ESH 2004 Paris 1

Blood Pressure Control by Home Monitoring

A 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)

RCTs suitable(n=21)

RCTs included(n=18)

Not meeting inclusion criteria

(n=232)

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

Egger’s test (p)

‘Trim & Fill’ estimate 95% C.I.

SBP(mmHg)

0.038 2.2 -0.9 to 5.3

DBP(mmHg)

0.095 1.9 0.6 to 3.2

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 2004o 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

o Staessen JA et al. JAMA 2004;291:955-64RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

o Bobrie G et al. JAMA 2004;291:1342-9Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP.

Studies published in 2004

ESH 2004 Paris 22

o Staessen JA et al. JAMA 2004;291:955-64RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

o Bobrie G et al. JAMA 2004;291:1342-9Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP.

o Cuspidi C et al. J Hum Hypert 2004; online 22 AprilCross-sectional study of 1350 hypertensives; 66% practising Home BP monitoring. Higher rate of Clinic BP control amongst them.

Studies published in 2004

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