• Richard J McManus, Jonathan Mant, M Sayeed Haque, Emma P Bray, Stirling Bryan, Sheila M Greenfield, Miren I Jones, Sue Jowett, Paul Little, Cristina Penaloza, Claire Schwartz, Helen Shackleford, Claire Shovelton, Jinu Varghese, Bryan Williams, F D Richard Hobbs, Trevor Gooding, Ian Morrey, Crispin Fisher, and David Buckley.
• National Institute for Health Research (NIHR) School for Primary Care Research, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
• JAMA. 2014 Aug 27; 312 (8): 799808799-808.

ImportanceSelf-monitoring of blood pressure with self-titration of antihypertensives (self-management) results in lower blood pressure in patients with hypertension, but there are no data about patients in high-risk groups.ObjectiveTo determine the effect of self-monitoring with self-titration of antihypertensive medication compared with usual care on systolic blood pressure among patients with cardiovascular disease, diabetes, or chronic kidney disease.Design, Setting, And PatientsA primary care, unblinded, randomized clinical trial involving 552 patients who were aged at least 35 years with a history of stroke, coronary heart disease, diabetes, or chronic kidney disease and with baseline blood pressure of at least 130/80 mm Hg being treated at 59 UK primary care practices was conducted between March 2011 and January 2013.InterventionsSelf-monitoring of blood pressure combined with an individualized self-titration algorithm. During the study period, the office visit blood pressure measurement target was 130/80 mm Hg and the home measurement target was 120/75 mm Hg. Control patients received usual care consisting of seeing their health care clinician for routine blood pressure measurement and adjustment of medication if necessary.Main Outcomes And MeasuresThe primary outcome was the difference in systolic blood pressure between intervention and control groups at the 12-month office visit.ResultsPrimary outcome data were available from 450 patients (81%). The mean baseline blood pressure was 143.1/80.5 mm Hg in the intervention group and 143.6/79.5 mm Hg in the control group. After 12 months, the mean blood pressure had decreased to 128.2/73.8 mm Hg in the intervention group and to 137.8/76.3 mm Hg in the control group, a difference of 9.2 mm Hg (95% CI, 5.7-12.7) in systolic and 3.4 mm Hg (95% CI, 1.8-5.0) in diastolic blood pressure following correction for baseline blood pressure. Multiple imputation for missing values gave similar results: the mean baseline was 143.5/80.2 mm Hg in the intervention group vs 144.2/79.9 mm Hg in the control group, and at 12 months, the mean was 128.6/73.6 mm Hg in the intervention group vs 138.2/76.4 mm Hg in the control group, with a difference of 8.8 mm Hg (95% CI, 4.9-12.7) for systolic and 3.1 mm Hg (95% CI, 0.7-5.5) for diastolic blood pressure between groups. These results were comparable in all subgroups, without excessive adverse events.Conclusions And RelevanceAmong patients with hypertension at high risk of cardiovascular disease, self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months.Trial Registrationisrctn.org Identifier: ISRCTN87171227.

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