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Blood Pressure Control by Home Monitoring

A Meta-Analysis of Randomised Trials

FP Cappuccio, SM Kerry, L Forbes, A Donald

Published in: Br Med J 2004; 329: 145-148

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Background

High blood pressure is the most preventable cause of death and disability due to CVD

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Background

High blood pressure is the most preventable cause of death and disability due to CVD

Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists)

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Background

High blood pressure is the most preventable cause of death and disability due to CVD

Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists)

With the introduction and validation of new electronic devices, self blood pressure monitoring at home is becoming increasingly popular

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Background

High blood pressure is the most preventable cause of death and disability due to CVD

Blood pressure is usually measured and monitored in the healthcare system by health professionals (doctors, nurses, pharmacists)

With the introduction and validation of new electronic devices, self blood pressure monitoring at home is becoming increasingly popular

However, there is little evidence as to whether using home monitoring is associated with a better control of high blood pressure

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Objective

To compare blood pressure levels and proportion on target in people with essential hypertension undergoing home blood pressure monitoring

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Design and Methods

Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system

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Design and Methods

Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system

Medline (1966 to Jan 2003), Embase (1980 to Jan 2003), Databases (Cochrane, Clinical Effectiveness, HTA, NHS Economic Evaluation, TRIP, CRD, AHRQ) identified 253 potential trials

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Flow Diagram

RCTs identified(n=253)

RCTs retrieved(n=21)

RCTs suitable(n=21)

RCTs included(n=18)

Not meeting inclusion criteria

(n=232)

Not using BP as outcome

(n=3)

Systolic (n=13) Diastolic (n=16)Mean (n=3) Targets (n=6)

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Design and Methods

Meta-analysis of randomised controlled trials comparing ‘home’ or ‘self’ blood pressure monitoring vs ‘usual’ blood pressure monitoring in the healthcare system

Medline (1966 to Jan 2003), Embase (1980 to Jan 2003), Databases (Cochrane, Clinical Effectiveness, HTA, NHS Economic Evaluation, TRIP, CRD, AHRQ) identified 253 potential trials

1359 patients allocated to home blood pressure monitoring and 1355 to ‘control’ groups

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Statistical Analysis

Random effects model

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Statistical Analysis

Random effects model Difference in BP (95% CI) Relative risk (95% CI)

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Statistical Analysis

Random effects model Difference in BP (95% CI) Relative risk (95% CI) Publication bias by funnel plot

and Egger’s test ‘Trim and fill’ method Heterogeneity by chi-square

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RESULTS 1. Systolic blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings

Heterogeneity p<0.001

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RESULTS 2. Diastolic blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings

Heterogeneity p=0.014

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RESULTS 3. Mean blood pressure achieved in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings

Heterogeneity p=0.319

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RESULTS 4. Funnel plot for systolic blood pressure

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RESULTS 5. Egger’s test for publication bias and revised estimates by ‘trim and fill’ test

0.6 to 3.21.90.095DBP(mmHg)

-0.9 to 5.32.20.038SBP(mmHg)

95% C.I.‘Trim & Fill’ estimate

Egger’s test (p)

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RESULTS 6. Standardised relative risk of blood pressure above target in people monitoring blood pressure at home compared with people whose blood pressure was monitored by health professionals in clinical settings

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Studies published in 2004

o Staessen JA et al. JAMA 2004;291:955-64RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

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o Staessen JA et al. JAMA 2004;291:955-64RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

o Bobrie G et al. JAMA 2004;291:1342-9Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP.

Studies published in 2004

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o Staessen JA et al. JAMA 2004;291:955-64RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

o Bobrie G et al. JAMA 2004;291:1342-9Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP.

o Cuspidi C et al. J Hum Hypert 2004; online 22 AprilCross-sectional study of 1350 hypertensives; 66% practising Home BP monitoring. Higher rate of Clinic BP control amongst them.

Studies published in 2004

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Summary and Conclusions

Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system

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Summary and Conclusions

Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system

A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’

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Summary and Conclusions

Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system

A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’

The reasons for this are not clear. However, greater direct involvement of the patient in his/her own care might be beneficial through greater awareness, motivation, concordance etc

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Summary and Conclusions

Patients who monitor their blood pressure ‘at home’ have a lower ‘clinic’ blood pressure compared to those whose blood pressure is monitored in the healthcare system

A greater proportion of them also achieve blood pressure targets when assessed ‘in the clinic’

The reasons for this are not clear. However, greater direct involvement of the patient in his/her own care might be beneficial through greater awareness, motivation, concordance etc

Home blood pressure measurement can be used as an adjunctive practice to help patients manage their hypertension more effectively