Adopting a Patient-Centered Approach to Blood Pressure Management

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Written By

Sheeva Chopra, PharmD
Patricia A. Ross, PharmD, BCPS, BCACP

Reviewed By

Brent Reed, PharmD, BCPS (AQ Cardiology)
Joel C. Marrs, PharmD, BCPS (AQ Cardiology), BCACP
Danielle Rhyne, PharmD, BCPS

Citation

McManus R, Mant J, Haque S, et al. Effect of Self-monitoring and Medication Self-titration on Systolic Blood Pressure in Hypertensive Patients at High Risk of Cardiovascular Disease: The TASMIN-SR Randomized Clinical Trial. JAMA. 2014; 312:799-808.

The American Heart Association reports that 1 out of 3 adults in the Unites States have high blood pressure and the direct and indirect costs exceeded $50 billion in 2009.  Clearly we need to develop a variety of approaches to manage hypertension.  It is far too common and costly for our health system.1,2 Self-monitoring of blood pressure (SMBP) has been widely used as a tool to evaluate patients with hypertension.1 While the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults published by the JNC 8 panel does not address SMBP, JNC 7 suggests the practice may enhance response to therapy, improve adherence, and aid in the evaluation of white-coat hypertension.1,3 A joint scientific statement by the American Heart Association, American Society of Hypertension, and the Preventive Cardiovascular Nurses’ Association also supports SMBP as an important ingredient in hypertension management.4

The Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups (TASMIN-SR) study sought to determine if SMBP and self-titration of antihypertensive medications resulted in lower blood pressure when compared to usual care.5 The population of patients enrolled in this study was considered high-risk due to preexisting conditions such as stroke, diabetes, and chronic kidney disease. An earlier study, the Telemonitoring and Self-Management in Hypertension 2 (TASMINH 2) study, enrolled patients at relatively low risk for CVD.6  Patients in the TASMINH-2 study who engage in SMBP and self-titration of blood pressure medicines had significantly lower systolic blood pressure when compared to usual care after one year.

TASMIN-SR was a 12-month prospective, unblinded, randomized clinical trial enrolling patients from 59 primary care practices in the United Kingdom (UK). A summary of the inclusion and exclusion criteria as well as pertinent baseline characteristics are listed in table 1 and 2. A total of 552 patients were randomized to receive either usual care or trained to perform SMBP and self-titrate antihypertensive medications according to an algorithm. Patients received an individualized 3-step medication titration plan which indicated when to increase or add an antihypertensive medication to their regimen. Patients were asked to check their blood pressure twice every morning the first week of each month. According the algorithm, a change in medication was warranted if four or more of the blood pressure readings were higher than goal. If a patient progressed through all three steps of the self-management plan, he/she was prompted to return to the provider for additional directions.  The target blood pressure in this study was less than 120/75 mmHg.

Table 1: TASMIN-SR Inclusion and Exclusion Criteria

Inclusion Criteria:

  • At least 35 years of age
  • Baseline blood pressure of 130/80 mmHg or greater
  • At least one of the following high-risk conditions: cerebrovascular disease, diabetes, stage 3 chronic kidney disease or coronary heart disease

Exclusion Criteria:

  • Terminal illness or house bound
  • Score of at least 10 on the short-orientation memory concentration test, or dementia preventing self-monitoring blood pressure
  • Blood pressure greater than 180/100 mm Hg at baseline
  • Postural hypotension
  • Taking more than three antihypertensives at baseline
  • Pregnant
  • Followed by a specialist for blood pressure management
  • Experienced a cardiovascular event in the last three months
  • Currently participating in another hypertension-related study, had participated in TASMINH 2, or have a spouse already enrolled in the current trial

 

Table 2: Baseline Characteristics of Patients Enrolled in TASMIN-SR

 

Usual Care
(n = 276)

Intervention
(n = 276)

Age, mean (SD), years

69.6 (9.7)

69.3 (9.3)

Men, No. (%)

164 (59.4)

166 (60.1)

Blood Pressure, mean (SD), mm Hg

 

 

     Systolic

144.2 (13.9)

143.5 (12.8)

     Diastolic

79.9 (9.4)

80.2 (9.7)

Race, No (%)

 

 

      White

267 (96.7)

266 (96.4)

Level of Education, No (%)

 

 

     Degree or higher

34 (12.3)

30 (10.9)

     School or professional certification

150 (54.4)

162 (58.7)

     No qualifications known

92 (33.3)

84 (30.4)

Occupation

 

 

     Professional/managerial and technical

124 (44.9)

134 (48.6)

 

The primary outcome of TASMIN-SR was the difference in blood pressure at 12 months. The mean difference in systolic blood pressure was 6.1 mm Hg after 6 months and 9.2 mm Hg after 12 months, favoring the self-management group.  In addition, the mean difference in diastolic blood pressure was 3.0 mm Hg after 6 months and 3.4 mm Hg after 12 months. When comparing the number of antihypertensive medications used, the intervention group used approximately one addition medication (0.9; 95% CI: 0.7-1.2). There was also a significant increase in the use of thiazide diuretics and calcium channel blockers in the self-management group. It is worth noting that despite the increased use of medications, there was no difference in adverse effects.

The TASMIN-SR trial demonstrated that with self-monitoring and self-titration of antihypertensive medications, patients can achieve a clinically important decrease in blood pressure without an increase in adverse effects.  The blood pressure goal targeted in this study is more stringent than our current guideline recommendations, such as JNC 8.7  Whether the approach taken in TASMIN-SR would results in fewer CV events is unknown.  Blood pressure targets significantly below 140/90 mm Hg have not been shown to be superior in reducing cardiovascular events.7,8

Prior to TASMIN-SR, Uhlig and colleagues conducted a meta-analysis of 19 studies that analyzed the net change in systolic and diastolic blood pressures when patients engaged in SMBP versus usual care. Consistent with the findings of TASMIN-SR, there was a significant net change in both systolic and diastolic blood pressure at 6 months (3.9 mm Hg and 2.4 mm Hg, respectively). 9 In contrast, the net difference in systolic or diastolic blood pressure was not statistically different at 12 months (1.5 mm Hg and 0.8 mm Hg, respectively).9  The inability to achieve a significant difference in blood pressure over 12 months raises concern about the sustainability of this approach.

The TASMIN-SR study demonstrates that a patient-centered approach using self-monitoring in conjunction with medication self-titration results in significant and clinically important reductions in blood pressure. However, patients checked blood pressure only in the morning and only one week each month; the possibility of fluctuations in patients’ blood pressures was not accounted for in this study and this might impact cardiovascular outcomes.10 Participants in TASMIN-SR were provided an individualized treatment plan; a generalizable algorithm was not reported. The lack of this information may make it challenging to replicate the approach in practice.

TASMIN-SR provides strong evidence that we should change our approach to hypertension management by engaging patients and giving them a more active role. When evaluating patients who are good candidates for self-management, providers must consider the patient’s education level, ability to accurately perform self-monitoring, and capacity to interpret and implement a medication self-titrate algorithm.  Given that high blood pressure is very common in middle aged and older adults who are otherwise healthy, this approach would be suitable for many, many patients. Is there anything that would hinder you from using a similar approach when managing your patients with hypertension?