ESH 2004 Paris1 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:

ESH 2004 Paris2 Background  High blood pressure is the most preventable cause of death and disability due to CVD

ESH 2004 Paris3 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 Paris4 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 Paris5 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 Paris6 Objective  To compare blood pressure levels and proportion on target in people with essential hypertension undergoing home blood pressure monitoring

ESH 2004 Paris7 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 Paris8 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 Paris9 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 Paris10 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 Paris11 Statistical Analysis  Random effects model

ESH 2004 Paris12 Statistical Analysis  Random effects model  Difference in BP (95% CI)  Relative risk (95% CI)

ESH 2004 Paris13 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 Paris14 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 Paris15 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 Paris16 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 Paris17 RESULTS 4. Funnel plot for systolic blood pressure

ESH 2004 Paris18 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) to 5.3 DBP (mmHg) to 3.2

ESH 2004 Paris19 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 Paris20 Studies published in 2004 oStaessen JA et al. JAMA 2004;291: RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP.

ESH 2004 Paris21 oStaessen JA et al. JAMA 2004;291: RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. oBobrie G et al. JAMA 2004;291: Prospective 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 Paris22 oStaessen JA et al. JAMA 2004;291: RCT of 400 participants up to 1 year (Clinic vs Home BP). Home BP lower than Clinic BP. oBobrie G et al. JAMA 2004;291: Prospective study of <5,000 treated elderly hypertensives followed for 3.2 years. Home BP better prognostic values for CVD events than Clinic BP. oCuspidi 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. Studies published in 2004

ESH 2004 Paris23 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 Paris24 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 Paris25 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 Paris26 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