In a recent study published in JAMA Network Open, researchers compared blood pressure (BP) self-monitoring along with self-titration of antihypertensive medication to usual care for patients with poorly controlled hypertension. To this end, the combination of BP self-monitoring with self-titration of antihypertensive medication led to a significant reduction in both systolic BP (SBP) and diastolic BP (DBP) as compared to usual care without increasing health care use or adverse events.

Study: Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients with Hypertension: A Secondary Analysis of the ADAMPA Randomized Clinical Trial. Image Credit: Anatoily Cherkas / Shutterstock.com

Improving BP management

Hypertension is the leading risk factor for heart disease and stroke globally; however, its management remains suboptimal, particularly in Europe. Despite available guidelines and tools, many patients fail to achieve adequate BP control.

The Chronic Care Model, which focuses on patient-centered and evidence-based care, has shown promise in improving outcomes for chronic conditions. Home BP monitoring (HBPM), when added to interventions like lifestyle changes or medication self-titration, can reduce BP levels; however, its effectiveness varies based on the intensity of accompanying interventions.

Previous studies on HBPM in combination with medication self-titration have shown mixed results, with some indicating reductions in blood pressure at 12 months. The evidence is heterogeneous due to various factors like study settings, interventions, and follow-up durations. Real-world evidence on the effectiveness of HBPM and medication self-titration in routine clinical practice over extended periods is still lacking, thus highlighting the need for further research in this area.

The Impact of Self-Monitoring of Blood Pressure and Self-Titration of Medication in the Control of Hypertension (ADAMPA) trial compared the efficacy of self-monitoring of BP and self-titration of antihypertensive medication to usual care for patients with poorly controlled BP. In the current study, researchers perform a secondary analysis of the ADAMPA trial results at 24 months to explore the long-term effects of the intervention in real-world settings.

About the study

The ADAMPA study was a pragmatic and unblinded clinical trial based in Spain. It randomized participants 1:1 in two parallel groups. The primary outcomes were assessed at 12 months, followed by passive follow-up through 24 months. The study included 312 and 219 individuals, respectively.

Study participants were either allocated to the intervention group that incorporated HBPM, educational components, and self-titration of antihypertensive medication based on pre-established adjustment plans by their primary care physician or a control group that received educational components along with routine hypertension care. These groups comprised 111 and 108 individuals, respectively.

All study participants were 40 years of age or older and exhibited uncontrolled hypertension, with mean SBP and DBP measurements exceeding 145 mm Hg and 90 mm Hg, respectively, at baseline. The mean age of participants was 64.3 years, 54.8% of whom were female, and 23.7% of them had diabetes.

The main outcome in the extension phase was the adjusted mean difference (AMD) in SBP between the intervention and control groups at 24 months. AMD was measured according to the European Society of Hypertension and European Society of Cardiology (ESH-ESC) guidelines using a validated home BP monitor.

Secondary outcomes included AMD in DBP, percentage of patients achieving BP target, health-related quality of life, behavioral changes, healthcare resource use, and adverse events assessed at the final visit. Statistical analysis involved the use of linear mixed-effects models, chi-square test, Student’s t-test, stratified analysis, and sensitivity analysis.

Study findings

The intervention and control groups both experienced an increase in prescriptions of antihypertensive drugs, with a higher mean number of medications in the intervention group. Both groups observed a significant reduction in SBP and DBP from baseline, with the intervention group exhibiting a greater reduction.  

Notable reductions in SBP were observed for patients with diabetes and those with diabetes with a baseline SBP greater than 160 mm Hg; however, interaction terms were not statistically significant. No significant differences were observed in the percentage of patients achieving the BP target or in adverse events, behavioral risk factors, quality of life, or healthcare resource use between the intervention and control groups, except for the mean number of visits to a primary care center without an appointment, which was higher in the control group.

The current study is limited by its unblinded study design, loss to follow-up related to the coronavirus disease 2019 (COVID-19) pandemic, potential bias from physicians managing patients in both groups, reliance on BP reduction as a surrogate endpoint, and exclusion of certain subgroups, such as those with well-controlled hypertension or very high BP.

Conclusions

The study findings suggest that self-management strategies for hypertension may effectively reduce blood pressure levels over 24 months without increasing healthcare resource utilization or adverse events as compared to usual care. Thus, simple, cost-effective, and easily implementable self-management interventions have the potential to enhance long-term hypertension control in routine clinical practice and improve patient outcomes, particularly in primary care settings.