Asian management of hypertension: Current status, home blood pressure, and specific concerns in Philippines (a country report)

Abstract

Incidence of cardiovascular diseases (CVD) in the Philippines based on the Philippine Heart Association survey among hospital‐based population showed hypertension as the highest (38.6%), followed by stroke (30%), coronary artery disease (CAD) (17.5%), and heart failure (10.4%). Based on Philippine FNRI data, the prevalence of coronary, cerebrovascular, and peripheral arterial diseases were 1.1%, 0.9%, and 1.0%, respectively. Cardiovascular risk factor prevalence were the following: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9% (BMI), and 10.2% and 65.6% by waist‐hip ratio in men and women, respectively. In a more recent study on risk factors, urban dwellers were more hypertensive, overweight, obese, and with impaired fasting glucose. More smokers and dyslipidemia by high TC, high non‐HDL‐C, and low HDL‐C were seen in those living in the rural areas. Subjects with higher level of education were more overweight, obese and have dyslipidemia by a high TC, TG, and LDL‐C while there were more smokers, low HDL‐C, and hypertensive participants who have reached a lower level of education. Latest data on prevalence of hypertension were 28% equal for males and females. Unaware was 9%. Treatment rate was 56%, compliance was 57%, and BP control rate was 20%. Antihypertensive medications used were beta‐blockers (36%), calcium channel blockers (CCB) (33%), angiotensin receptor blockers (ARB) (28%), ACE inhibitors (5%), and centrally acting agents (4%). Mortality from CVD was stroke, mostly infarct (22.6%), myocardial infarction (6.5%), and Heart Failure (6.5%)

1. INTRODUCTION: CURRENT STATUS OF CARDIOVASCULAR DISEASES (CVD) INCIDENCE AND HYPERTENSION MANAGEMENT IN THE PHILIPPINES

Incidence of CVD in the Philippines based on the Philippine Heart Association survey among hospital‐based population showed hypertension as the highest (38.6%), followed by stroke (30%), coronary artery disease (CAD) (17.5%), and heart failure (10.4%).1 Based on Philippine FNRI data, the prevalence of coronary, cerebrovascular, and peripheral arterial diseases were 1.1%, 0.9%, and 1.0%, respectively. Cardiovascular risk factor prevalence were the following: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9% (BMI), and 10.2% and 65.6% by waist‐hip ratio in men and women, respectively.2

In a more recent study on risk factors, urban dwellers were more hypertensive, overweight, obese, and with impaired fasting glucose. More smokers and dyslipidemia by high TC, high non‐HDL‐C, and low HDL‐C were seen in those living in the rural areas. Subjects with higher level of education were more overweight, obese and have dyslipidemia by a high TC, TG, and LDL‐C while there were more smokers, low HDL‐C, and hypertensive participants who have reached a lower level of education.3

Latest data on prevalence of hypertension were 28% equal for males and females; 9% were unaware. Treatment rate was 56%, compliance was 57%, BP control rate was 20%. Antihypertensive medications used were beta‐blockers (36%), calcium channel blockers (CCB) (33%), angiotensin receptor blockers (ARB) (28%), ACE inhibitors (5%), and centrally acting agents (4%).4

Mortality from CVD was stroke, mostly infarct (22.6%), myocardial infarction (6.5%), and Heart Failure (6.5%)1

2. HOME BP MONITORING: POSITIONING OF THE CURRENT STATUS OF HOME BP MONITORING (HBPM) IN THE MANAGEMENT OF HYPERTENSION

HBPM is performed in the Philippines, but not routinely, and there are no published data on the use of HBPM in the country. HBPM is currently used to investigate the status of BP control in patients with known hypertension who are taking treatment but with uncontrolled BP on follow‐up. Some specialists use HBPM to make a diagnosis of hypertension in conjunction with clinic BP. Barriers to the use of HBPM include the cost and availability of HBPM devices, with only around 25% of the population with hypertension currently having access to such devices. Another barrier is the lack of trust among patients regarding the accuracy of their digital BP devices.

The Philippine Hypertension Guidelines released in 2011 utilizing the BP classification of JNC 7 made mention of the importance of HBPM and was an option for clinicians and their patients. However, with the growing data on its advantage, local physicians encourage their patients to monitor BP at home to better assess their treatment effectivity and also to rule out “white coat”, masked hypertension and other parameters. The local guidelines will be updated this year.

3. DATA DEMONSTRATION OF THE PHILIPPINE SUB‐ANALYSIS OF ASIABP@HOME STUDY

Important data on the use of HBPM gave new insights in the assessment and management of hypertension. It represents a new but simple approach in the comprehensive management of hypertension. This is the solution to diversified problems and obstacles encountered particularly in Asia.5, 6

In the HOPE Asia Network study, parameters like BP morning surge and variability showed interesting data.7 The importance of the role of HBPM in achieving BP control must be given emphasis to improve treatment outcomes.8

Based on AsiaBP@Home study as a multi‐national Asian specialty center performance regarding home and clinic BP control was published, majority of the uncontrolled hypertension simulated by the new lower ACC/AHA guideline threshold corresponds to additional 18% increase in sustained uncontrolled hypertension (SUCH) and to additional 5% increase in white coat uncontrolled hypertension (WUCH).9

In a sub‐group analysis of the Philippines in this study (Figure 1), using the conventional threshold values, the well‐controlled clinic SBP was only 69% and well‐controlled morning home SBP was 79%. Using the new threshold levels, the well‐controlled clinic SBP decreased to 43% and well‐controlled morning home SBP was lower at 67%. Comparing the conventional to the new thresholds, well‐controlled hypertension decreased from 62% to 37%, masked (uncontrolled) morning hypertension decreased from 8% to 6%, Sustained (uncontrolled) hypertension increased from 13% to 27%, and white coat hypertension increased from 18% to 31%.10

Figure 1.

Distributions of blood pressure (BP) control status based on different clinic and morning home BP thresholds in the Philippines sub‐analysis from the AsiaBP@Home study. Left panel represents the results based on cutoff values of 140 mm Hg for clinic systolic BP (SBP) and 135 mm Hg for home SBP. Right panel represents the results based on cutoff values of 130 mm Hg for both clinic SBP and home SBP

4. POSITIONING OF HOME BP MONITORING IN THE PHILIPPINE HYPERTENSION MANAGEMENT GUIDELINES 2018

For the past decade, hypertension prevalence in the Philippines have progressively increased, from 11% in 1992,11 22% in 1997,12 22.5% in 2003,13 21% in 2007, 14 25.3% in 2008, 15 and 28% in 2013.4 However, BP control rate remain dismal, from 10% in 1992 to 20% in 2013. This is compounded with CVD related to hypertension as the continuing leading cause of morbidity and mortality in the Philippines. Office BP measurement remains to be our standard for hypertension assessment and it appears to be insufficient in guiding us in strategizing our management approach. Hence, hypertension remains to be a big problem that poses health and economic burden to all. With the availability now of data derived from HBPM more particularly in ASIA, our treatment approach will improve and eventually to better outcomes. In our move to update our Philippine hypertension guidelines for 2019, HMBP will definitely be given emphasis. This will empower the patients to be more aware of their BP and would help the clinician in the management.

5. TRADITIONAL ANTIHYPERTENSIVE THERAPY AND THE POPULAR ANTIHYPERTENSIVE DRUGS IN THE PHILIPPINES

In the Philippines, traditional mode of treating hypertension has always been part of our culture. This is especially true for a third world country where a significant chunk of the population has no privilege of consulting a professional health care provider. In a local study, twenty‐one percent of population surveyed have consulted non‐physicians. Hence, they are continually exposed to inappropriate management as well as traditional beliefs and practices. Traditional non‐pharmacologic approaches include exercise (41%), diet (41%), herbal medicines (19%), pineapple juice (3%), water therapy (1%), and acupuncture (1%). 16

Through the many years of surveys in the Philippines, the popular antihypertensive drugs used from 1992 to 1997 were CCBs, followed by beta‐blockers and ACEi. From 2007 to 2013, the more commonly used drugs were beta‐blockers, followed by CCBs and ARBs. After 2013, the use ARBs have increased tremendously in conjunction with fixed combination preparations. The updated data will soon be available. During the past decade, monotherapy has been the mode of treatment in more than 80% of patients. This could also explain why the BP control rates have been low.

6. SPECIFIC CONCERNS AND PERSPECTIVES OF THE HYPERTENSION MANAGEMENT

With the availability of recent guidelines and BP classifications more particularly from ESH/ESC and AHA/ACC, management of hypertension in the Philippines will undergo a paradigm shift, wherein targeting of BP goals will vary depending on the risk profile of the patient as well as the inclination of the attending physician. The Philippine Heart Association has come up with a position statement in collaboration with the Philippine Society on Hypertension. With the new BP thresholds set by AHA/ACC, the associations believe that the strong preventive implications of the guidelines have great value in a country like the Philippines where hypertension prevalence is high and awareness, treatment adherence, and JNC‐recommended BP goal attainment are low. A BP threshold of 130/80 that can be detected by HBPM can serve as a “red‐flag” to the physician to re‐assess the patient's risk since studies showed intensive lowering of BP resulted in better outcomes. This exacting BP scale has the potential to stir people to the awareness of the power of hypertension as a risk factor for CVD. The Framingham observation that a significant number of previously categorized normal to high normal BPs eventually develop definite hypertension is important.17

The importance of home BP monitoring (HBPM, ie, out of office or self BP monitoring) is highly recognized, hence it is also deemed reasonable to define a HBPM of 135/85 as hypertension (the equivalent of clinic BP of 140/90 in the guideline). The patient with this HBP level, therefore, may be considered a candidate for pharmacologic treatment. All studies in hypertension have generally used 140/90mm Hg as entry BP. More than 90% of the patients in SPRINT, which is believed by many as the main driver of the guideline, have BP of 140/90 and above. In essence, this guideline treats patients with BP of 130/80 mm Hg by virtue of the presence of risk factors.18

In summary, hypertension still remains a major problem in the Philippines as it accounts for more deaths and disabilities. Hypertension‐related stroke is the top cause of mortality in our country. This is brought about by lack of awareness, poor compliance, and inadequate BP control. With the availability of newer and practical tools such as the home BP monitoring, it will certainly improve hypertension evaluation, patient awareness, physician's alertness in achieving better BP control and hence, better outcomes.

CONFLICT OF INTEREST

J. Sison has received honoraria from Pfizer, AstraZeneca, Boehringer Ingelheim, and Novartis. R. Divinagracia has received honoraria as a member of speaker's bureaus for Bayer, Novartis, and Pfizer. Other author reports no potential conflicts of interest in relation to this article.

Sison J, Divinagracia R, Nailes J. Asian management of hypertension: Current status, home blood pressure, and specific concerns in Philippines (a country report). J Clin Hypertens. 2020;22:504–507. 10.1111/jch.13802