esh 2004 paris 1 blood pressure control by home monitoring
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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
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ESH 2004 Paris 2
Background
High blood pressure is the most preventable cause of death and disability due to CVD
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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)
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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
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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
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ESH 2004 Paris 6
Objective
To compare blood pressure levels and proportion on target in people with essential hypertension undergoing home blood pressure monitoring
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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
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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
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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)
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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
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ESH 2004 Paris 11
Statistical Analysis
Random effects model
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ESH 2004 Paris 12
Statistical Analysis
Random effects model Difference in BP (95% CI) Relative risk (95% CI)
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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
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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
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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
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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
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ESH 2004 Paris 17
RESULTS 4. Funnel plot for systolic blood pressure
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ESH 2004 Paris 18
RESULTS 5. Egger’s test for publication bias and revised estimates by ‘trim and fill’ test
0.6 to 3.21.90.095DBP(mmHg)
-0.9 to 5.32.20.038SBP(mmHg)
95% C.I.‘Trim & Fill’ estimate
Egger’s test (p)
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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
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ESH 2004 Paris 20
Studies published in 2004
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.
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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
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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
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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
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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’
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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
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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