Optimised Treatment for Hypertension Trial

RATIONALE FOR TRIAL DESIGN: Current pharmacological treatment of hypertension involves titration of treatment according to serial BP monitoring. However, BP is intrinsically variable and subject to significant measurement and random error that leads to a notoriously poor signal-to-noise ratio. Accordingly, measurement of BPs within 1 to 2 months of starting BP lowering treatment are not associated with true treatment response, adverse effects or cardiovascular risk reduction. Two contrasting solutions include 1) 'fire and forget' by prescribing BP lowering drugs empirically based on the desired average BP response observed from placebo controlled randomised trials without measuring repeat BP or 2) continue usual care with more intensive BP monitoring to try and improve the signal-to-noise ratio. OBJECTIVES: The primary aim is to compare the efficacy of remote empirical prescribing of BP lowering drugs informed by randomised trial data without routine BP monitoring ('fire and forget') versus usual care enhanced with intensive BP monitoring ('intensive BP monitoring'). The secondary aims are to determine if, compared to usual care with intensive BP monitoring, remote empirical treatment of high BP is acceptable to patients, is cost-effective and safe. PARTICIPANT ELIGIBILITY: Key Inclusion Criteria: * Adult aged ≥18 years * High BP defined as home SBP ≥135 or DBP ≥85 mmHg, either untreated or receiving one or two BP lowering drugs * Among untreated individuals, indicated for pharmacological treatment of high BP according to 2023 NHF Cardiovascular Risk Management Guidelines Key Exclusion Criteria: * Currently receiving three or more BP lowering drugs * Home SBP ≥155 mmHg for untreated participants * Home SBP ≥150 mmHg for participants on one BP lowering drug * Home SBP ≥145 mmHg for participants on two BP lowering drugs * Baseline eGFR \<45 ml/min/m2 * Any abnormalities on baseline electrolytes that would prevent initiation of BP lowering therapy * Participants with any other medical condition or taking any other concomitant medication which in the opinion of the investigator would make the participant unsuitable for the trial TRIAL INTERVENTION \& RANDOMISATION: All participants who meet the eligibility criteria for the trial will be randomised (1:1) to: Fire and forget: Remote evidence informed empirical prescribing of BP lowering therapy without serial BP monitoring. Regimen chosen based on the average BP reduction and lowest risk of adverse effects observed in placebo controlled randomised trials Intensive BP monitoring: usual care as per GP prescribing enhanced with intensive BP monitoring TRIAL OUTCOMES: Primary: Mean difference in change in home SBP from baseline to 12 weeks Secondary: * Efficacy: Proportion achieving home BP control \<135/85 mmHg, difference in change in systolic DBP from baseline to 12 weeks * Safety: Incidence of adverse events leading to treatment withdrawal, adverse events of special interest such as symptoms of hypotension, and SAEs from baseline to 12 weeks. * Acceptability: interviews of participants * Self-reported medication adherence * Cost-effectiveness: Average total cost per patient achieving BP control