Self-management of Hypertension

Self-measurement of Blood Pressure

Interventions using self-measurement of blood pressure (BP) have been shown to produce greater BP reductions than standard care using office-based BP measurement.^[1] Home BP is a significant predictor of cardiovascular (CV) mortality and CV events and is possibly superior to office BP as a predictor of target organ damage.^[2,3] However, despite a call for routine adoption of home BP monitoring in patients with known or suspected hypertension, issued jointly in 2008 by the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association ,^[4] many physicians do not encourage patients to self-monitor. Current hypertension management guidelines that acknowledge the value of home measurement (self-monitoring) of BP,^[5,6,7] as well as guidelines focused exclusively on home BP monitoring,^[8,9,10,11] view home BP measurement as an adjunct, albeit an important one, to conventional office BP measurement, the "gold standard" for screening, diagnosis, and management of hypertension.^[5] Recent European hypertension guidelines have been criticized for the "muted enthusiasm"^[12] and failure to update their recommendations for home BP monitoring beyond validation of clinic readings.^[12,13]

The hypertension guidelines also stress that home monitoring helps healthcare providers determine whether treatments are working, but that patients should not adjust their prescribed antihypertensive medication without consulting their physicians.^[10] However, a short-term trial of self-management of hypertension that included self-titration also showed a greater BP reduction over usual care.^[14] In 2010, Prof Richard McManus and colleagues reported the results of a longer-term study, the Telemonitoring and Self-Management of Hypertension Trial (TASMINH2),^[14] in which self-monitoring of BP plus self-titration of antihypertensive drugs according to a predetermined plan was shown to be significantly more effective than usual care in lowering systolic BP over 1 year.^[15] TASMINH2 included more than 500 primary care patients with BP higher than 140/90 mm Hg who were being treated with two or more antihypertensive drugs. The reduction in systolic BP was 5.4 mm Hg greater in the intervention group, which they estimated to be equivalent to a > 20% reduction in risk for stroke and a > 10% reduction in risk for coronary heart disease. This was achieved without increases in most adverse events or in patient anxiety. The cohort of patients studied in TASMINH2 included only a few high-risk patients, however, and the BP reduction appeared smaller in this subgroup.

To further investigate the effects of self-management in high-risk patients, McManus and colleagues carried out the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups (TASMIN-SR) trial,^[16] the results of which were first presented at the 2013 European Meeting on Hypertension and Cardiovascular Protection and published recently in JAMA.^[17] The unblinded, randomized trial, conducted between March 2011 and January 2013, involved 552 patients aged 35 years or older with a history of stroke, coronary heart disease, diabetes, or chronic kidney disease and baseline BP of ≥ 130/80 mm Hg, who were being treated at 59 UK primary care practices. BP targets in these patients were based on UK guidelines that were current at the time, which were < 130/80 mm Hg in the office measurement group (usual care) and < 120/75 mm Hg in the home measurement group.^{[18,19,20,21,22]} Usual care consisted of patient visits to their healthcare provider for routine BP measurement and adjustment of medication if necessary. Self-monitoring of BP was combined with self-titration according to an individualized algorithm.

After 12 months, mean BP had declined to 128.2/73.8 mm Hg in the intervention group vs 137.8/76.3 mm Hg in the control group, a difference of 9.2/3.4 mm Hg following correction for baseline BP. Multiple imputation for missing values gave similar results. The BP reduction seen with self-management was greater than seen previously and appeared to have been obtained through more extensive use of antihypertensive medication, with increases in both dose and number of drugs, particularly thiazide diuretics and calcium channel blockers. These results were comparable in all subgroups, without any excess in adverse events. On the basis of previous outcomes trials, the researchers calculated that if the BP reduction was maintained, self-management in TASMIN-HR could be associated with a 30% reduction in stroke risk.

In an editorial published in the same issue as the TASMIN-HR report,^[23] Peter M. Nilsson, MD, PhD (Lund University, Skåne University Hospital, Malmö, Sweden) and Fredrik H. Nystrom, MD, PhD (Linköping University, Linköping, Sweden) hailed the trial findings as "an important step toward modern patient-centered treatment of hypertension."

Prof McManus spoke with Linda Brookes, for Medscape, about the implications of TASMIN-HR for the wider use of home BP management by patients who want to take part in their own risk factor control and how clinicians can introduce patient self-management in clinical practice.

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