What are the Philippine guidelines for diagnosing and managing hypertension?

Philippine Guidelines on Hypertension Diagnosis and Management

The Philippine Society of Hypertension defines hypertension as an office blood pressure (BP) of 140/90 mmHg or above following proper standard BP measurement techniques. 1

Diagnostic Criteria and Blood Pressure Measurement

Office BP Measurement Protocol

• Measurements should be taken in a quiet room with comfortable temperature 2
• Patient preparation includes:
  • Avoiding smoking, caffeine, and exercise for 30 minutes before measurement 2
  • Emptying the bladder 2
  • Sitting relaxed for 3-5 minutes before measurement 2
  • No talking by patient or staff before, during, or between measurements 2

Proper Positioning

• Patient should be seated with:
  • Arm resting on table with mid-arm at heart level 2
  • Back supported on chair 2
  • Legs uncrossed and feet flat on floor 2

Equipment and Technique

• Use validated electronic (oscillometric) upper-arm cuff device 2
• Alternatively, use calibrated auscultatory device with 1st Korotkoff sound for systolic and 5th for diastolic BP 2
• Select appropriate cuff size according to the individual's arm circumference 2
• For manual devices, the inflatable bladder should cover 75-100% of arm circumference 2

Measurement Protocol

• Take 3 measurements with 1 minute between them 2
• Calculate the average of the last 2 measurements 2
• If first reading is <130/85 mmHg, no further measurement is required 2
• Initial evaluation: Measure BP in both arms; if consistent difference >10 mmHg, use arm with higher BP 2
• Standing BP should be measured in treated hypertensives after 1 and 3 minutes when postural symptoms exist and in elderly and diabetic patients 2

Confirming Hypertension Diagnosis

• Diagnosis should not be made on a single office visit 2
• Usually 2-3 office visits at 1-4 week intervals are required to confirm hypertension 2
• Diagnosis can be made on a single visit if BP ≥180/110 mmHg and there is evidence of cardiovascular disease 2
• Out-of-office BP measurement (home or ambulatory) is preferred for confirmation 2

BP Thresholds for Action

• For screening office BP 140-159/90-99 mmHg: Confirm with out-of-office BP measurement; if not available, use repeated office measurements on more than one visit 2
• For screening BP 160-179/100-109 mmHg: Confirm as soon as possible (within 1 month) preferably with home or ambulatory BP 2
• For BP ≥180/110 mmHg: Exclude hypertensive emergency 2

Essential Diagnostic Workup

Laboratory Investigations

• Blood tests: Sodium, potassium, serum creatinine, estimated glomerular filtration rate (eGFR) 2
• If available: Lipid profile and fasting glucose 2
• Urinalysis: Dipstick urine test 2
• 12-lead ECG to detect atrial fibrillation, left ventricular hypertrophy, and ischemic heart disease 2

Assessment of Cardiovascular Risk

• Evaluate additional risk factors as part of diagnostic workup 2
• Common additional risk factors include:
  • Diabetes (15-20%) 2
  • Lipid disorders (30%) 2
  • Overweight-obesity (40%) 2
  • Hyperuricemia (25%) 2
  • Metabolic syndrome (40%) 2
  • Unhealthy lifestyle habits (smoking, high alcohol intake, sedentary lifestyle) 2

Additional Diagnostic Tests When Indicated

Imaging Techniques

• Echocardiography for LVH, systolic/diastolic dysfunction, atrial dilation 2
• Carotid ultrasound for plaques and stenosis 2
• Kidney/renal artery imaging when indicated 2
• Fundoscopy for retinal changes, especially with BP >180/110 mmHg or in diabetic patients 2

Additional Laboratory Tests

• Urinary albumin/creatinine ratio 2
• Serum uric acid levels 2
• Liver function tests 2
• Further testing for secondary hypertension if suspected 2

Management Recommendations

Lifestyle Modifications

• Sodium restriction to as low as 1500 mg/day 2
• DASH meal plan low in sodium and high in dietary potassium (for patients without renal insufficiency) 2
• Moderate-intensity aerobic exercise of ≥150 min/week 2
• Resistance training 2-3 times/week 2
• Aim for healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 2
• Limit alcohol consumption to less than 100g/week of pure alcohol 2
• Restrict free sugar consumption, especially sugar-sweetened beverages 2
• Smoking cessation 2

Screening Recommendations

• Opportunistic screening for hypertension should be considered at least every 3 years for adults aged <40 years 2
• Annual screening for adults aged ≥40 years 2
• For individuals with elevated BP not meeting treatment thresholds, repeat BP measurement and risk assessment within 1 year 2

Current Status of Hypertension in the Philippines

• Prevalence has increased from 22% in 1993 to 25.15% in 2013 1
• Almost half of hypertensive Filipinos are unaware of their condition 1
• Only 27% have their hypertension under control 1
• Among older Filipinos (≥60 years), 69.1% have hypertension, but only 61.6% are aware of their condition 3
• Most common complications include stroke (11.6%), ischemic heart disease (7.7%), chronic kidney disease (6.3%), and hypertensive retinopathy (2.3%) 1

Common Pitfalls in Hypertension Management

• Monotherapy has been the predominant treatment approach for >80% of Filipino patients, which may contribute to low BP control rates 1
• Failure to screen for secondary causes of hypertension in appropriate patients 2
• Inadequate assessment of target organ damage 2
• Poor adherence to medication and lifestyle modifications 4
• Missed opportunities for hypertension screening during healthcare visits 5