Blood pressure measurement and hypertension: current developments and new study data

European Guidelines 2018. Also: New study results on diagnosis and monitoring of hypertension in the general population and for specific risk groups: self-measurement vs. measurement by medical personnel.

According to the new AHA (American Heart Association 2017) guidelines, the cut-off value for phase 1 hypertension is now ≥130/80 mmHg (previously: ≥140/90 mmHg) [1], with a systolic value of 120-129 mmHg considered elevated blood pressure [2]. In contrast, the ESH (European Society of Hypertension) and ESC (European Society of Cardiology) will leave the cut-off value at ≥140/90 mmHg in the new guidelines expected in August 2018, as announced at the ESH 2018 Congress in Barcelona [3]. One of the reasons given by the AHA expert panel for lowering the cut-off value is that it makes the risk of myocardial infarction and other cardiovascular risks more detectable and treatable [4]. The evidence base for this was provided by, among others, the SPRINT trial, which found that a target systolic of <120 mmHg compared with a target systolic of <140 mmHg contributed to a significant reduction in cardiovascular events [5,6]. In contrast, the Northern Shanghai Study showed that there were no significant differences in the risk of hypertension-related organ damage at 140/90 mmHg compared with 130/80 mmHg [7]. According to another epidemiological study, individuals with a systolic value of 90-114 mmHg and a diastolic value of 60-74 mmHg have the lowest risk of cardiovascular disease [8]. The debate about cut-off values is probably still ongoing.

Positive effects of blood pressure self-measurements

It is well known that hypertension is one of the modifiable risk factors for cardiovascular diseases [9,10]. Effective treatment of hypertension can reduce the risk of sequelae and mortality, but often hypertension goes undiagnosed [10]. After diagnosis of hypertension and initial medication, monitoring of blood pressure values is an important factor for any further adjustments in medication. According to a 2018 review that examined the efficacy of different pharmacotherapeutic treatment options, patients with a systolic of 20 mmHg above normal or a diastolic of 10 mmHg above normal should be switched from monotherapy to combination therapy [11].

That blood pressure self-monitoring can improve blood pressure control in patients with essential hypertension (>140/90 mmHg) who are taking no more than three antihypertensive medications is shown by the results of the randomized-controlled TASMINH4 trial (n=1182) published in 2018 [12]. Randomized self-monitoring with regular reporting to primary care physicians resulted in faster titration of medications and improvement in blood pressure control compared with “usual care” (blood pressure measurement in the physician’s office only) [13]. Systolic blood pressure values were better at 12 months of follow-up in both the self-measurement and telemonitoring conditions compared with usual care (self-measurement: 137.0 mmHg (SD 16.7); telemonitoring: 136.0 mmHg (SD 16.1); usual care: 140.4 mmHg (SD 16.5) [12]. The results of a meta-analysis regarding interventions to improve blood pressure control in persons with hypertension confirm that regular blood pressure control through a combination of self-measurement and measurement in the physician’s office and adjustment of medication based on this is central [14]. This is also in line with the conclusion of a review published in 2017, mentioning patient education and lifestyle modifications as possible further complementary measures [15].

There is also empirical evidence in favor of this strategy of blood pressure monitoring in specific risk groups, although in some cases an additional 24-h blood pressure measurement has been shown to be beneficial. According to the results of the PAMELA study (n=1182) with a follow-up period of ten years, a combination of regular blood pressure measurement at home with occasional measurements in the doctor’s office can contribute to a better risk detection of an emerging metabolic syndrome [23]. Additional 24-h blood pressure measurements are especially recommended in diabetic patients with hypertension, because diabetic patients have a higher incidence of nocturnal blood pressure elevation than nondiabetic patients [16]. A 24-h blood pressure measurement in addition to regular measurements performed at home is also propagated by other authors [17], although a comparison of 24-h blood pressure measurement and conventional measurement method in the cardiovascular risk group of kidney transplant patients could not demonstrate any clear advantages in favor of one or the other measurement method [18].

“Collaborative care” interventions

Factors at the organizational level, among others, play a role in the effective control and treatment of hypertension [12]. The implementability and effectiveness of collaborative care measures vary by region and also depend on local care structures. In a study conducted in China, collaboration between experts and government units improved the diagnosis and treatment of hypertension [19]. The corresponding measures included training for medical personnel and for the population and led to a reduction in hypertension-related hospitalizations as well as to a decrease in the number of cardiovascular events and strokes and the mortality caused by them [19]. North American and European trial data refer primarily to “collaborative care” approaches based on cooperation between medical and pharmaceutical personnel [20,21,22]. The conclusion of an analysis of European study data is that collaboration of clinics and physicians’ practices with pharmacies can contribute to better monitoring of blood pressure levels [22]. That these measures have proven effective has been shown in further studies [20,21]. Specifically, such programs include a treatment plan tailored to the individual problem, with regular follow-up at the doctor’s office or pharmacy and appropriate medication adjustments, as well as recommendations regarding lifestyle modification and self-management [20,21].

Source: ESH Meeting on Hypertension and Cardiovascular Protection, June 8-11, 2018, Barcelona.

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