My takeaway from the Webinar: Management Strategies in Early Hypertension spoken by Dr. Deborah Ignacia David-Ona

Hypertension accounts for 18.6 million of deaths every year and is causing 33% of all global deaths. More than 75% of the cardiovascular deaths take place in low and middle-income countries. It is also the number one risk factor for developing cardiovascular disease and the 5th leading cause of mortality in the country.

Many of the Filipinos are aware that they hypertensive but more than half of the percentage still have uncontrolled hypertension.

The COVID-19 pandemic partially disrupted the seeking of health care for the management of non-infectious diseases due to lockdowns and having hypertension along with other cardiovascular and cerebrovascular disease increased the odds for severity of COVID-19 and mortality.

Because of the ongoing lockdown, people were predispose to a sedentary lifestyle, weight gain and increased stress which are risk factors in developing hypertension.

Addressing the gaps in assessment and management of hypertension includes:

• Dissemination of clinical practice guidelines
• Multi-specialty collaboration which includes allied health professionals
• Government policies and programs
• Public-private partnerships
• Physician-driven patient education
• Patient awareness campaigns

In the 2020 Philippine Guidelines, for a population of:

• Adult less than 80 years old
• Target BP (blood pressure) is less than 130/80 mmHg 
• Treatment threshold BP is not more than or equal to 140/90 mmHg
• Adult more than or equal to 80 years old
• Target BP is less than 140/90 mmHg 
• Treatment threshold BP is not more than or equal to 150/90 mmHg
• People with diabetes
• Target BP is less than 130/90 mmHg and not to lower than 120/70 mmHg (as studies show that lower than that would increase complications)
• Treatment threshold BP is not more than or equal to 140/90 mmHg
• People with Chronic Kidney Disease
• Target BP is less than 140/90 mmHg - low cardiovascular risk and if with proteinuria less than of equal to 130/80 mmHg
• Treatment threshold BP is not more than or equal to 140/90 mmHg

For hypertension to be defined as such, one should have a measurement of more than or equal to 140/90 mmHg at least on two separate occasions. In office and out-of-office blood pressure recommendation using a digital device can be taken. Manual device that is taken by a trained personnel and calibrated regularly are still recommended.

For the non-pharmacologic interventions for hypertension:

1. Lifestyle modification is the cornerstone  for the management of hypertension as this is the first line anti-hypertensive treatment and is synergistic to the effects of anti-hypertensive medications.
2. Sodium restriction to as low as 1500 mg/day or not more than half a teaspoon a day.
3. Dietary Approaches to Stop Hypertension (DASH) meal plan is recommended for all patients with hypertension without renal insufficiency. These are low in sodium and high in dietary potassium, rich in fruits, vegetables, low-fat dairy, fish, whole grains, fiber, and other minerals at recommended levels. It should also have low in red and processed meat, sugar sweetened foods and drinks, saturated fat, cholesterol and sodium.
4. Aerobic physical activity and dynamic resistance exercises. Heart rate should increase to 120 beats per minute or  dedicate at least 30 minutes of exercise that makes your heart pumping every day.
5. Abstinence from alcohol or moderate alcohol intake. Filipinos are more on binge drinkers but this practice is also discouraged.
6. Significant weight loss of more than or equal to 5% of the baseline weight for overweight or obese patients. Studies show that for every kilogram lost is a drop in 1 mmHg in the systolic blood pressure.
7. Smoking cessation

For pharmacologic approaches:

• For uncomplicated hypertension suitable antihypertensive drugs include ACE inhibitors, ARBs, Calcium channel blockers, thiazide/thiazide-like diuretics or as monotherapy or combination.
• Ideal combination therapy has the RAS blocker with calcium channel-blocker or thiazide/thiazide-like diuretics
• Do not combine ACE inhibitors & ARBs. Also ACE-I or ARBs with direct renin inhibitors
• SPC (Single Pill Combination) or free combination? - Use of free combinations is recommended if SPC therapy is not available or not affordable.

Amlodipine has proven efficacy across a range of hypertensive patient profiles. Taking Amlodipine as prescribed greatly decreases risk for stroke. It is long acting drug and it doesn't matter what time of the day to take it as long as you take it regularly. Because it also vasodilates the vessels, common side effect experienced by patients is edema so leg elevation can be done. Losartan is a short acting drug and takes effect for 6-10 hours.

For Blood Pressure Measurement in Public Spaces/Pharmacies, these are useful for screening untreated individuals and following treated hypertensives but diagnosis and treatment decisions should not to be based solely on such measurements.

Due to technological advancement, wearable devices for BP taking are readily available in the market. These types are wrist-cuff devices through oscillometry (wrist cuff) and cuffless (wrist band) through photoplethysmography, applanation tonometry, pulse transit  time, and others. A 2021 European  Society of Hypertension Practice guidelines published an article that cuffless wearable BP monitors have great potential but its accuracy and usefulness are uncertain today that diagnostic and treatment should not be based on these measurements.

Technology can play a key role throughout the patient journey in enhancing adherence through:

• Packing innovations such as calendar-based packaging, electronic monitoring devices
• Electronic reminders which alerts you to take the medication or refill prescription
• Electronic health records which share patient's complete medication list for collaborative care
• Electronic prescribing into which notification if prescription is already filled (or not)
• Digital feedback such as incentives and rewards

Finally, to improve hypertension control in low and middle income countries, there is a need to collaborate with the key stakeholders, promote access and adherence and implement innovative, cost-effective and sustainable programs for hypertension prevention and control