The n e w e ng l a n d j o u r na l of m e dic i n e
Initial Treatment of Hypertension
To the Editor: In her review article on the ini-
tial treatment of hypertension, Taler (Feb. 15 is-
sue)1 notes a lack of evidence that home blood-
pressure measurement improves blood-pressure
control. Several studies included in the meta-
analysis that Taler cites to support her position
indeed concluded that when identical office and
home blood-pressure treatment targets were used,
adjustment of antihypertensive treatment on the
basis of home blood-pressure measurement led
to worse blood-pressure control and less treat-
ment than adjustment on the basis of office blood-
pressure measurement.2 However, these studies
may have overlooked the fact that in persons with
hypertension, blood pressure measured in the of-
fice can be up to 15 mm Hg higher than blood
pressure measured at home.3 The use of identical
treatment targets therefore results in a greater
decrease in blood pressure when therapy is ad-
justed on the basis of office blood pressure rath-
er than on home blood pressure; this falsely fa-
vors office blood-pressure measurement.
Other studies that have used universally recom-
mended self-monitoring targets that are 5 mm Hg
lower than office targets have shown home
blood-pressure measurement to be superior to
office blood-pressure measurement in improv-
ing blood-pressure control.4,5 We consider these
data to highlight the importance of home blood-
pressure measurement in the management of hy-
pertension.
Teemu J. Niiranen, M.D.
University of Turku
Turku, Finland
Daniel Gordin, M.D.
Joslin Diabetes Center
Boston, MA
daniel​.­gordin@​­joslin​.­harvard​.­edu
No potential conflict of interest relevant to this letter was re-
ported.
1. Taler SJ. Initial treatment of hypertension. N Engl J Med
2018;​378:​636-44.
2. Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood
pressure monitoring in overcoming therapeutic inertia and im-
proving hypertension control: a systematic review and meta-
analysis. Hypertension 2011;​57:​29-38.
3. Niiranen TJ, Asayama K, Thijs L, et al. Outcome-driven
thresholds for home blood pressure measurement: international
database of home blood pressure in relation to cardiovascular
outcome. Hypertension 2013;​61:​27-34.
4. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-
1952 n engl j med 378;20 nejm.org  May 17, 2018
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management in the control of hypertension (TASMINH2): a ran-
domised controlled trial. Lancet 2010;​376:​163-72.
5. McManus RJ, Mant J, Franssen M, et al. Efficacy of self-
monitored blood pressure, with or without telemonitoring, for
titration of antihypertensive medication (TASMINH4): an un-
masked randomised controlled trial. Lancet 2018;​391:​949-59.
DOI: 10.1056/NEJMc1804084
To the Editor: Taler highlights pharmacologic
and nonpharmacologic strategies for the initial
management of hypertension. The strategy of
lifestyle modifications continues to be the main-
stay for the treatment of mild-to-moderate hy-
pertension. However, the article does not men-
tion mind–body and stress-reduction practices.
Since Benson et al. described the relaxation re-
sponse in the treatment of hypertension,1 multi-
ple studies have shown how these practices can
help treat blood pressure through reduced sym-
pathetic tone, increased nitric oxide levels, and
decreased peripheral vascular resistance.2
Recently, the American Heart Association has
issued a position statement on the role of medi-
tation in reducing the risk of cardiovascular
disease.2 This is a reasonable treatment option,
often available at low or no cost, with a low
adverse-effect profile. Although these approach-
es have been historically marginalized as “alter-
native,” it is fair to say that there is a reasonable
evidence base, in conjunction with scientific
plausibility and active investigation, that makes
mind–body and stress-reduction approaches im-
portant considerations in the mainstream man-
agement of hypertension.
Indranill Basu‑Ray, M.D.
Catholic Health Initiatives St. Vincent Infirmary
Little Rock, AR
ibasuray@​­yahoo​.­com
Darshan H. Mehta, M.D., M.P.H.
Massachusetts General Hospital
Boston, MA
Sumit Shah, M.D., M.P.H.
University of Arkansas for Medical Sciences
Little Rock, AR
No potential conflict of interest relevant to this letter was re-
ported.
1. Benson H, Rosner BA, Marzetta BR, Klemchuk HM. De-
creased blood-pressure in pharmacologically treated hyperten-
sive patients who regularly elicited the relaxation response. Lan-
cet 1974;​1:​289-91.
 Correspondence
2. Levine GN, Lange RA, Bairey-Merz CN, et al. Meditation and
cardiovascular risk reduction: a scientific statement from the
American Heart Association. J Am Heart Assoc 2017;​ 6(10):​
e002218.
DOI: 10.1056/NEJMc1804084
To the Editor: Taler states that if the estimated
10-year risk of cardiovascular disease is less than
10%, “it is reasonable to implement lifestyle mod-
ifications alone for a period of 3 to 6 months.”
This statement implies that after that time, phar-
macologic therapy should be used if blood pres-
sure remains above goal. The American Heart
Association (AHA) guideline clearly discourages
pharmacologic therapy for this low-risk group;
instead, lifestyle modification alone is recom-
mended for the 21 million people in this category.1
An important concept, often attributed to Yogi
Berra, is that, “In theory, theory and practice are
the same, in practice they are not.” If the AHA
recommendations are to be implemented in the
way in which they were intended, clinicians need
to carefully follow the AHA recommendations to
use ongoing lifestyle modification in low-risk
persons and not then move on to pharmacologic
therapy when it is not indicated.
Neil Skolnik, M.D.
Abington–Jefferson Health
Abington, PA
nskolnik@​­comcast​.­net
Dr. Skolnik reports receiving advisory-board fees from Astra-
Zeneca, Teva, Lilly, Boehringer Ingelheim, Sanofi, and Janssen
Pharmaceuticals, lecture fees from AstraZeneca and Boehringer
Ingelheim, and grant support from Sanofi, AstraZeneca, and
Boehringer Ingelheim. No other potential conflict of interest
relevant to this letter was reported.
1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/
AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline
for the prevention, detection, evaluation, and management of
high blood pressure in adults: executive summary: a report of
the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines. J Am Coll Cardiol
2017 November 7 (Epub ahead of print).
DOI: 10.1056/NEJMc1804084
The author replies: Niiranen and Gordin de-
scribe the potential benefits and challenges of us-
ing home blood-pressure measurement, including
the conflict between using office versus home
measurements in defining efficacy. It is commonly
assumed that office blood pressure will run high-
er than home blood pressure, although automated
office blood-pressure measurement may be closer
to home blood-pressure measurement, and these
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The New England Journal of Medicine
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Copyright © 2018 Massachusetts Medical Society. All rights reserved.
differences would not affect same-setting com-
parisons. A systematic review of randomized, con-
trolled trials that was performed for the American
College of Cardiology–AHA (ACC–AHA) Hyper-
tension Guideline showed a reduction in systolic
blood pressure by 4.9 mm Hg (95% confidence
interval [CI], 1.3 to 8.6) with self-measurement of
blood pressure, as compared with usual care at
6 months; this improvement did not persist at
12 months (reduction of 0.1 mm Hg; 95% CI,
−2.54 to 2.8).1 Agarwal et al. found a change in
systolic blood pressure of −2.63 mm Hg (95% CI,
−4.24 to −1.02) and a change in diastolic blood
pressure of −1.68 mm Hg (95% CI, −2.58 to
−0.79) in the home blood-pressure monitoring
group, as compared with those assigned to office
measurements only, with a greater effect in stud-
ies that were small, used telemonitoring, were
restricted to patients undergoing dialysis, or par-
adoxically were not associated with a medication
titration protocol.2 The main effect of home
blood-pressure measurement was a reduction in
medications, not increased rates of blood-pres-
sure control.
Furthermore, most studies lack outcome data
on cardiovascular events or mortality. A recent
systematic review and meta-analysis of multiple
implementation strategies showed a significant
change in systolic blood pressure with home
blood-pressure measurement of −2.7 mm Hg
(95% CI, −3.6 to −1.7) and a change in diastolic
blood pressure of −1.5 mm Hg (95% CI, −2.3 to
−0.8).3 A minority of studies that combine self-
measured blood pressure with telemonitoring
and active medication titration showed improve-
ments in blood-pressure control that were sus-
tained longer than 6 months,4,5 and this approach
merits further trials. I think home blood-pressure
measurement has potential if combined with ad-
ditional interventions.
Basu-Ray et al. highlight the value of mind–
body and stress-reduction practices, and they note
a scientific statement by the AHA endorsing medi-
tation for reduction of the risk of cardiovascular
disease. As detailed in this statement, system-
atic reviews show slight benefit to no significant
benefit; however, heterogeneity of study design,
high dropout rates, and lack of reproducibility
limit applicability for most patients. The 2017
ACC–AHA guideline did not endorse behavioral
therapies because of a lack of strong evidence for
their long-term effects in lowering blood pressure.
1953
 notices
Skolnik brings up an important point on how
to address persistent stage 1 hypertension after
an unsuccessful 6-month trial of lifestyle change.
The assumption that this would then be the time
to start pharmacologic treatment is not stated
and should not be implied. I would advise contin-
ued lifestyle efforts until such time as the blood
pressure increases to stage 2 hypertension or the
patient’s age, risk estimation, or coexisting condi-
tions indicate the need to initiate medication.
Sandra J. Taler, M.D.
Mayo Clinic
Rochester, MN
taler​.­sandra@​­mayo​.­edu
Since publication of her article, the author reports no further
potential conflict of interest.
1. Reboussin DM, Allen NB, Griswold ME, et al. Systematic
review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/
ASPC/NMA/PCNA guideline for the prevention, detection, evalu-
ation, and management of high blood pressure in adults:​a re-
port of the American College of Cardiology Foundation/Ameri-
can Heart Association Task Force on Clinical Practice Guidelines.
Hypertension 2017 November 13 (Epub ahead of print).
2. Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood
pressure monitoring in overcoming therapeutic inertia and im-
proving hypertension control: a systematic review and meta-
analysis. Hypertension 2011;​57:​29-38.
3. Mills KT, Obst KM, Shen W, et al. Comparative effectiveness
of implementation strategies for blood pressure control in hy-
pertensive patients: a systematic review and meta-analysis. Ann
Intern Med 2018;​168:​110-20.
4. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-
management in the control of hypertension (TASMINH2): a ran-
domised controlled trial. Lancet 2010;​376:​163-72.
5. McManus RJ, Mant J, Franssen M, et al. Efficacy of self-
monitored blood pressure, with or without telemonitoring, for
titration of antihypertensive medication (TASMINH4): an un-
masked randomised controlled trial. Lancet 2018;​391:​949-59.
DOI: 10.1056/NEJMc1804084
Correspondence Copyright © 2018 Massachusetts Medical Society.
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