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High-risk patients benefit from BP self-monitoring

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Moving toward modern patient-centered treatment

The findings of McManus et al. are encouraging, given that hypertension is a common cause of premature mortality and that the improvements seen with home monitoring as compared with usual care would be expected to result in considerable reduction of cardiovascular risk, according to Dr. Peter M. Nilsson and Dr. Fredrik H. Nystrom.

"The findings ... represent an important gain in knowledge about efficacy and safety of self-titration of antihypertensive drugs based on home blood pressure recordings using fairly inexpensive oscillometric devices," they wrote in an editorial (JAMA. 2014;312:795-6).

The findings also suggest that a "bring it home" approach to blood pressure lowering is suitable for patients with hypertension and comorbidities, wrote Dr. Nilsson and Dr. Nystrom.

Although the TASMIN-SR study marks an important step toward modern patient-centered treatment of hypertension, questions remain with respect to appropriate timing of home blood pressure recordings and selection of medications for self-titration. Additional study to address these questions and to assess the effects of self-titration on cardiovascular events is needed, they said.

Dr. Nilsson is with Lund University, Skane University Hospital, Malmo, Sweden. Dr. Nystrom is with Linkoping University, Linkoping, Sweden. Both authors reported having no disclosures.


 

FROM JAMA

References

Self-monitoring of blood pressure with self-titration of antihypertensive medication was more effective than was usual care for lowering blood pressure in patients with hypertension and high cardiovascular disease risk in the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups (TASMIN-SR) randomized clinical trial.

After 12 months, mean systolic blood pressure in 220 patients in the self-monitoring group and 230 patients in the usual care group was 128.2 mm Hg and 137.8 mm Hg, respectively (mean difference of 9.2 mm Hg after adjustment for baseline differences), and the mean diastolic blood pressure was 73.8 mm Hg vs. 76.3 mm Hg, respectively (mean difference of 3.4 mm Hg after adjustment for baseline differences), reported Dr. Richard J. McManus of the University of Oxford, England. The report was published online Aug. 26 in JAMA.

Patients in the study were at least 35 years old, had a baseline blood pressure of 130/80 mm Hg, and were at high risk for cardiovascular disease based on a history of cardiovascular disease, diabetes, stage 3 chronic kidney disease, or coronary heart disease. Patients in the self-monitoring group were trained to self-monitor blood pressure and were provided with an individualized self-titration algorithm, and had a home measurement target of 120/75 mm Hg. Control group patients saw their health care clinicians for blood pressure measurement and a medication review at baseline and as needed for medication adjustments (JAMA 2014;312:799-808 [doi:10.1001/jama.2014.10057]).

Self-titration of antihypertension drugs was the second part of this study. Patients who measured their own blood pressure also adjusted their dosage in response to the numbers. "Prescription of antihypertensive drugs increased in both groups but significantly more in the intervention group: The mean defined daily doses at 12 months for the intervention group was 3.34 (95%CI, 3.1, 3.7) vs 2.61 (95%CI, 2.4-2.9) for the control group (mean difference, 0.9; 95% CI, 0.7-1.2) ... Comparison with the number of drug classes prescribed shows that this represents both an increase in dose and in the number of medications. The main changes seen were in the prescription of calcium channel blockers, and thiazides, which significantly increased in the intervention group compared with the control group," the researchers wrote.

Self-monitoring is increasingly common, and has been shown to be associated with lower blood pressure in patients with hypertension; the current findings confirm that self monitoring is feasible and also results in clinically significant improvements in blood pressure – with no increase in adverse events – in high-risk patients with hypertension, the investigators concluded.

Dr. McManus reported receiving equipment for research from Omron and Lloyds Healthcare. Coauthor Dr. Bryan Williams works in academic collaboration with Healthstats, Singapore, in developing novel blood pressure monitoring approaches. Dr. Richard Hobbs has received research support from Microlife and BP TRU, and he is supported by the NIHR SPCR, the NIHR Oxford BRC, and the NIHR CLAHRC Oxford. The remaining authors reported having no disclosures.

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