absolute systolic BP (SBP) difference between clinic and awake ambulatory BPs (primary predictor) and death and end‐stage renal disease. Of 610 AASK Cohort Study participants, 200 (32.8%) died during a median follow‐up of 9.9 years; 178 (29.2%) developed end‐stage renal disease. There was a U‐shaped association between the clinic and ambulatory SBP difference with risk of death, but not end‐stage renal disease. A 5– to <10–mm Hg higher clinic versus awake SBP (white‐coat effect) was associated with a trend toward higher (adjusted) mortality risk (adjusted hazard ratio, 1.84; 95% CI, 0.94–3.56) compared with a 0– to <5–mm Hg clinic‐awake SBP difference (reference group). A ≥10–mm Hg clinic‐awake SBP difference was associated with even higher mortality risk (adjusted hazard ratio, 2.31; 95% CI, 1.27–4.22). A ≥−5–mm Hg clinic‐awake SBP difference was also associated with higher mortality (adjusted hazard ratio, 1.82; 95% CI, 1.05–3.15) compared with the reference group. CONCLUSIONS: A U‐shaped association exists between the magnitude of the difference between clinic and ambulatory SBP and mortality. Higher clinic versus ambulatory BPs (as in white‐coat effect) may be associated with higher risk of death in black patients with chronic kidney disease.