Solving the paradox of self blood-pressure measurement

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Abstract

BACKGROUND

The routine office measurement of blood pressure (BP) can lead to overestimation of a patient's BP and misdiagnosis of hypertension. Self-BP measurement (SBPM) is less prone to overestimation and could identify patients who do not need hypertensive medication.

OBJECTIVE

To determine whether treatment for hypertension based on SBPM rather than office BP measurement (OBPM) can reduce medication usage and healthcare costs while maintaining BP control.

DESIGN AND INTERVENTION

The Home versus Office Measurement, Reduction of Unnecessary Treatment Study (HOMERUS) was a multicenter, prospective, double-blind, randomized trial conducted in The Netherlands. Patients were eligible for enrollment if they were aged 18 years or older and had a systolic BP greater than 139 mmHg, a diastolic BP greater than 89 mmHg, or both. Patients were randomly assigned to either the OBPM group or the SBPM group. The study began with a 4-week placebo run-in period, during which existing antihypertensive medication was stopped. At each clinic visit, all patients underwent three consecutive BP measurements taken with an automated device from the nondominant arm after at least 5 min of rest. Additionally, patients in the SBPM group commenced home BP monitoring 3 weeks after study entry. SBPMs were taken six times per day for a 7-day period before each clinic visit. All patients underwent 24 h ambulatory BP monitoring (ABPM) at baseline and at the end of the trial. Target BP was 140/90 mmHg.

OUTCOME MEASURES

The outcome measures were treatment costs, medication use, BP control, and target organ damage (heart and kidney).

RESULTS

A total of 430 patients (median age 55 years, 55% male) entered the trial run-in period, 216 of whom were allocated to OBPM and 214 to SBPM. At study entry, 69% of participants were receiving antihypertensive medication. After a median follow-up of 351 days (range 336-366 days), significantly more patients in the SBPM group than in the OBPM group were able to stop taking antihypertensive medication (10.7% vs 1.9%; P <0.0001). Furthermore, the overall cost of medication in the SBPM group was significantly lower than in the OBPM group (US$4,147 vs $3,023; P <0.001). There were significantly fewer cases of resistant or refractory hypertension among patients in the SBPM group (9% vs 18%; P <0.01) and more self-monitored patients reached the target BP (74% vs 50%; P <0.001). At the end of the trial, there was no significant difference in final office BP (absolute BP or changes in BP), changes in left ventricular mass, or changes in urinary microalbumin concentration between the two groups. Mean 24 h ABPM values were, however, significantly lower in the OBPM group than in the SBPM group at the end of the trial (systolic: 123.8 mmHg vs 125.9 mmHg, P = 0.04; diastolic: 76.1 mmHg vs 77.2 mmHg, P = 0.05).

CONCLUSION

When compared with OBPM, a strategy of SBPM reduces medication costs, lowers the incidence of refractory hypertension, and increases the likelihood of achieving target BP in hypertensive patients without comorbidities, without increasing target organ damage.

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