{"id":848,"date":"2015-10-13T15:09:05","date_gmt":"2015-10-13T15:09:05","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=848"},"modified":"2017-08-21T11:33:55","modified_gmt":"2017-08-21T11:33:55","slug":"primary-care-corner-with-geoffrey-modest-md-bp-self-monitoringself-titrating-decreases-bp","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/10\/13\/primary-care-corner-with-geoffrey-modest-md-bp-self-monitoringself-titrating-decreases-bp\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: BP Self-Monitoring\/Self-Titrating Decreases BP"},"content":{"rendered":"<p>By Dr. Geoffrey Modest<\/p>\n<p>Article in JAMA on benefit of patients&#8217; blood pressure monitoring and self-management\u00a0(see\u00a0doi:10.1001\/jama.2014.10057). In this UK\u00a0study 552 high-risk patients (at least 35 yo\u00a0with history of stroke or TIA;\u00a0coronary artery disease with either CABG, MI or poorly controlled angina;\u00a0diabetes; or\u00a0chronic kidney disease stage 3 with\u00a0GFR 30-59,\u00a0and a\u00a0baseline BP&gt;130\/80),\u00a0were randomized (unblinded) to the intervention (blood pressure self-monitoring with individualized self-titration algorithm) vs control (usual care),\u00a0with target BP of 125\/75). Patients were excluded if BP&gt;180\/100, or on more than 3 BP meds.\u00a0Main outcome was difference in systolic blood pressure after 12 months. Results:<\/p>\n<ul>\n<li>Mean baseline BP was 143\/80. mean age 70, 60% men, 97% white, BMI 31, 79% professional or skilled workers<\/li>\n<li>After 12 months: the intervention group achieved BP 128\/74, control group 139\/77, with a significant difference from the baselines of each group of 9.2\/3.4. Data at 6 months was 6.1\/3.0 difference. More meds in intervention group (mean daily dose, per WHO criteria, 3.34 vs 2.61). Subgroup analysis: no diff by underlying disease, gender, age<\/li>\n<li>No diff in adverse events<\/li>\n<\/ul>\n<p>For perspective, a few\u00a0points:<\/p>\n<ol>\n<li>Hypertension is leading risk \u00a0factor for disease burden\/cause of premature mortality globally;\u00a0and in the US, only about 1\/2 meet the guideline-suggested goal (which, is better with JNC-8 criteria, but still in the 50% range)<\/li>\n<li>There are evident issues with this study methodology: those in the intervention group had more personal\u00a0training and contact with health professionals; this was a pretty particular group with very particular inclusions and exclusions; the group was a pretty educated white middle-class group so ?? generalizability<\/li>\n<li>Blood pressure goals have changed since this study started (are higher), so is this useful?<\/li>\n<\/ol>\n<p>BUT&#8230;<\/p>\n<ol>\n<li>There probably is a real utility in empowering patients in terms of their health (i.e., converting the traditional doctor-patient relationship from one of the patient passively accepting the wisdom and instruction of the clinician to one where the patient is actively involved in monitoring and fixing the problem). And there are some old medication adherence studies from the 1970s which found that in the group of patients who were not\u00a0taking\u00a0hypertension meds regularly, giving them blood pressure cuffs and training led to much higher levels of medication taking (my recollection: in 2 studies, one in a workplace and one in a shopping mall, they found patients who were not taking their meds and acknowledged it, were given BP cuffs and instructions, and on follow-up\u00a0about\u00a030% of them had achieved improved medication-taking and blood pressure control).<\/li>\n<li>In my own practice over the years (in a predominantly poor, non-English speaking community), home blood pressure monitoring has improved blood pressure control (I always ask the patient to bring in their cuff to make sure it is accurate), and a few patients with more erratic blood pressure have done exceedingly well self-titrating their medications depending on the blood pressure readings (with my giving them clear instructions about how to do so). My guess is that part of the benefit of this self-titration approach is that blood pressure does vary significantly from day-to-day (related to food intake, variability of smoking\/alcohol, weather \u2013 e.g. esp. my older patients have lower blood pressure on hot days when they sweat a lot, exercise, etc.), and that self-titration allows better day-to-day control (sort of similar to diabetics who can check their blood sugar after a meal to see which foods\u00a0are good or bad for them, as well as\u00a0adjust their rapid insulin based on the result)<\/li>\n<li>There are relatively impressive data suggesting that home blood pressure evaluation is more predictive of clinical events than office-based blood pressure readings, adding another aspect validating this home-based\u00a0approach. E.g., see meta-analysis <strong>(htn ambulat bp monitor metanal bmj 2011<\/strong> in dropbox, or\u00a0doi: 10.1136\/bmj.d3621) or the really extensive (and really good, from my perspective) NICE recommendations (see\u00a0<a href=\"https:\/\/www.nice.org.uk\/guidance\/qs28\/resources\/guidance-quality-standard-for-hypertension-pdf\">https:\/\/www.nice.org.uk\/guidance\/qs28\/resources\/guidance-quality-standard-for-hypertension-pdf<\/a> for a summary of recommendations, or\u00a0<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22855971\">http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22855971<\/a> for full recommendations)<\/li>\n<li>It seems reasonable to assume that the above technique would apply equally well to the higher BP goals we currently accept.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: BP Self-Monitoring\/Self-Titrating Decreases BP [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/10\/13\/primary-care-corner-with-geoffrey-modest-md-bp-self-monitoringself-titrating-decreases-bp\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-848","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/848","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=848"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/848\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=848"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=848"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=848"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}