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Review: In hypertension, BP self-monitoring interventions improve BP levels and BP control at 12 months

Question In patients with hypertension, does blood pressure (BP) self-monitoring improve BP levels and control compared with usual care? Review scope Included studies assessed BP self-monitoring interventions without clinician input for monitoring using a validated device compared with usual care (no organized self-monitoring) in outpatients with hypertension, were published after 2000, included 100 patients, and had follow-up 6 months. Primary outcomes were systolic BP (SBP), diastolic BP (DBP), and BP control (BP target level defined in individual trials) at 12 months. Review methods MEDLINE, EMBASE/Excerpta Medica, and Cochrane Library were searched to Jun 2016 for randomized controlled trials (RCTs). Investigators were contacted for individual patient data (IPD). 36 published RCTs and 1 unpublished RCT met inclusion criteria; patient-level data were provided for 25 RCTs (n =10487, baseline BP range 125/71 to 164/96 mm Hg). Among the 25 RCTs with IPD, BP self-monitoring interventions were stratified by intensity level: 6 RCTs had interventions with level 1 intensity (minimal additional contact), 5 had level 2 (automated feedback or support), 4 had level 3 (active support intervention), 5 had level 4 (substantial individually tailored support), and 5 had 1 intervention with different levels of support intensity. 16 RCTs had different home- and clinic-based BP targets, including 12 with targets of 135/85 mm Hg and 140/90 mm Hg, respectively. 24 RCTs had adequate allocation concealment, 12 blinded outcome assessors, and 19 had >80% follow-up. Main results IPD meta-analysis showed that BP self-monitoring interventions improved SBP and DBP and reduced the proportion of patients with uncontrolled BP compared with usual care at 12 months (Table). In prespecified subgroup analyses by intervention intensity, BP self-monitoring with more intensive interventions reduced the proportion of patients with uncontrolled BP (level-3 intensity, relative risk reduction [RRR] 43%, 95% CI 27 to 56; level-4 intensity, RRR 56%, CI 43 to 66) and improved SBP and DBP (data not shown) compared with usual care at 12 months. Low-intensity (level 1) interventions did not reduce the proportion of patients with uncontrolled BP (RRR 1%, CI 37 to 28) or BP levels (data not shown) compared with usual care; results were mixed for level 2 interventions. Conclusion In patients with hypertension, blood pressure (BP) self-monitoring interventions with active or individually tailored support improve BP levels and BP control compared with usual care at 12 months. Individual patient data meta-analysis of BP self-monitoring interventions vs usual care in patients with hypertension* Outcomes Weighted event rates At 12 mo BP self-monitoring Usual care RRR (95% CI) NNT (CI) Uncontrolled BP 35% 50% 30% (14 to 44) 7 (5 to 15) Mean difference (CI) Clinic systolic BP, mm Hg 3.2 (4.9 to 1.6) Clinic diastolic BP, mm Hg 1.5 (2.2 to 0.75) *BP = blood pressure; other abbreviations defined in Glossary. Weighted event rates, RRR, NNT, and CI calculated from relative risk and CI in article and usual care event rate provided by author. Based on 15 RCTs (n =6300) with data for the primary BP outcomes. P <0.001 for heterogeneity across BP intervention intensity levels (1 to 4). Differences <1 indicate benefit with BP self-monitoring interventions. Commentary Recent guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) newly define adult hypertension as SBP 130 mm Hg and/or DBP 80 mm Hg (1). According to the National Health and Nutrition Examination Surveys, the prevalence of hypertension using ACC/AHA 2017 criteria is 46% in US adults >18 years of age (1). This translates into 103 million persons with hypertension. Unfortunately, BP remains uncontrolled in up to 50% of them (2). Efforts to improve BP control may target providers, patients, or both. The review and IPD meta-analysis by Tucker and colleagues focuses on interventions with self-monitored BP, which may focus exclusively on the patient (level 1), on the patient with automated feedback (level 2), or on the patient with varying levels of contact with providers (levels 3 and 4). In the IPD meta-analysis, there was a step-wise decrease in SBP from 1.0 mm Hg to 6.1 mm Hg with increasing intervention intensity. As Tucker and colleagues note, important questions remain. Would the findings persist after 12 months? This question is especially important for a disease that lasts for many decades. What is the cost of the various interventions, and to whom should they be targeted? These questions are important in a disease that afflicts >100 million Americans, of whom only about 50% are at target BP. Level-1 self-monitoring interventions seem to have minimal effect on BP control, so using this strategy makes little sense despite widespread application. Any level of intervention was less effective in patients receiving greater numbers of antihypertensive medications. Most important, it would be useful to identify the least costly interventions to effectively combine with BP self-monitoring interventions.