Re: Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial
McKinstry B, et al’s paper is timely important in delineating whether using a six month intervention of telemonitored support of self monitoring in patients with uncontrolled blood pressure within the context of their usual primary care services, with optional patient decision support and appropriate supervision from primary care clinicians, could lead to clinically important reductions in blood pressure. They also determined the impact of such telemonitored support on use of health service resources.1 The mean difference in daytime systolic ambulatory blood pressure adjusted for baseline and minimisation factors between intervention and usual care was 4.3 mm Hg and for daytime diastolic ambulatory blood pressure was 2.3 mm Hg, with higher values in the usual care group. The intervention was associated with a mean increase of one general practitioner and 0.6 practice nurse consultations during the course of the study.
Based on the current study, supported self monitoring by telemonitoring is an effective method for achieving clinically important reductions in blood pressure in patients with uncontrolled hypertension in primary care settings. However, as authors stated, it was associated with increase in use of National Health Service resources and whether the reduction in blood pressure is maintained in the longer term and whether the intervention is cost effective should be confirmed in the future before applying to the real world.
On the other hand, distinct outcomes between different treatment regimens suggest that control of blood pressure per se is not the only important consideration. Indeed, some believe that prevention of atherosclerosis progression is more crucial than control of blood pressure per se. However, it is more likely that blood pressure control combined with amelioration of atherosclerosis is essential for preventing and treating cardiovascular diseases. Only 14% of coronary events in hypertensive men and 5% in hypertensive women occur in the absence of additional cardiovascular risk factors.
Therefore, appropriate targeted therapy for hypertensive patients involves risk stratification. Overall improvement in multivariate risk profiles contribute to achieving optimal therapeutic goals.2 Indeed, multivariate adjustment demonstrates that better control of blood pressure accounts for about half of the differences in coronary events (and ~40% of differences in stroke events) between treatment regimens tested.3 Accordingly, an optimal treatment plan for patients with hypertension involves simultaneously targeting both blood pressure and atherosclerosis.
Solid evidence from robust clinical trials should be the principal basis for developing rational hypertension management guidelines. It is imperative that clinicians are well informed and educated regarding the development of treatment plans according to evidenced-based guidelines. Therapeutic life style changes including increased physical activity, lower calorie intake, and diets high in potassium and low in sodium intake are clearly beneficial. However, compliance with these interventions is problematic and their effects are not large in terms of secondary prevention.4 To practicing clinicians and physician-scientists, it is evident that reliable, reproducible, convenient, and precise methods for measurement of blood pressure are essential to guide clinical therapy and research. Even assuming adequate measurements are available, controversy exists regarding whether blood pressure control per se or additional effects of anti-hypertensive therapies determine maximal health benefits. Failure of short-acting calcium channel blockers to reduce cardiovascular disease despite adequate control of blood pressure is important evidence that contributes to this controversy.5,6
In summary, it is important to improve methods- how to control blood pressure better. However, based on solid evidence from both translational basic science and clinical intervention trials, there is emerging support for simultaneously targeting multiple therapeutic pathways in the optimal treatment of hypertension.
Funding: None, Disclosures: None
1. McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, et al. Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial. BMJ 2013;346:f3030.
2. Kannel WB. Risk stratification in hypertension: new insights from the Framingham Study. Am J Hypertens 2000;13:3S-10S.
3. Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M, et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005;366:895-906.
4. Koh KK. Quon MJ. Targeting converging therapeutic pathways to overcome hypertension. Int J Cardiol 2009;132:297-9.
5. Yusuf S. Calcium antagonists in coronary artery disease and hypertension. Time for reevaluation? Circulation 1995;92:1079-82.
6. Tijssen JG, Hugenholtz PG. Critical appraisal of recent studies on nifedipine and other calcium channel blockers in coronary artery disease and hypertension. Eur Heart J 1996;17:1152-7.
Competing interests: No competing interests