Blood Pressure Control by Home Monitoring A Meta-Analysis of Randomised Trials

1. Blood Pressure Control by Home MonitoringA Meta-Analysis of Randomised Trials FP Cappuccio, SM Kerry, L Forbes, A Donald Published in: Br Med J 2004; 329: 145-148 ESH 2004 Paris

2. Background • High blood pressure is the most preventable cause of death and disability due to CVD ESH 2004 Paris

3. 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) ESH 2004 Paris

4. 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 ESH 2004 Paris

5. 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 ESH 2004 Paris

6. Objective • To compare blood pressure levels and proportion on target in people with essential hypertension undergoing home blood pressure monitoring ESH 2004 Paris

7. 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 ESH 2004 Paris

8. 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 ESH 2004 Paris

9. Flow Diagram RCTs identified (n=253) RCTs retrieved (n=21) Not meeting inclusion criteria (n=232) RCTs suitable (n=21) RCTs included (n=18) Not using BP as outcome (n=3) Systolic (n=13) Diastolic (n=16) Mean (n=3) Targets (n=6) ESH 2004 Paris

10. 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 ESH 2004 Paris

11. Statistical Analysis • Random effects model ESH 2004 Paris

12. Statistical Analysis • Random effects model • Difference in BP (95% CI) • Relative risk (95% CI) ESH 2004 Paris

13. 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 ESH 2004 Paris

14. 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 ESH 2004 Paris

15. 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 ESH 2004 Paris

16. 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 ESH 2004 Paris

17. RESULTS 4. Funnel plot for systolic blood pressure ESH 2004 Paris

18. RESULTS 5. Egger’s test for publication bias and revised estimates by ‘trim and fill’ test ESH 2004 Paris

19. 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 ESH 2004 Paris

20. Studies published in 2004 • Staessen JA et al. JAMA 2004;291:955-64 RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. ESH 2004 Paris

21. Studies published in 2004 • Staessen JA et al. JAMA 2004;291:955-64 RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. • Bobrie G et al. JAMA 2004;291:1342-9 Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP. ESH 2004 Paris

22. Studies published in 2004 • Staessen JA et al. JAMA 2004;291:955-64 RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. • Bobrie G et al. JAMA 2004;291:1342-9 Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP. • Cuspidi C et al. J Hum Hypert 2004; online 22 April Cross-sectional study of 1350 hypertensives; 66% practising Home BP monitoring. Higher rate of Clinic BP control amongst them. ESH 2004 Paris

23. 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 ESH 2004 Paris

24. 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’ ESH 2004 Paris

25. 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 ESH 2004 Paris

26. 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 ESH 2004 Paris