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Australian Journal of Pharmacy : March 2005
pharmacy e current drug information Dr Jack Thomas, consultant editor Monitoring blood pressure at home H YPERTENSION is widespread and a significant risk factor for stroke and other cardiovascular complications. It has become standard practice for general practitioners to routinely measure patients’ blood pressure irrespective of why the patient has sought the interview. In the majority of cases there is no underlying detectable cause for the hypertension. Even though there is a heightened awareness of the dangers of hypertension both in health professionals and the community at large, because the condition is symptomless, there is evidence that it is underdiagnosed and undertreated. With the introduction and validation of new electronic devices, self blood pressure monitoring at home is becoming increasingly popular with both doctors and patients. However, not all health professionals are convinced that a patient measuring their own blood pressure is appropriate. Two studies have recently been published that address home blood pressure monitoring. Study one A review of the literature to determine the effect of home blood pressure monitoring on blood pressure levels and proportion achieving targets in people with essential hypertension has been carried out.1 The objective of the review was to identify published trials that met the inclusion criteria by examining a large range of databases. A determined effort was made to identify randomised controlled trials of home or self blood pressure monitoring in people with high blood pressure. Eighteen randomised controlled trials were identified as conforming to the inclusion criteria and a meta-analysis of these was performed. Some 1,359 people with essential hypertension allocated to home blood pressure monitoring and 1,355 allocated to the ‘control’ group seen in the healthcare system for two to 36 months were involved in the study. The main outcome measures that were determined were differences in systolic (n=13 studies), diastolic (n=16), or mean (n=3) blood pressures, and proportion of patients achieving targets (n=6), between intervention and control groups. The results obtained showed that: • systolic blood pressure was lower in people with hypertension who had home blood pressure monitoring than in those who had standard blood pressure monitoring in the healthcare sys- tem (standardised mean difference 4.2 mm Hg); • diastolic blood pressure was lower by 2.4 mm Hg; • mean blood pressure was lower by 4.4 mm Hg; • the relative risk of blood pressure above predetermined targets was lower in people with home blood pressure monitoring (risk ratio 0.90). ‘When publication bias was allowed for, the differences were 210 ? THE AUSTRALIAN JOURNAL OF PHARMACY, VOL.86 MARCH 2005 attenuated: 2.2mmHg for systolic blood pressure and 1.9mmHg for diastolic blood pressure. It was concluded: ‘Blood pressure control in people with hypertension (assessed in the clinic) and the proportion achieving targets are increased when home blood pressure monitoring is used compared with standard blood pressure monitoring in the healthcare system. The reasons for this are not clear. The difference in blood pressure control between the two methods is small but likely to contribute to an important reduction in vascular complications in the hypertensive population.’ In discussing their results the authors stated: ‘We conclude that blood pressure monitoring by patients at home is associated with better blood pressure values and improved control of hypertension than usual blood pressure monitoring in the healthcare system. It could be considered as a useful, though adjunctive, practice to involve patients more closely in the management of their own blood pressure and help to manage their hypertension more effectively.’ Study two A further recent study concerning self-measurement of blood pressure addressed the question of how it affects the treatment of hypertension.2 The objective of the study was to compare use of blood pressure measurements taken in physicians’ offices and taken at home in the treatment of patients with hypertension. A total of 400 participants with a diastolic blood pressure of 95mmHg or higher as measured at physicians’ offices were enrolled and followed up for one year. The study was a blinded, randomised, controlled trial conducted from March 1997 to April 2002 and involved 56 primary care practices and three hospital-based outpatient clinics. Antihypertensive drug treatment was adjusted in a stepwise fashion based on either the self-measured diastolic blood pressure at home (average of six measurements per day during one week; n=203) or the average of three sitting diastolic blood pressure readings at the physician’s office (n=197). Results were reviewed at bimonthly office visits and treatment adjustments were made. If the diastolic blood pressure guiding treatment was above (>89 mm Hg), at (80–89 mm Hg), or below (<80 mm Hg) target, a physician blinded to randomisation intensified antihypertensive treatment, left it unchanged, or reduced it, respectively. It was found that at the end of the study more home blood pressure than office blood pressure patients had stopped antihypertensive drug treatment (25.6 per cent versus 11.3 per cent; P<.001) with no significant difference in the proportions of