Hypertension (HTN) and cardiovascular disease (CVD) remain the top killer in most parts of the world,^[1] and in the Philippines, they account for more than a quarter of all deaths.^[2] Based on the mortality statistics released by the Philippine Statistics Authority, of the 582,183 deaths in 2016, around 164,524 were due to ischemic heart disease, cerebrovascular disease, and other HTN-related diseases.^[3] Just like in most parts of the world, elevated blood pressure (BP) is the single most attributable cause of deaths in our country.^[4]

How to cite this article: Castillo RR, Mercado-Asis LB. Preventing a Hypertension “Storm Surge” in Southeast Asia. Hypertens 2019;5(2): 40-42.

Source of support: Nil,

Conflict of interest: None

Received: 29-04-2019;

Accepted: 14-05-2019

When Prof. Ramon F. Abarquez, Jr., MD, EFACC, FPCC, FPCP, CSPSH founded the Philippine Society of Hypertension (PSH) 26 years ago in 1993, he asked during the inaugural meeting of the Society: “Why do millions have to die due to hypertensionrelated complications when something could be done.”

How to cite this article: Castillo RR. Prof. Ramon Abarquez Jr. Hypertens 2019;5(2): 43-44.

Source of support: Nil,

Conflict of interest: None

Received: 04-05-2019;

Accepted: 12-05-2019

The need for better blood pressure (BP) control has been advocated for years with its high correlation to cardiovascular morbidity and mortality. The rise of hypertension (HTN) in several countries, particularly the Southeast Asian region, has caused the increased numbers of cerebrovascular and cardiovascular diseases. Several factors have been identified that led to the rise of HTN; namely, the aging population, a lower socioeconomic status, lower educational attainment, sedentary lifestyle, a high Western diet, increasing obesity, and certain ethnicity. Although countries, such as Singapore, have better control of BP levels, most of the countries in the region have low awareness and treatment control of HTN. It is only through population-based programs in controlling raised BP that has been proven successful in HTN control.

Key words: Cardiovascular disease, hypertension, prevalence, Southeast Asia

How to cite this article: Oliva RV. A Review on the Status of Hypertension in Six Southeast Asian Countries. Hypertens 2019;5(2):45-48.

Source of support: Nil,

Conflict of interest: None

Received: 29-04-2019;

Accepted: 14-05-2019

Background: For lack of the Philippine consensus on diagnosis, evaluation, and management of childhood and adolescent hypertension (HTN), local practice follows the United States (US) and European guidelines. Aim: The latest US and the European guidelines were examined for its potential benefits, limitations, and impact on local practice. Results: Essential differences and similarities between these two guidelines were recognized. Identified gaps include discrepancies in the diagnosis and classification of HTN among adolescents, including the age cutoff (13 vs. 16 years old). The applicability of the 24-h ambulatory blood pressure (BP) monitoring - although more superior in terms of BP information - is not practical at present. The European Society of HTN (ESH) recommendation for home BP monitoring is more feasible to implement. Adoption of the more rigorous screening and follow-up schedules of the American Academy of Pediatrics and the extensive diagnostic workup of the ESH guidelines are essential aspects useful to local practice. These strategies can minimize both over- and under-diagnosing pediatric HTN. The non-pharmacologic and pharmacologic treatment approaches of both guidelines are practical and feasible to implement. The optimal BP targets, especially those of high-risk populations to prevent excessive cardiovascular morbidity and mortality, are ideal. Conclusion: Due to the limitations of both guidelines in its applicability to local practice, the formulation of a country-specific BP consensus guideline is ideal. Modeling some parts of the recommendations in the screening, workup, and treatment that can contribute to best practice and outcomes is a goal.

Key words: Adolescents, american academy of pediatrics, european society of hypertension, filipino children, impact

How to cite this article: Resontoc LPR, Bonzon DD. A Closer Look at the Latest United States and European Pediatric Hypertension Guidelines and its Impact on Local Practice. Hypertens 2019;5(2): 49-52.

Source of support: Nil,

Conflict of interest: None

Received: 04-05-2019;

Accepted: 14-05-2019

Hypertension (HTN) remains to be the single most important risk factor for the development of cardiovascular disease worldwide. Moreover, the global burden of disease is expected to rise even more in the coming years due to the obesity epidemic and the aging population. However, control rates of high blood pressure (BP) remain low. The American College of Cardiology/American Heart Association 2017 Guidelines and the European Society of Cardiology/European Society of HTN 2018 Guidelines have different thresholds and targets, with the US guideline “redefining” HTN to a new lower level, while the European guideline remains unchanged from its previous levels. There is now emphasis on proper BP measurement for accurate initial diagnosis, and the use of home and ambulatory BP monitors is encouraged to ensure strict 24-h (morning and evening) BP control. Lifestyle modifications are encouraged, especially in the elderly who are more responsive to salt restriction. Asian characteristics of HTN warrant further study. Enhanced salt sensitivity, high dietary salt intake, aging population, and obesity are just some of the different characteristics of Asian HTN. More importantly, stroke is a more common consequence of uncontrolled HTN in Asia (compared to coronary artery disease), with hemorrhagic stroke having a relatively higher prevalence. Hence, lower BP targets are needed since BP levels correlate more linearly with stroke. China, Japan, Taiwan, and Korea have come up with published guidelines, highlighting some key points and difference with the US and European guidelines. The Philippine Society of HTN also previously came out with the “140/90 Report,” locally attuning foreign guidelines. Several years back, there has been a call for the development of our own Asian HTN guidelines. With newer findings on the benefits of lower BP targets/goals and its possible benefits to the Asian population and more findings on the different Asian characteristics of HTN, it might be the best time now to heed that call.

Key words: American college of cardiology/american heart association hypertension guidelines, asian hypertension guidelines, european society of cardiology/european society of hypertension guidelines, philippine society of hypertension

How to cite this article: Mina ABC, Defensor-Mina MV, Morales DD. The Impact of the 2017 American College of Cardiology/American Heart Association and the 2018 European Society of Cardiology/European Society of Hypertension Guidelines on the Asian Population: Is it Time for Our Own Asian Hypertension Guidelines? Hypertens 2019;5(2):53-57.

Source of support: Nil,

Conflict of interest: None

Received: 30-04-2019;

Accepted: 09-05-2019

Obtaining a target goal blood pressure (BP) is crucial in the management of hypertension so as to prevent cardiovascular disease, kidney failure, and stroke. Home BP monitoring is one method to achieve target pressure and has the potential to improve the outcomes of hypertensive patients. Several advantages have been identified with the use of home monitoring, particularly in properly diagnosing white coat and masked hypertension. Studies have shown that home monitoring significantly reduce BPs, may improve compliance and lessen therapeutic inertia. It has a significant correlation with cardiovascular risk factors and appropriate control may reduce mortality. The downside in the use of home monitoring is the cost of validated automatic machines, which may be expensive for Filipino patients. Despite that limitation, home monitoring of BP may be incorporated into the care for Filipino patients with hypertension.

Key words: Ambulatory blood pressure monitoring, home blood pressure monitoring, hypertension, office blood pressure monitoring

How to cite this article: Oliva RV. Advocating Home Blood Pressure Monitoring in Improving Hypertension Control in the Philippines. Hypertens 2019;5(2):58-60.

Source of support: Nil,

Conflict of interest: None

Received: 02-05-2019;

Accepted: 16-05-2019

The effects of excessive dietary salt on blood pressure (BP) vary in certain individuals, with some developing a hypertensive response to salt loading (salt-sensitive individuals), while some do not experience any increase in BP (salt-resistant individuals). There are mechanisms that enable an individual to adapt to a high-salt load, and hypertension develops only when the kidney’s ability to excrete excess salt is impaired. At present, there are no clinically practical tests available to determine salt sensitivity, and more research is needed so that in the future, a drug specifically working on salt sensitivity will be developed. The effects of high salt diet on gut bacteria and its relationship with diet and disease is an exciting new area of research. Nonpharmacologic and lifestyle modifications, delving on weight loss, exercise (that promotes physical fitness), diet (especially Dietary Approaches to Stop Hypertension diet), and other nutrients (such as potassium and flavonoids) should be emphasized to both hypertensive as well as non-hypertensive patients. The next generation should be taught to not only limit their salt intake but also they should learn to eat healthy to prevent chronic diseases later in life. Clinicians should, therefore, play a more active role in promoting lifestyle changes, most especially dietary salt restriction, and empower patients to take charge of their health, keeping in mind that the strongest benefit can be attained by doing lifestyle interventions in its totality.

Key words: Gut microbiome in salt-sensitive hypertension, non-pharmacologic and lifestyle interventions, salt in hypertension, salt sensitivity, therapeutic lifestyle changes

How to cite this article: Defensor-Mina MV, Mina ABC, Morales DD. Revisiting Salt Sensitivity and the Therapeutic Benefits of Salt Restriction in Hypertension. Hypertens 2019;5(2):61-64.

Source of support: Nil,

Conflict of interest: None

Received: 02-05-2019;

Accepted: 13-05-2019

Background: The same problems of access to health care due to inadequate and inequitable distribution of human resources for health continue to be present in countries worldwide, including the Philippines. However, these conditions have not stimulated the development of the role on advanced practice nursing (APN) in the country, despite hypertension (HTN) being a prevalent public health problem that can be addressed at the primary care level. Nurses, being the most numerous health professionals, can be trained to fulfill this deficiency.

Objective: This study aimed to determine the validity and effectiveness of the investigatordesigned HTN training program for advanced practice nurses.

Methods and Design: This was one group, pre-test-post-test design, involving nursing clinics for wellness in a government-subsidized university, located in Manila, the Philippines. Out of the 28 masters-prepared nurses who consented, 24 participants completed the training program and answered the post-training instruments; the majority were females, with a mean age of 32.42 years (standard deviations [SD] = 8.397) and mean the clinical experience of 5.84 years (SD = 3.503). A panel of six experts reviewed and validated the seven modules for the HTN training program. It consisted of lectures, demonstration sessions, small group discussions, oral examination, skill performance evaluation, and clinic visit with a demonstration, totaling 32 h of in-person training. Participants took the written examinations before and after the training program.

Results: The expert panel determined that the module content covered the learning objectives adequately. After the training program, the total knowledge score of the participants increased from 33.00 points (SD = 5.25) to 43.08 points (SD = 43.08), which was statistically significant (t = -11.245, P < 0.001). Furthermore, self-efficacy scores increased significantly (t = -6.187, P < 0.001), from 8.08 points (SD = 1.16) to 9.06 (SD = 0.69).

Conclusions: The validated HTN training program module effectively equipped the masters-prepared nurses with the required knowledge, skills, and attitudes in providing entry-level APN care for patients with primary HTN, addressing the competencies outlined by the National Organization of Nurse Practitioner Faculty in the United States. Since the positive outcomes on the nurse participants translated to the patient outcomes seen in the advanced practice nurse-led HTN Clinic done after this study, the competencies included in the training program modules should be integrated into the country’s master’s degree curriculum in Adult Health Nursing to provide adequate preparation for entry-level APN care.

Keywords: Adult Health Nursing, advanced practice nursing, hypertension in the Philippines, nursing education research

How to cite this article: Duller SF, Tating DLRP, Tejero LMS. The Effectiveness of a Training Program for Advanced Practice Nurses in the Philippines on the Care of Patients with Primary Hypertension. Hypertens 2019;5(2): 65-70.

Source of support: This research received partial funding from the University of the Philippines National Graduate Office for the Health Sciences Graduate Assistance Program and the Philippine Nurses Association, Inc. These sponsors had no involvement in study design, data collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the article for publication,

Conflict of interest: None

Received: 01-05-2019;

Accepted: 17-05-2019

Background: Beta-blockers have long been used as the treatment for hypertension (HTN) with comorbidities such as heart failure (HF), angina, and myocardial infarction. Numerous clinical trials showed the effects of beta-blockers to prolong life and to relieve symptoms. In particular, four particular beta-blockers - namely metoprolol, carvedilol, bisoprolol, and nebivolol, have been shown to have salutary effects in HF patients.

Objectives: We evaluated the effects of these four beta-blockers in patients with HTN and HF with reduced ejection fraction (HFrEF).

Methods: We carried out a systematic literature search in PubMed and Cochrane for randomized controlled trials on the use of beta-blockers in HTN and HFrEF in reducing hospitalization, morbidity, and mortality.

Conclusion: The beneficial effects of metoprolol, carvedilol, bisoprolol, and nebivolol primarily stem from their attenuation of sympathetic nervous system (SNS) activity that prevents further cardiac structural changes and dysfunction, as seen in relation to uncontrolled HTN. However, other effects such as antioxidant and anti-endothelin effects possessed by carvedilol and the enhanced secretion of nitric oxide with nebivolol are also being attributed to having protective and beneficial outcomes on HF patients.

Keywords: Adrenergic beta-blockers, beta-antagonists, beta-blockers, bisoprolol, carvedilol, congestive heart failure, hypertension, metoprolol, nebivolol

How to cite this article: Go JG, Santiago LD, Miranda AC, Jara RD. Effect of Beta-blockers on Hypertension and Heart Failure with Reduced Ejection Fraction: A Systematic Review of Randomized Controlled Trials. Hypertens 2019;5(2): 71-76.

Source of support: Nil,

Conflict of interest: None

Received: 05-05-2019;

Accepted: 15-05-2019

The blood pressure (BP) targets for patients with chronic kidney disease (CKD) to decrease the risk of cardiovascular outcomes and progression of renal disease remain unclear. In 2012, the Kidney Disease: Improving Global Outcomes (KDIGO) published a clinical practice guideline on the management of BP in CKD patients not on renal replacement therapy, for both diabetic and non-diabetic population. KDIGO recommended the target BP of <140/90 mmHg for CKD patients without albuminuria and <130/80 mmHg for those with albuminuria. Since then, new data arising from recent clinical trials such as the 2015 Systolic BP Intervention Trial have added to the evidence base. As well as, the current recommendations from the American College of Cardiology/American Heart Association Clinical Practice Guideline in 2017 have made us reevaluate our BP targets and hypertension management in the CKD population.

Key words: Albuminuria, blood pressure, chronic kidney disease, dialysis, hypertension, renal replacement therapy

How to cite this article: Villanueva ART, Flores-Riva CE, Valdez JR. Treatment of Hypertension in The Different Various Stages of Chronic Kidney Disease. Hypertens 2019;5(2):77-81.

Source of support: Nil,

Conflict of interest: None

Received: 04-05-2019;

Accepted: 12-05-2019

Stroke is still a highly prevalent complication of hypertension and cause of death in the Philippines and in the rest of Southeast Asia. Management of acute elevation of the blood pressure (BP) can be a challenge which can impact both short- and longterm outcomes. The dilemma of allowing or not some degree of “permissive hypertension” in an acute stroke is a question every clinician is confronted with. This paper aims to summarize the recent guidelines on BP management in the setting of acute stroke based on the recommendations of three international guidelines, namely the American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology/European Society of Hypertension (ESC/ESH), and the Canadian Stroke Best Practices. It also reviews the major randomized controlled trials and other publications evaluating the management of BP elevation in an acute stroke setting. The updated guidelines in the ACC/AHA, ESC/ESH, and Canadian best practice have no significant difference in their recommended BP threshold for intervention. In general, BP lowering is not recommended unless BP is ≥220/110 mmHg. However, in patients who are eligible for intravenous (IV) thrombolysis and have very high systolic BP (SBP) ≥185 mmHg or diastolic BP ≥110 mmHg, cautious BP lowering should be done before IV thrombolysis and should be maintained during the treatment duration. In the acute BP management of intracerebral hemorrhage (ICH) earlier guidelines favored lowering of BP to <140 mmHg, SBP based on a large randomized controlled trial — the Intensive BP reduction in acute cerebral hemorrhage (ATACH) trial 2. On the other hand, outcomes of the antihypertensive treatment in ATACH-2 trial showed a significantly higher rates of neurological deterioration within 24 h in those with reduced and renal events and pneumonia was higher in the group where intensive BP management was instituted. In general, clinical practice guidelines advocate that in those with acute ICH and SBP between 150 and 220mmHg, reducing SBP to <140 mmHg within 6 h is not beneficial in terms of death and functional outcome and can be potentially harmful. In acute ICH and SBP >220 mmHg, it is reasonable to lower BP with IV therapy to around 180 mmHg.

Key words: Hypertension management in acute stroke, permissive hypertension, spontaneous intracerebral hemorrhage

How to cite this article: Diaz ABF, Evangelista JR, Chua C, Aquino A, Castillo RR. Management of Hypertension in the Setting of Acute Stroke: A Literature Review. Hypertens 2019;5(2): 82-86.

Source of support: Nil,

Conflicts of interest: None

Received: 29-04-2019;

Accepted: 15-05-2019

Primary hyperaldosteronism (PA) or Conn’s syndrome and pheochromocytoma (Pheo) are functioning tumors of the adrenal glands that can cause secondary hypertension. Bilateral adrenal hyperplasia and aldosterone-producing adrenal tumor are the most common causes of PA. Due to the high circulating aldosterone, hypokalemia results which cause weakness, tingling sensation, muscle spasms, and periods of temporary paralysis. Pheo is a rare adrenomedullary tumor that can synthesize, metabolize, store, and secrete catecholamines and their metabolites. A high index of clinical suspicion remains the pivotal point to initiate biochemical studies for Pheo, particularly in those patients with a certain pattern of blood pressure elevation (paroxysmal or alternating with hypotension), drug-resistant hypertension, sudden palpitations (in some patients accompanied by pallor), unexplained sweating, especially during night or in cold weather, and unexplained hyperglycemia. Only after PA and Pheo are biochemically established should imaging be performed. The current imaging modalities include anatomical (computed tomography [CT] and magnetic resonance imaging [MRI]) and functional (molecular) imaging procedures using various radiopharmaceuticals depending on the clinical situation. For equivocal imaging results in PA, bilateral adrenal venous sampling is the “gold standard” to distinguish unilateral from bilateral lesions. Prompt diagnosis is important because delay in the diagnosis and treatment can lead to untoward cardiovascular complications including myocardial infarction, strokes, and fatal arrhythmias. Clinicians must be trained to have the “clinical eye” and awareness of early detection and management of these two curable causes of secondary hypertension.

Key words: Conn’s syndrome, pheochromocytoma, primary aldosteronism, resistant hypertension, secondary hypertension

How to cite this article:Mercado-Asis LB, Castillo RR. Clinical Presentation, Diagnosis, and Management of Primary Aldosteronism and Pheochromocytoma. Hypertens 2019;5(2): 87-91.

Source of support: Nil,

Conflict of interest: None

Received: 29-04-2019;

Accepted: 14-04-2019