The current study included patients with hypertension at a high risk of cardiovascular disease (history of stroke, coronary heart disease, diabetes, or chronic kidney disease). Those allocated to the intervention arm were trained to self-monitor their BP with self-titration of medication following a predetermined plan, which was agreed with their GP. They took their blood pressure (BP) twice each morning during the first week of each month, and a change in medication according to the plan was made if at least four of these readings were above the target for two consecutive months. The study did not specifically address which medications to choose for self-titration.
The results found a benefit for self-management, with a reduction in systolic BP that was larger than that seen with standard care (associated with almost one extra higher intake of defined daily dose vs. the control group), with no observed increase in adverse events. The authors estimate that the observed BP difference would be expected to be associated with an approximate 30% reduction in stroke risk should it be sustained.
Of note, only 555 patients out of 10,746 potentially eligible were randomised, and follow-up was lower than expected (although the results were similar when missing data were accounted for in a sensitivity analysis). The authors postulate that the intervention might be suitable in practice for about 20% of patients. The study population was mainly white and from a professional or skilled manual background, which may limit the generalisability of the findings.
An accompanying editorial discusses some of the issues surrounding home monitoring of BP and adjustment of antihypertensive medications. These include for example:
• The possibility of adjustment based on increases that are only transient (e.g. during times of stress)
• The requirement of good adherence to measurement technique (otherwise the recorded measurement could be misleading)
• Several antihypertensives may be required to obtain optimum BP control – interactions and unwanted effects are common and may require monitoring (titration in this case cannot be governed solely by BP measurements)
It suggests this research is an important step toward adaptation of treatment for patients who want to actively take part in their own risk-factor control; future studies evaluating the effects of self-management on cardiovascular events are however needed.