Context Self-measurement of blood pressure is increasingly used in clinical
practice, but how it affects the treatment of hypertension requires further
Objective To compare use of blood pressure (BP) measurements taken in physicians'
offices and at home in the treatment of patients with hypertension.
Design, Setting, and Participants Blinded randomized controlled trial conducted from March 1997 to April
2002 at 56 primary care practices and 3 hospital-based outpatient clinics
in Belgium and 1 specialized hypertension clinic in Dublin, Ireland. Four
hundred participants with a diastolic BP (DBP) of 95 mm Hg or more as measured
at physicians' offices were enrolled and followed up for 1 year.
Interventions Antihypertensive drug treatment was adjusted in a stepwise fashion based
on either the self-measured DBP at home (average of 6 measurements per day
during 1 week; n = 203) or the average of 3 sitting DBP readings at the physician's
office (n = 197). If the DBP guiding treatment was above (>89 mm Hg), at (80-89
mm Hg), or below (<80 mm Hg) target, a physician blinded to randomization
intensified antihypertensive treatment, left it unchanged, or reduced it,
Mean Outcome Measures Office and home BP levels, 24-hour ambulatory BP, intensity of drug
treatment, electrocardiographic and echocardiographic left ventricular mass,
symptoms reported by questionnaire, and costs of treatment.
Results At the end of the study (median follow-up, 350 days; interquartile range,
326-409 days), more home BP than office BP patients had stopped antihypertensive
drug treatment (25.6% vs 11.3%; P<.001) with no
significant difference in the proportions of patients progressing to multiple-drug
treatment (38.7% vs 45.1%; P = .14). The final office,
home, and 24-hour ambulatory BP measurements were higher (P<.001) in the home BP group than in the office BP group. The mean
baseline-adjusted systolic/diastolic differences between the home and office
BP groups averaged 6.8/3.5 mm Hg, 4.9/2.9 mm Hg, and 4.9/2.9 mm Hg, respectively.
Left ventricular mass and reported symptoms were similar in the 2 groups.
Costs per 100 patients followed up for 1 month were only slightly lower in
the home BP group (€3875 vs €3522 [$4921 vs $4473]; P = .04).
Conclusions Adjustment of antihypertensive treatment based on home BP instead of
office BP led to less intensive drug treatment and marginally lower costs
but also to less BP control, with no differences in general well-being or
left ventricular mass. Self-measurement allowed identification of patients
with white-coat hypertension. Our findings support a stepwise strategy for
the evaluation of BP in which self-measurement and ambulatory monitoring are
complementary to conventional office measurement and highlight the need for
prospective outcome studies to establish the normal range of home-measured