Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines

Abstract Hypertension is the most common cause of death and disability worldwide with its prevalence rising in low to middle income countries. It remains to be an important cause of morbidity and mortality in the Philippines with poor BP control as one of the main causes. Different societies and groups worked and collaborated together to develop the 2020 Philippine Clinical Practice Guidelines of hypertension arising for the need to come up with a comprehensive local practice guideline for the diagnosis, treatment, and follow up of persons with hypertension. A technical working group was organized into six clusters that analyzed the 30 clinical questions commonly asked in practice, looking into the definition of hypertension, treatment thresholds, blood pressure targets, and appropriate medications to reach targets. This guideline also includes recommendations for the specific management of hypertension among individuals with uncomplicated hypertension, hypertension among those with diabetes, stroke, chronic kidney disease, as well as hypertension among pregnant women and pediatric populations. It also looked into the appropriate screening and monitoring of patients when managing hypertension, and identification of groups who are at high risk for cardiovascular (CV) events. The ADAPTE process was used in developing the statements and recommendations which were then presented to a panel of experts for discussion and approval to come up with the final statements. This guideline aims to aid Filipino healthcare professionals to provide evidence‐based care for persons with hypertension and help those with hypertension adequately control their blood pressure and reduce their CV risk

organized into six clusters that analyzed the 30 clinical questions commonly asked in practice, looking into the definition of hypertension, treatment thresholds, blood pressure targets, and appropriate medications to reach targets. This guideline also includes recommendations for the specific management of hypertension among individuals with uncomplicated hypertension, hypertension among those with diabetes, stroke, chronic kidney disease, as well as hypertension among pregnant women and pediatric populations. It also looked into the appropriate screening and monitoring of patients when managing hypertension, and identification of groups who are at high risk for cardiovascular (CV) events. The ADAPTE process was used in developing the statements and recommendations which were then presented to a panel of experts for discussion and approval to come up with the final statements. This guideline aims to aid Filipino healthcare professionals to provide evidence-based care for persons with hypertension and help those with hypertension adequately control their blood pressure and reduce their CV risk

K E Y W O R D S
hypertension-general, lifestyle modification/hypertension, treatment and diagnosis/guidelines

INTRODUCTION
Hypertension is a major cause of premature death worldwide and is the most important modifiable risk factor for disability adjusted life-years lost worldwide. 1,2 The prevalence of hypertension in low and middle income countries has been seen to be steadily rising, but in the Philippines, the latest National Nutrition Survey (NNS) conducted by the Despite the decreasing trends in hypertension prevalence in the country, poor blood pressure control continues to contribute to the top two causes of mortality in the Philippines, which are heart disease and stroke. This, therefore, is the reason for the urgency of developing local practice guidelines for the management of this common disease. While there are many international practice guidelines which can be adopted in its totality, this guideline is meant to address issues that are unique and relevant to the Filipino population and when available, include local research in the development of the recommendations.
This guideline is a collaborative work of different specialties in the interest of curbing the morbidity and mortality due to hypertension in the country, by providing a set of recommendations that could guide the Filipino physician in the management of elevated blood pressure.
The objective of the guidelines is to present evidence-based recommendations on the diagnosis and treatment of hypertension that are adapted from international practice guidelines, but which take into consideration local realities and the practice of doctors in the Philippines. It is intended to help physicians make sound clinical decisions in the management of hypertension by presenting the latest information about diagnosis, treatment, and follow-up of persons with hypertension. The primary targets for these guidelines are physicians in general practice, but these recommendations are also useful for all healthcare professionals in the Philippines.
The guideline includes statements and recommendations on the definition of hypertension, treatment thresholds, and blood pressure targets, appropriate medications to reach targets, and specific management of hypertension among individuals with uncomplicated hypertension, hypertension among those with diabetes, stroke, chronic kidney disease, as well as the hypertension among pregnant women and pediatric populations. It also includes statements on the appropriate screening and monitoring when managing hypertension, and identification of groups who are at high risk for cardiovascular (CV) events.

METHODOLOGY
The project to develop the Philippine Practice Guideline was

Development of guideline recommendations and evidence summaries
Each cluster then developed and presented their draft recommendations for approval to the panel of experts for discussion and approval by consensus of the majority. These draft recommendations were then revised and presented again to the panel and were finalized. Several public presentations have also been made to further elicit feedback from various stakeholders on the details of the guidelines. The recommendations presented here are the result of these iterative processes.

Clinical question 1. Among adult Filipinos, what is the definition of hypertension?
Statements: 1.1 Hypertension is defined as an office blood pressure (BP) of 140/90 mm Hg or above, typically at least twice taken on two separate days.

1.2
It is recommended that office BP be classified as Normal, Borderline, Hypertension.

1.3
Out of office BP measurements are recommended to confirm the diagnosis of hypertension, with ambulatory blood pressure monitoring (ABPM) as the preferred method, and home blood pressure monitoring (HBPM) as an acceptable alternative.
The TWG also decided to adopt the joint position statement of the Philippine Heart Association (PHA) and the Philippine Society of Hypertension (PSH) 6 which was a response to the 2017 ACC/AHA Guideline for the Prevention, Detection, and Management of High Blood Pressure on adults. 7 The 2020 Philippine Clinical Practice Guidelines (CPG) has adopted this blood pressure classification from the consensus statement as shown in Table 1.
This guideline defines hypertension as an office BP of 140/90 mm Hg or above taken in accordance with the proper standard BP measurement. A cut-off value has been set to simplify the diagnosis of hypertension and to rationalize the treatment decisions surrounding it. The continuum between BP level and the occurrence of CV and renal events is not clear, making the setting of a cut off value arbitrary. Nevertheless, hypertension is defined here as the level of BP at which the ben-

2.2
The aneroid sphygmomanometer (manual device) may be used in office or out of office provided the examiner is efficient and well trained, and the device is periodically checked according to standard maintenance procedures.

2.3
The aneroid sphygmomanometer is recommended for special cases like the presence of arrhythmias or extremes in BP levels. All guidelines agree that patients with hypertension should receive anti-hypertensive treatment on top of diet and lifestyle modification to reduce blood pressure to treatment targets. Lowering blood pressure to less than 140/90 has been shown repeatedly to reduce morbidity and mortality. [9][10][11][12] This local guideline takes a practical approach to BP targets in recommending a threshold of greater than 140/90 mm Hg to start therapy. This can be addressed with diet and lifestyle modifications alone in low-risk hypertensives or concomitant lifestyle changes with medical treatment in high-risk individuals. We recommend these interven-

Ideal combination therapy includes renin-angiotensinsystem (RAS) blocker with calcium channel-blocker (CCB)
or thiazide/thiazide-like diuretics. Other combinations of the five major classes may also be used in patients with compelling indications for the use of specific drug classes.

ACE inhibitors & ARBs are not recommended to be used in com-
bination. Likewise, combinations of ACE-I or ARBs with direct renin inhibitors should not be used.

4.2.4
The use of free combinations is recommended if single-pill combination therapy is not available or not affordable.

Beta blockers are suitable as initial therapy in hypertensive
patients with coronary artery disease, acute coronary syndrome, high sympathetic drive and pregnant women. Beta blockers for those with congestive heart failure was specified to be bisoprolol, carvedilol, metoprolol succinate or nebivolol.

4.2.6
Among patients with BP > 150/100 mm Hg (or >160/100 mm Hg in the elderly), a combination of two agents, preferably combination of a RAAS inhibitor (ARB/ACE-is) and CCB or diuretic, should be given initially since it is unlikely that any single agent would be sufficient to achieve the BP target. As already stated in the general guidelines, the choice for starting on initial combination therapy results in greater achievement of BP lowering at the shortest amount of time. Low-dose combination therapy has been shown to be more effective than maximal dose monotherapy in the general population of persons with hypertension.

8.2
The combination of ACE and ARB is not recommended due to a higher risk of hyperkalemia and renal failure.

III. Management of hypertension in persons with chronic kidney disease
Hypertension is highly prevalent in individuals with chronic kidney A two-drug combination should consider these mechanisms in the choice of anti-hypertensives: calcium channel blockers and diuretics to address volume dependent type of hypertension, and ACE, ARB and beta blockers for the renin dependent type.  A patient with a history of stroke will most likely have another stroke in his lifetime. In the United States, recurrent strokes make up almost 25% of the nearly 800,000 strokes annually. 23 Hypertension remains to be the most important risk factor for both ischemic and hemorrhagic strokes. Therefore, adequate BP control plays a significant role in secondary stroke prevention.

V. Management of hypertension in pregnancy
Hypertensive disorders of pregnancy constitute one of the major causes of maternal and perinatal morbidity and mortality worldwide.
It has been estimated that preeclampsia complicates 2-8% of all pregnancies globally.  Conditions that may indicate superimposed preeclampsia, that warrants a referral to a maternal fetal medicine specialist/perinatologist, include the following: 1. Acute, severe, and persistent elevations in blood pressure.
2. Sudden increase in baseline hypertension.
3. New-onset proteinuria or sudden increase in proteinuria. Initiating therapy in non-severe disease, however, is a patient of controversy. The NICE, ISSHP and SOGC recommends therapy when the blood pressure remains above 140/90 mm Hg but SOGC suggests a lower threshold in patients with other co-morbidities. [26][27][28][29] The ACOG recommends conservative management of non-severe disease but stressed on the importance of control in the severe type. 30 Table 3 26.1.2 Symptomatic hypertension or Stage 2 hypertension 26.1.3 Presence of co-morbidities like chronic kidney disease (CKD) or diabetes mellitus (DM), or any evidence of target organ involvement (eg, left ventricular hypertrophy).

26.2.
The goal of pharmacologic therapy should be a reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) to <90 th percentile for age, sex and height and <120/80 mm Hg in adolescents ≥13 years of age.

26.3.
For children with CKD, BP targets should be less than or equal to 50 th percentile for age, sex and height.

26.4.
The goal of treatment of hypertension in the pediatric population is not only to reduce BP to <90 th percentile for age, sex and height and <130/80 mm Hg, but also to reduce CV risk factors, and prevent target organ damage.

26.5.
Follow-up every 4-6 weeks is recommended for monitoring and evaluation of therapy.

29.2
For children with co-existing chronic kidney disease, proteinuria or diabetes mellitus, an ACE-inhibitor or ARB is recommended as the initial antihypertensive drug unless with absolute contraindications. Referral to a specialist is highly recommended.

29.3
Therapy should start with a single drug at the lowest possible dose and titrated up every 2-4 weeks until target BP is achieved, or the maximal dose reached, or adverse effects occur.

29.4
If BP is not controlled with a single agent (maximal dose is reached or adverse effects occur), a second agent can be added to the regimen and titrated as with the initial drug. Because the use of other anti-hypertensive agents can lead to compensatory salt and water retention, the addition of a thiazide diuretic to an initial drug for uncontrolled hypertension is prudent.

29.5
In combining agents from different drug classes, it is preferable to give those with complementary modes of action. Ideally, no two drugs which act separately on the RAAS, should be used in combination because of the risk of hyperkalemia, impaired kidney function and hypotension.

Clinical question 30: What is the recommended technique and BP
device for accurate BP measurement in pediatric patients? Statements:

30.1
The use of proper technique and appropriately-sized cuff is critical for the accurate measurement of BP in children.

30.2
An auscultatory device using an aneroid non-mercury sphygmomanometer is recommended for children.

30.3
An oscillometric device is a suitable alternative to auscultation for initial BP screening and monitoring in the pediatric population.

30.4
Ambulatory BP monitoring (ABPM) is recommended in children (> 5 years old) and adolescents with the following conditions:

30.5
Home BP monitoring should not be used to diagnose hypertension, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement if clinically validated oscillometric apparatus and appropriate-sized cuffs are used.

CONCLUSIONS
The clinical questions and statements in this clinical practice guideline allow us to holistically manage the Filipino hypertensive individual. We recommend that the diagnosis of hypertension among adults should be based on a BP reading of equal or more than 140/90 mm Hg. The target BP should be less than 130/80 mm Hg to prevent hypertensionmediated organ damage. We also recommend that lifestyle modification be advised to all persons with hypertension. The use of appropriate anti-hypertensive medications depending on the co-morbidity of the individual is recommended. We also recommended management for the pediatric and the pregnant hypertensive. Simplified algorithms are provided to serve as a quick reference guide to clinicians. There was limited Filipino data, particularly in the pediatric population thus, local studies are needed to collect real-world data on the use of various medications in various populations, and even of the utility of this practice guideline.
The 2020 CPG is designed to be a guide for clinicians in managing hypertension for the Filipino patient. This, however, should not replace sound clinical judgment, and the ultimate decision for treatment should be shared by both clinician and the patient.

ACKNOWLEDGMENTS
The authors would like to express their gratitude to the members of the steering committee and the representatives of the different medical organizations who comprised the expert panel, for their valuable inputs during the creation of the guidelines.