Self-titration of antihypertensive therapy in high-risk patients: bringing it home.

Hypertension is a common cause of premature mortality yet has been amenable to pharmacologic treatment for more than 8 decades. Resting blood pressure fluctuates for various reasons, and individual responses to different classes of antihypertensive drugs vary considerably. In another high-risk common chronic condition, diabetes, glucose levels vary widely due to factors including individual drug response, physical activity, and carbohydrate intake. Patients treated with insulin are generally taught to adjust their insulin dose guided by self-measurement of glucose levels. Physician-guided treatment of hypertension likely poses problems in terms of patient adherence, whereas use of selfmanaged home blood pressure could help improve medication adherence and blood pressure control. In some countries, such as Canada and Finland, home recorders are commonly purchased, and in contrast to self-measurement of glucose levels (ie, involving the need for test-strips), there is no additional cost, after the initial purchase, for frequent recordings. Also, antihypertensive drug changes usually do not pose apparent acute risks similar to those that occur with an excess dose of insulin. So why have physicians not encouraged patients to selfmonitor their blood pressure and self-adjust their medications? There may be a number of possible explanations. All high blood pressure measurements do not necessarily pose a risk. Blood pressure temporarily increases during physical activity, although patients who exercise frequently have better prognosis than those who do not.1 Self-measurement also requires good adherence to the technique; otherwise, the recorded measure can be misleading and potentially cause unwarranted medication changes. Blood pressure can also increase transiently when a patient is startled, frightened, or under stress, and these fluctuations might not justify drug modifications unless those increases are sustained.2 Unlike diabetes, there is no summary value for blood pressure similar to hemoglobin A1c this too may give physicians pause about focusing on home values. Another factor to consider in self-titration of antihypertensive medication is that several antihypertensive drugs are often needed to reach blood pressure goals, and interactions between medications as well as unwanted adverse effects with perturbation of electrolyte levels are common during longterm treatment of hypertension. These effects render it necessary to monitor electrolyte and creatinine levels in many patients and hence the self-titration of antihypertensive drugs cannot be governed only by blood pressure measurements. Yet, all of these considerations could potentially be addressed in a properly managed home program. In this issue of JAMA, McManus et al3 present the 1-year results of self-monitoring and self-titration of hypertension compared with traditional office-based guidance (the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups [TASMIN-SR] study) for patients with hypertension. The 230 patients in the self-monitoring group achieved a 9.2-mm Hg lower mean systolic blood pressure than did the similarly sized control group. This difference in blood pressure control would be expected to be associated with a considerable reduction of cardiovascular complications, and the effect was based on an extra 0.91 higher intake of defined daily dose of antihypertensive drugs in the intervention group than in the control group. The findings reported by McManus et al represent an important gain in knowledge about efficacy and safety of self-titration of antihypertensive drugs based on home blood pressure recordings using fairly inexpensive oscillometric devices. What makes the study of particular clinical importance is the recruitment of patients who were at high risk of cardiovascular disease (ie, a history of stroke or transient ischemic attack, coronary bypass graft surgery, myocardial infarction, angina, diabetes, or stage 3 chronic kidney disease), and the demonstration that the patient-centered technique was safe with no increase in adverse events compared with traditional treatment in a randomized setting. The study aimed for an ambitious home blood pressure goal compared with many current guidelines, less than 120/75 mm Hg. This was based on consensus at the time the trial was designed. Although some clinicians may find this goal a limitation in terms of clinical implementation, others may interpret the findings differently. Antihypertensive trials with blood pressure targets well below 140/90 mm Hg have not proven superior in achieving major primary end points, such as in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which compared this level of control with achieving less than 120/80 mm Hg in patients with diabetes. These results could be potentially explained by the use of office blood pressure for titration.4 Home blood pressure levels are more strongly related to indices of target organ damage5 and have better prognostic value6 than blood Related article page 799 Opinion