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

Study Questions:

What is the impact of self-monitoring of blood pressure with self-titration of antihypertensive medication (i.e., self-management), compared with usual care, on systolic blood pressure among high-risk patients with existing cardiovascular disease, diabetes mellitus, or chronic kidney disease?

Methods:

TASMIN-SR (The Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups) was an unblinded, randomized trial. Eligible patients had at least one “high-risk” condition (defined as cardiovascular disease, diabetes mellitus, stage 3 chronic kidney disease, or coronary heart disease) with a blood pressure reading during the baseline examination of at least 130/80 mm Hg; participants were not required to have been prescribed antihypertensive medication. Those randomized to self-management were trained to use a validated monitor and follow a predetermined plan (taught in 2-3 approximately 1-hour sessions) to self-titrate medications. Target blood pressure was <120/75 mm Hg. The primary prespecified outcome was the difference between intervention and control groups in systolic blood pressure at 12 months.

Results:

The analytic sample included 450 patients (81% of 555 patients randomized). Mean baseline blood pressure was 143.1/80.5 mm Hg and 143.6/79.5 mm Hg in the intervention and control groups, respectively. The mean blood pressure decreased to 128.2/73.8 mm Hg and 137.8/76.3 mm Hg in the intervention and control groups, respectively, after 12 months. There was a difference of 9.2 mm Hg (95% confidence interval [CI], 5.7-12.7) in systolic and 3.4 mm Hg (95% CI, 1.8-5.0) in diastolic blood pressure between groups. With multiple imputation for missing value, the difference in diastolic blood pressure did not meet statistical significance.

Conclusions:

The authors concluded that self-management of blood pressure in patients with or at high risk of cardiovascular disease resulted in lower systolic blood pressure at 12 months.

Perspective:

This is an important study that suggests the merits of a strategy of self-monitoring of blood pressure with self-titration of antihypertensives in select patients. Any strategies to mitigate the substantial and global burden of hypertension are welcome. It should be noted that the blood pressure target of 120/75 mm Hg (based on recommendations by the British Hypertension Society and the Joint British Society Guidelines) is significantly lower than the 150/90 mm Hg threshold recommended by the Eighth National Committee (JNC 8) panel members in adults older than 60 years of age (in TASMIN-SR, mean age in randomized patients in the usual care and intervention groups was 69.6 and 69.3, respectively). Furthermore, the mean baseline blood pressure in both groups was below this threshold. Although the thresholds defined by JNC 8 are not without controversy, it would be valuable to test such a strategy of self-monitoring in patients with significantly worse hypertension at baseline.

Clinical Topics: Prevention, Hypertension

Keywords: Stroke, Self Care, Blood Pressure Monitoring, Ambulatory, Coronary Disease, Confidence Intervals, Cost of Illness, Hypertension, Diabetes Mellitus, Renal Insufficiency, Chronic


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