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Self-titration of hypertension drugs 'slashes stroke risk by a third'

Patients with cardiovascular disease who self-manage their own blood pressure medications can slash their risk of a stroke by a third compared with usual physician-led care, claim UK researchers.

Enrolled in a scheme where they were required to self-monitor and titrate their own medications, the 500 patients in the study achieved a significant, 9 mmHg reduction in systolic blood pressure levels over a year, compared with those receiving usual care.

The researchers said that this would equate to a 30% reduction in stroke risk and added further support for the approach to be widely adopted in primary care.

The study builds on a previous work that showed self-management of blood pressure was more effective than usual care in a hypertension population, with a difference in systolic levels between groups of 5.4 mmHg.

This new study - presented at the Society of Academic Primary Care annual conference in Nottingham last week - showed that self-management was perhaps even more beneficial in high-risk patients with diabetes, chronic kidney disease or cardiovascular disease, with a difference between the intervention and the usual care group of 9.2 mmHg.

Patients who carried out self-management were tasked with monitoring their own blood pressure and then titrating their antihypertensive medication if needed according to a pre-agreed treatment plan. Among patients in the self-management intervention arm, mean blood pressure decreased from 143.1 mmHg at baseline to 128.2 mmHg at 12 months, compared with a decrease from 143.6 to 137.8 mmHg in the usual care group.

The improved blood-pressure lowering in the self-management arm was associated with an increase in antihypertensive medication use. The average number of medications patients were taking went up from 1.6 at baseline to 2.2 in people self-managing their blood pressure compared with 1.7 in the usual care arm. Despite this, there was no increase in side effects in the self-management group.

Lead researcher Professor Richard McManus, professor of primary care at the University of Oxford and a practicing GP, said the reduction in systolic blood pressure was clinically relevant, of a magnitude that would be expected to result in a 30% reduction in relative risk of stroke if sustained.

Speaking to Pulse, Professor McManus said the results were particularly encouraging because patients included in the study were relatively elderly and frail – with a mean age of 70 and no upper limit – yet coped well with carrying out their own measurements and following the medication protocol.

He said: ‘These new results show that people with vascular disease are able to self-manage their own blood pressure to achieve excellent control with no excess side effects compared to usual care.

‘The fact that the outcomes are better than in essential hypertension needs further analysis to consider the effects on health behaviours and adherence. Self-management is likely to only be suitable for a proportion of patients but given that over 30% are now self-monitoring there is a definite opportunity to improve care by giving patients more control.’

He added that research suggests patients adapt to self-management well, with concerns it could cause them anxiety greater among clinicians than patients themselves.

Dr Alan Begg, a GP in Montrose and a member of the SIGN guidelines steering committee, said the findings appeared to confirm expectations that ‘the more you empower patients to take control of their blood pressure the better the control’. 

Dr Begg added: ‘Self management of hypertension is a feature of the North American JNC7 guideline - which says that self measurement can allow patients to assess their response to medication and to improve adherence. Perhaps NICE guidance needs to take more account of this.’

Readers' comments (2)

  • Vinci Ho

    A bit of biofeedback ?
    A bit better with compliance?
    HBPM is certainly a better idea to titrate the dose of antihypertensives
    The key is selecting the right patient for the task.

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  • I agree with Vinci but if Hunt brings in the named GP scheme, I'll probably become a total control freak.

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