Therapeutics
In hypertension with high CV risk, BP self-monitoring and medication self-titration reduced BP at 12 months Clinical impact rating:
McManus RJ, Mant J, Haque MS, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014;312:799-808.
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Question
Conclusion
In patients with hypertension and high cardiovascular (CV) risk, does blood pressure (BP) self-management reduce BP compared with usual care?
In patients with hypertension and high risk for cardiovascular disease, blood pressure self-monitoring with self-titration of antihypertensive medications reduced blood pressure at 12 months.
Methods
*Information provided by author.
Design: Randomized controlled trial (Targets and SelfManagement for the Control of Blood Pressure in Stroke and at Risk Groups [TASMIN-SR] study). Current Controlled Trials ISRCTN87171227. Allocation: {Concealed}*.†
†See Glossary. Sources of funding: National Institute for Health Research (NIHR) and NIHR National School of Primary Care Research.
Blinding: Unblinded.†
For correspondence: Dr. R.J. McManus, University of Oxford, Oxford, England, UK. E-mail [email protected].
Follow-up period: 12 months.
Commentary
Setting: 59 primary care practices in the UK.
McManus and colleagues empowered high-risk patients with relatively well-controlled BP to manage their own health care by selfmonitoring BP and self-titrating antihypertensive treatment. They found reductions in systolic and diastolic BP with self-management.
Patients: 555 patients ≥ 35 years of age (mean age 69 y, 60% men, mean systolic BP 144 mm Hg, mean diastolic BP 80 mm Hg) with BP ≥ 130/80 mm Hg at baseline examination and ≥ 1 of CV disease, stage 3 chronic kidney disease, coronary heart disease, diabetes, or stroke. Exclusion criteria included BP > 180/100 mm Hg, postural hypotension, use of > 3 antihypertensive drugs, care by a specialist rather than a primary care clinician, terminal illness, pregnancy, acute CV event in the past 3 months, or inability to self-monitor. Intervention: Self-management program including 2 to 3 onehour patient training sessions about self-monitoring BP using a validated monitor (target home BP < 120/75 mm Hg) and selftitrating BP medications based on individualized 3-step algorithms, with agreement from family physicians (n = 277); or usual care after a routine BP check and medication review with family physicians (n = 278). Outcomes: The primary outcome was change in systolic BP at 12 months, measured with an electronic, automated sphygmomanometer during an office visit. Other outcomes included office diastolic BP and adverse events. Patient follow-up: 81%.
Main results Self-management reduced systolic and diastolic BP compared with usual care at 12 months (Table). The effect of self-management on systolic BP at 12 months was consistent in all prespecified subgroups (age, sex, baseline systolic BP ≤ or > 145 mm Hg, diabetes, chronic kidney disease, stroke or transient ischemic attack, coronary heart disease, or deprivation index). Self-management and usual care did not differ for any adverse events.
Home BP goals for the intervention group were < 120/75 mm Hg. The control group was not given a specific BP goal; nevertheless, they met current Joint National Committee⫺8 parameters (1), with a mean BP of 138/76 mm Hg at 12-month follow-up. Although the decline in BP with self-management was impressive, the mean difference in systolic BP of 9.2 mm Hg may not reduce CV events beyond that achieved with adequate BP control in the control group. The ACCORD trial, which focused on patients with diabetes, found that a reduction in systolic BP (to 119 mm Hg) with intensive BP management did not reduce CV events compared with standard management, which achieved a systolic BP of 134 mm Hg (2). The self-management program may be appropriate for a minority of patients in a particular practice. McManus and colleagues found similar success in a group of patients with mean starting BP of 152/85 mm Hg (3); however, the results of the TASMIN-SR study may not be generalizable to populations with very poorly controlled BP or those outside of the UK. Studies suggest that home BP measurement may be superior to office measurement as a determinant of target-organ damage and as a measurement of “true” BP (4). The TASMIN-SR study shows that home management is safe and effective in appropriate patients. More widespread implementation is promising as we invite our patients to be valued members of their health care team. Dana J. Herrigel, MD Laura Rees Willett, MD, FACP Rutgers–Robert Wood Johnson Medical School New Brunswick, New Jersey, USA References
BP self-management program vs usual care in patients with hypertension and high cardiovascular risk‡ Outcomes
Self-management
Usual care
Mean difference (95% CI) at 12 mo§
Baseline
12 mo
Mean systolic BP, mm Hg
143
128
144
138
9.2 (5.7 to 13)
Mean diastolic BP, mm Hg
81
74
80
76
3.4 (1.8 to 5.1)
‡BP = blood pressure; CI defined in Glossary.
Baseline 12 mo
1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-20. 2. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-85. 3. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet. 2010;376:163-72. 4. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52:1-9.
§Adjusted for baseline differences.
20 January 2015 Annals of Internal Medicine ACP Journal Club Downloaded From: http://annals.org/ by a Dalhousie University-Dal-11762 User on 05/17/2015
JC7
姝 2015 American College of Physicians
In hypertension with high CV risk, BP self-monitoring and medication self-titration reduced BP at 12 months Clinical impact rating:
McManus RJ, Mant J, Haque MS, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014;312:799-808.
多多多多多多夞
Question
Conclusion
In patients with hypertension and high cardiovascular (CV) risk, does blood pressure (BP) self-management reduce BP compared with usual care?
In patients with hypertension and high risk for cardiovascular disease, blood pressure self-monitoring with self-titration of antihypertensive medications reduced blood pressure at 12 months.
Methods
*Information provided by author.
Design: Randomized controlled trial (Targets and SelfManagement for the Control of Blood Pressure in Stroke and at Risk Groups [TASMIN-SR] study). Current Controlled Trials ISRCTN87171227. Allocation: {Concealed}*.†
†See Glossary. Sources of funding: National Institute for Health Research (NIHR) and NIHR National School of Primary Care Research.
Blinding: Unblinded.†
For correspondence: Dr. R.J. McManus, University of Oxford, Oxford, England, UK. E-mail [email protected].
Follow-up period: 12 months.
Commentary
Setting: 59 primary care practices in the UK.
McManus and colleagues empowered high-risk patients with relatively well-controlled BP to manage their own health care by selfmonitoring BP and self-titrating antihypertensive treatment. They found reductions in systolic and diastolic BP with self-management.
Patients: 555 patients ≥ 35 years of age (mean age 69 y, 60% men, mean systolic BP 144 mm Hg, mean diastolic BP 80 mm Hg) with BP ≥ 130/80 mm Hg at baseline examination and ≥ 1 of CV disease, stage 3 chronic kidney disease, coronary heart disease, diabetes, or stroke. Exclusion criteria included BP > 180/100 mm Hg, postural hypotension, use of > 3 antihypertensive drugs, care by a specialist rather than a primary care clinician, terminal illness, pregnancy, acute CV event in the past 3 months, or inability to self-monitor. Intervention: Self-management program including 2 to 3 onehour patient training sessions about self-monitoring BP using a validated monitor (target home BP < 120/75 mm Hg) and selftitrating BP medications based on individualized 3-step algorithms, with agreement from family physicians (n = 277); or usual care after a routine BP check and medication review with family physicians (n = 278). Outcomes: The primary outcome was change in systolic BP at 12 months, measured with an electronic, automated sphygmomanometer during an office visit. Other outcomes included office diastolic BP and adverse events. Patient follow-up: 81%.
Main results Self-management reduced systolic and diastolic BP compared with usual care at 12 months (Table). The effect of self-management on systolic BP at 12 months was consistent in all prespecified subgroups (age, sex, baseline systolic BP ≤ or > 145 mm Hg, diabetes, chronic kidney disease, stroke or transient ischemic attack, coronary heart disease, or deprivation index). Self-management and usual care did not differ for any adverse events.
Home BP goals for the intervention group were < 120/75 mm Hg. The control group was not given a specific BP goal; nevertheless, they met current Joint National Committee⫺8 parameters (1), with a mean BP of 138/76 mm Hg at 12-month follow-up. Although the decline in BP with self-management was impressive, the mean difference in systolic BP of 9.2 mm Hg may not reduce CV events beyond that achieved with adequate BP control in the control group. The ACCORD trial, which focused on patients with diabetes, found that a reduction in systolic BP (to 119 mm Hg) with intensive BP management did not reduce CV events compared with standard management, which achieved a systolic BP of 134 mm Hg (2). The self-management program may be appropriate for a minority of patients in a particular practice. McManus and colleagues found similar success in a group of patients with mean starting BP of 152/85 mm Hg (3); however, the results of the TASMIN-SR study may not be generalizable to populations with very poorly controlled BP or those outside of the UK. Studies suggest that home BP measurement may be superior to office measurement as a determinant of target-organ damage and as a measurement of “true” BP (4). The TASMIN-SR study shows that home management is safe and effective in appropriate patients. More widespread implementation is promising as we invite our patients to be valued members of their health care team. Dana J. Herrigel, MD Laura Rees Willett, MD, FACP Rutgers–Robert Wood Johnson Medical School New Brunswick, New Jersey, USA References
BP self-management program vs usual care in patients with hypertension and high cardiovascular risk‡ Outcomes
Self-management
Usual care
Mean difference (95% CI) at 12 mo§
Baseline
12 mo
Mean systolic BP, mm Hg
143
128
144
138
9.2 (5.7 to 13)
Mean diastolic BP, mm Hg
81
74
80
76
3.4 (1.8 to 5.1)
‡BP = blood pressure; CI defined in Glossary.
Baseline 12 mo
1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-20. 2. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-85. 3. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet. 2010;376:163-72. 4. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52:1-9.
§Adjusted for baseline differences.
20 January 2015 Annals of Internal Medicine ACP Journal Club Downloaded From: http://annals.org/ by a Dalhousie University-Dal-11762 User on 05/17/2015
JC7
姝 2015 American College of Physicians
