PracticeUpdate Cardiology Best of 2018

EDITOR’S PICKS 11

Efficacy of Self- Monitored Blood Pressure for Titration of Antihypertensive Medication The Lancet Take-home message • In this large randomized, controlled trial (n=1182), the authors evaluated the clinical utility of blood pressure (BP) self-moni- toring compared with telemonitoring or clinic blood pressure readings for managing medication titration for high BP. At 12-month follow-up, participants undergoing telemonitoring or performing self-monitoring had lower BP compared with participants monitored by in-clinic measurement. Telemoni- toring and self-monitoring produced similar results in regard to overall high BP control. • The authors concluded that BP self-monitoring is an effective method for monitoring BP for the purposes of medication titration and offers a simple and accurate strategy for moni- toring BP in patients managed by primary care practitioners. Abstract BACKGROUND Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. METHODS This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mmHg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisationwas by a secureweb- based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pres- sure at 12months from randomisation. Primary analysis was of available cases. FINDINGS 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups comparedwith usual care (self-monitoring, 137·0 [SD 16·7] mmHg and telemon- itoring, 136·0 [16·1] mmHg vs usual care, 140·4 [16·5]; adjustedmean differences vs usual care: self-monitoring alone, -3·5mmHg [95%CI -5·8 to -1·2]; telemon- itoring, -4·7 mm Hg [-7·0 to -2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1·2 mm Hg [95% CI -3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. INTERPRETATION Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individ- uals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care. Efficacy of Self-Monitored Blood Pressure, With or Without Telemon- itoring, for Titration of Antihypertensive Medication (TASMINH4): An Unmasked Randomised Controlled Trial. Lancet 2018 Feb 27;[EPub Ahead of Print], RJ McManus, J Mant, M Franssen, et al. www.practiceupdate.com/c/64937

COMMENT By Ronald G. Victor MD S elf-monitored home blood pressure – even without tele- monitoring – leads to lower blood pressure in general practice, reports a paper in the recent edition of The Lan- cet . Almost 1200 patients (mean age 67, baseline systolic BP 153 mmHg) from 142 general medical practices in the UK were randomly assigned (1:1:1) to self-monitoring of BP, self-monitor- ing plus telemonitoring, or usual care (office BP readings). After 12 months, the mean systolic BP was lower with both inter- ventions: 137.0 mmHg with self-monitoring and 136.0 mmHg with self-monitoring plus telemonitoring vs 140.6 mmHg with usual care. Thus, after multivariable adjustment, systolic BP was 3.5 mmHg lower with self-monitoring than usual care and 4.7 mmHg lower with self-monitoring plus telemonitoring. The strengths of the study are the rather large sample size and the statistically significant intervention effect(s). There also are major weaknesses. First, the effect size is modest. The final group mean systolic BP levels do not approach the new 2017 ACC/AHA goal of <130/80 mmHg, although the general prac- titioners at the time were targeting higher values. Second, the primary endpoint was office BP. Third, and more importantly, there was only a marginal intervention effect on drug regimen intensification. All 3 groups were under-treated at the end of the study, with <2 drug classes being prescribed per patient. Most hypertensive patients will need 2 or 3 drugs to control their BP. So, what explains the modest benefit? Possibly better medica- tion compliance, which was not rigorously measured. Missed opportunities for drug regimen intensification for high BP are common in primary care, with shared responsibility between patients (push-back), doctors (clinical inertia), and health systems (20 minutes for a new patient visit, and only 10 minutes for follow-up visits). Reliance on conventional office BP will over-estimate ambulatory BP due to the white coat reaction or under-estimate it due to masked hypertension in 3 out of every 4 patients. Ambulatory BP monitoring is the gold standard because it is the only way to obtain BP readings during normal daily activities and during sleep. We need to convince the Center for Medicare and Medicaid Services (CMS) to pay for it. I am not a big fan of frequent home BPmonitoring. Some patients will cherry-pick good readings to please the doctor. Others will check their BP whenever they feel stressed, with high readings indicating panic attacks. Some patients become so obsessed with their BP readings that daily (sometimes hourly) self-moni- toring becomes counterproductive; it can be very difficult to get such patients to stop. We should never instruct patients to take an extra BP pill if their home reading exceeds a certain level – this places far too much responsibility on the patient and it exacer- bates blood pressure lability. In this regard, PRN clonidine is the work of the devil! Based on this publication, I recommend that most patients mon- itor their blood pressure 2 to 4 weeks after each medication change – after sufficient time has elapsed to achieve steady state reductions in blood pressure.

Dr. Victor was Director of Cedars-Sinai Center for Hypertension, Associate Director, Clinical Research, and Burns and Allen Chair in Cardiology Research at Cedars-Sinai Heart Institute in Los Angeles, California.

VOL. 3 • NO. 4 • 2018