Top POEMs of 2019: Hypertension

Top 20 POEMs of 2019

Bedtime Dosing of Antihypertensives Improves Outcomes

Clinical question
Does bedtime ingestion instead of morning ingestion of hypertension medications produce better cardiovascular disease risk reduction in adults with hypertension?

Bottom line
This study found a significant reduction in mortality and morbidity among patients who took their once-daily antihypertensive medications at bedtime instead of on awakening. Although no significant difference occurred in compliance rates between bedtime and awakening ingestion times in this study, individual experiences may differ in clinical practice.

Hermida RC, Crespo JJ, Dominguez-Sardina M, et al, for the Hygia Project Investigators. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. European Heart J 2019 Oct 22. pii: ehz754. [Epub ahead of print]

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (primary care)

Synopsis: These investigators identified 19,168 adults, 18 years or older, who met standard criteria for hypertension that required prescription treatment to lower blood pressure (BP). The study participants randomly received (uncertain concealment) assignment to the intervention group and were told to ingest the entire daily dose of one or more prescribed BP-lowering medications at bedtime, or to the control group and were told to ingest the entire daily dose on awakening. Clinicians provided care without restriction to choice of BP-lowering medication approved for once-daily dosing (eg, angiotensin receptor blocker, angiotensin-converting enzyme inhibitor, calcium channel blocker, beta-blocker, and/or diuretic). Statins, aspirin, and diabetes medications were also prescribed as needed and ingested as recommended. Individuals masked to treatment group assignment assessed outcomes, including the primary composite outcome of myocardial infarction, coronary revascularization, heart failure, stroke, and CVD death. Complete follow-up occurred for more than 99% of participants at a median of 6.3 years. Using intention-to-treat analysis, significantly fewer patients in the bedtime group experienced the primary cardiovascular disease outcome (n = 1752 total) compared with the awakening group (adjusted HR = 0.55; 95% CI 0.50 - 0.61; number needed to treat = 20.3; 17.4 - 24.3). Adverse events occurred similarly in both groups. Similarly poor adherence was reported at any visit during follow-up in both groups (approximately 3%).

David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC

Use Automated Blood Pressure Measurements to Guide Treatment

Clinical question
Is fully automated blood pressure measurement more accurate than manual sphygmomanometry?

Bottom line
There are 2 takeaways and a recommendation from this analysis of in-office automated blood pressure measurement. The takeaways: (1) Automated measurement aligns better with ambulatory blood pressure monitoring, the best predictor of cardiovascular events, than manual measurement; and (2) manual readings are an average 13.4 to 14.5 mm Hg (systolic) higher than daytime ambulatory or automated readings in patients with hypertension. The recommendation: Since the recent guidelines from the American College of Cardiology/American Heart Association are based on automated readings, follow them only if you switch from the squeeze bulb to the machine.

Roerecke M, Kaczorowski J, Myers MG. Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension. A systematic review and meta-analysis. JAMA Intern Med 2019;179(3):351-362.

Study design: Meta-analysis (other)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis: The authors searched 3 databases, including the Cochrane Central Register of Controlled Trials, to identify studies that compared automated office blood pressure readings with standard or research-based manual measurement or ambulatory automated recording during awake hours (the latter used as the reference standard). The authors also searched reference lists of identified articles. They included papers in any language, 2 authors independently selected articles for inclusion, and a single investigator extracted data. Automated measurement had be performed without anyone activating the machine and used 3 to 5 readings separated by 1-minute to 2-minute intervals. In 31 studies of 9279 participants, the pooled mean differences between routine measurement and awake ambulatory measurements were 13.4 mm Hg systolic and 5.9 mm Hg diastolic. There was no difference between ambulatory and automated blood pressure. The difference between manual and automated blood pressures was 14.5 mm Hg systolic in patients with hypertension. There was a great deal of heterogeneity among studies for all outcomes that could not be explained by any of the variables available to the researchers. There was no evidence of publication bias.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

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