Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

Katherine L Tucker ,Kenneth Earle ,Mary Ann Mclaughlin ,Bahman P Tabaei ,Willem J Verberk ,Johnson George ,Brian Mckinstry ,Emma P Bray ,Bonnie J Wakefield ,Jonathan Mant ,Karen L Margolis ,Gianfranco Parati ,Ilkka Kantola ,Marshall Godwin ,David J Magid ,Stefano Omboni ,Juha Varis ,Sally Kerry ,Paul L Hebert ,Nashat Qamar ,F D Richard Hobbs ,Alfonso Leiva ,Alfred A Bové ,James P Sheppard ,Olugbenga Ogedegbe ,Hayden B Bosworth ,Beverly B Green ,R J Stevens ,Richard J Mcmanus

doi:10.1371/journal.pmed.1002389

Abstract

BackgroundSelf-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension.Methods and findingsMedline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes—change in mean clinic or ambulatory BP and proportion controlled below target at 12 months—were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (−3.2 mmHg, [95% CI −4.9, −1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (−1.0 mmHg [−3.3, 1.2]), to a 6.1 mmHg (−9.0, −3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic −0.2 mmHg [−2.2, 1.8]; ambulatory 1.1 mmHg [−0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies.ConclusionsSelf-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Highlights

Treatment of hypertension results in significant reductions in risk of subsequent cardiovascular disease [1,2]
Self-monitoring was associated with reduced clinic systolic blood pressure compared to usual care at 12 months (−3.2 mmHg, [95% CI −4.9, −1.6 mmHg])
The aim of this work was to use individual patient data (IPD) from relevant trials to assess the effectiveness of blood pressure (BP) self-monitoring on BP reduction and hypertension control, evaluating how best to utilise self-monitoring of BP and to determine which subpopulation is most likely to benefit

Summary

Introduction

Treatment of hypertension results in significant reductions in risk of subsequent cardiovascular disease [1,2]. Self-monitoring of blood pressure (BP), where individuals measure their own blood pressure, usually in a home environment, can improve BP control and is an increasingly common part of hypertension management. Self-monitoring is well tolerated by patients and has been shown to be a better predictor of end organ damage than clinic measurement [5,6,7,8] This is despite potential issues with quality control of self-measurement such as poor technique or withholding of results [9,10]. Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension.

Objectives

Methods

Results

Conclusion