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lood pressure (BP) levels in the doc- tor's clinic may not always reflect those of daily living, as indicated by 24-h ambulatory or self-monitoring mea- surements. Simple logic implies that treatment should be guided by the actual BP levels, rather than by imprecise clinic measurements. On average, BP measured in the clinic is higher than out-of-office BP. This difference occurs in a consider- able number of patients with white-coat hypertension (WCH). The issue is com- plicated, since most studies define WCH as an elevated office BP in patients with normal awake ambulatory BP. However, the "awake" state may not fully reflect the 24-h BP load. Average 24-h BP, and par- ticularly that during sleep, which is more likely to be higher in subjects with diabe- tes (1,2), could be elevated in a patient with normal awake BP. The presence of abnormal clinic BP in such a patient dis- closes true hypertension rather than WCH. Indeed, among 4,121 subjects re- ferred for ambulatory BP monitoring, 4.5% had isolated abnormal sleep BP (120/70 mmHg) and normal 24-h BP (3). Nevertheless, in this presentation, we assume that the common definition of WCH is elevated clinic readings with nor- mal awake BP. Assessment of WCH in diabetes is complicated by the fact that normal BP measured at the clinic is defined as 130/80 mmHg (as opposed to 140/90 mmHg in the general population), whereas there are still no accepted thresh- olds for ambulatory or home-based BP levels. Characteristics unique to the white- coat response in patients with diabetes, associated prognostic implications, and the need for treatment are discussed.

White-Coat Hypertension Should Not Be Treated in Subjects With Diabetes