CLINICAL UPDATE

Clinical Pathways for the Management of

Hypertension in Family and Community Practice

Noel L. Espallardo, MD, MSc, FPAFP; Limuel Anthony B. Abrogena, MD, FPAFP; Marishiel Mejia-Samonte, MD, DFM
Anna Guia O. Limpoco, MD, FPAFP and Ryan Jeanne V. Ceralvo, MD, FPAFP

Background: Hypertension is a major risk factor for cardiovascular disease. The prevalence of hypertension in the Western
Pacific Region is 37% of adults older than 24, while in the Philippines it is 25% of adults 21 years old and above. Several
guidelines have been developed for the management of hypertension. All these guidelines have recommendations for
assessment and treatment.
Objectives: The overall objective of the development and implementation of this clinical pathway is to improve outcomes
of patients with hypertension seen in family and community practice.
Methods: The PAFP Clinical Pathways Group reviewed published medical literature to identify, summarize, and operationalize
the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical
pathway in family medicine practice. The group developed a time-related representation of recommendations on patient
care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic
interventions as well as social and community strategies to treat hypertension and prevent complications.
Recommendations: Recommendations were made based on the number of visits. During the first visit, all adult patients
consulting at the clinic should be screened for hypertension with appropriate BP measurement. A thorough history
focusing on symptoms, family history using genogram, smoking and other lifestyle and co-existing chronic disease and
a thorough physical examination focusing on the weight/BMI, waist/hip ratio, funduscopy, neurological, cardiac, renal
and peripheral arteries should be done. For the laboratory, request for 12-lead ECG, urinalysis, FBS, creatinine, serum K
and lipid profile to determine co-morbidities and baseline values. If the patient is already diagnosed hypertensive, start/
continue medications with either or a combination of thiazide-type diuretic, calcium channel blockers, angiotensin-
converting enzyme inhibitors and angiotensin receptor blocker depending on co-morbidities or side effects. But if there
is a need for further confirmation, no medication is warranted. Educate the patient about hypertension, risk factors and
complications. If medications were prescribed, explain the dose, frequency, intended effect, possible side effects and
importance of medication adherence. Lifestyle modifications focusing on weight control, exercise and smoking cessation
should be adviced. During the first visit it is expected that the patient is aware of the diagnosis of hypertension, its risks
factors and complications to encourage compliance.
Implementation: Education, training and audit are recommended strategies to implement the clinical pathway.

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 Introduction The overall objective of the development and
implementation of this clinical pathway is to improve
Hypertension is a condition of persistently high outcomes of patients with hypertension seen in family
systemic arterial blood pressure. It is currently defined as and community practice. This is expected to be achieved
a systolic pressure consistently greater than 140 mm Hg by: 1) Improving the quality of care for patients with
or diastolic pressure is consistently 90 mm Hg or more in hypertension in individual clinic of family and community
multiple readings.1 Blood pressure measurement should be medicine practitioners, 2) Standardizing the quality of
taken on two separate occasion at least one week apart. care among the members of the Philippine Academy of
Hypertension is a major risk factor for cardiovascular Family Physicians, Inc., 3) Implementing organizational and
disease. Worldwide, it is estimated that almost half of deaths health system strategies to promote the use of this clinical
due to stroke and heart disease are cause by hypertension. pathway.
Adequate management of hypertension may lead to a
significant decrease in stroke and myocardial infarction. The Methods of Development and Implementation
prevalence of hypertension in the Western Pacific Region is
37% of adults older than 24, while in the Philippines it is 25% The PAFP Clinical Pathways Group reviewed published
of adults 21 years old and above.2 This is approximately 10 medical literature to identify, summarize, and operationalize
million adults in 2008 and the incidence is increasing.3 the clinical content of diagnostics, interventions and clinical
In 2010, hypertension is the leading single risk indicators or outcomes to develop an evidence-based clinical
factor for global burden of disease.4 The annual mortality pathway in family medicine practice. The group developed a
per 100,000 people from hypertensive heart disease in time-related representation of recommendations on patient
Philippines has increased by an average of 3.9% a year since care processes, in terms of history and physical examination,
1990. In 2013 there were 696 deaths per 100,000 among laboratory tests, pharmacologic and non-pharmacologic
men 690 deaths per 100,000 among women. The mortality interventions as well as social and community strategies to
rate is highest at age 80 and above in both sexes.5 The cost treat hypertension and prevent complications.
of treatment is usually attributed to antihypertensive drugs The group adopted several strategies in developing
(42.7%), followed by hospital admission (28.4%), clinic the recommendations. The first strategy is emphasizing
visits (15.1%) and laboratory tests (10.6%).6 on evidence-based recommendations as recommended
Several guidelines have been developed for the assessments and interventions. The second strategy is
management of hypertension. All these guidelines have recognition of potential variations between-patient and
recommendations for assessment and treatment. Aside between specific practice settings. The third strategy is
from pharmacologic treatment, they also recommended the recognition of “stakeholder groups” outside of family
lifestyle interventions like smoking cessation, reduction and community practice with careful attention to getting
of sodium and fat intake, aerobic exercise, maintenance of their opinion and support but without sacrificing the
ideal body mass index and moderation of alcohol intake. For objectives of the project. The fourth strategy is emphasis
patients with co-morbidity like diabetes and dyslipidemia, on the commitment to establishment of the ultimate goal
pharmacologic treatment to control blood sugar and of improving the effectiveness, efficiency and quality of
cholesterol is adviced.7 These guideline recommendations patient care in family and community practice.
are published in several medical journals from Canada, USA, The evidences for the patient care processes were
Europe and UK. This clinical pathway for hypertension is an reviewed and summarized as notes on the recommendations.
attempt to implement these recommendations in family The clinical pathway was then disseminated to the selected
and community medicine practice in the Philippines. PAFP chapters and members and other stakeholders for

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consensus development. Dissemination was publication Panel Grade Levels
in the Filipino Family Physician journal, conference
presentations and focused group discussions. A - All the panel members agree that the recommendation
The implementation of clinical pathways to be should be adopted because it is relevant, applicable
adopted by the PAFP will be quality improvement and will benefit many patients.
activities in a form of patient record reviews, audit and
feedback. Audit standards will be the assessment and B - Majority of the panel members agree that the
intervention recommendations in the clinical pathway. recommendation should be adopted because it is
Implementation of clinical pathways will be at the relevant, applicable in many areas and will benefit
practice and organizational levels. Practice level can many patients.
be a simple count of family and community medicine
practitioners using and applying the clinical pathways. C - Panel members were divided that the recommendation
Organizational outcomes can be activities of the PAFP should be adopted and is not sure if it will be applicable
devoted to the promotion, development, dissemination in many areas or will benefit many patients.
and implementation of clinical pathways.
Evidence Grade Levels
Grading of the Recommendations
I - The best evidence cited to support the recommendation
The PAFP QA Committee met as a panel and graded is a well-conducted randomized controlled trial. The
the recommendations as shown in Table 1. The grading CONSORT standard may be used to evaluate a well-
system was a mix of the strength of the reviewed published conducted randomized controlled trial.
evidence and the consensus of a panel of experts. In some
cases, the published evidence may not be applicable if II - The best evidence cited to support the recommendation
Philippine family practice setting, so a panel grade based on is a well-conducted observational study i.e. match
the consensus of clinical experts was also used. Thus if the control or before and after clinical trial, cohort studies,
recommendation was based on a published evidence that case control studies and cross-sectional studies. The
is a well done randomized controlled trial and the panel STROBE statement may be used to evaluate a well-
of expert voted unanimously for the recommendation, it conducted observational study.
was given a grade of A-I. If the level of evidence is based
on an observational study but the panel still unanimously III - The best evidence cited to support the recommendation
considered the recommendation, the grade given was A-II is based on expert opinion or observational study that
and if the level of evidence is just an opinion but the panel did not meet the criteria for level 2.
still unanimously recommended it, the grade was A-III.

Table 1. Grading of the recommendations. In the implementation of the clinical pathways, the
PAFP QA committee strongly recommend compliance
Panel Grade Level Evidence Grade Level to guideline recommendations that are graded as
1 2 3
either A-I, A-II or B-I. However, the committee also
A A-I A-II A-III recommend using sound clinical judgment and patient
B B-I B-II B-III involvement in the decision making before applying the
C C-I C-II C-III recommendations.

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Pathway Recommendations
Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

First Visit __All adult patients consulting Diagnosed Diagnosed Patient interventions __Aware of initial
at the clinic should be screened hypertension hypertension __Educate the patient about diagnosis (A-III)
for high blood pressure with __Request for 12- __Start/continue hypertension, risk factors and __Aware of risk factors
appropriate BP measurement (A-III) lead ECG, urinalysis, medications with complications (A-I) and complications
__Make a thorough history FBS, creatinine, either or a combination __If medications were prescribed, (A-III)
focusing on symptoms, family serum K and lipid of thiazide-type explain the dose, frequency, __Aware of
history using genogram, smoking profile to determine diuretic, calcium intended effect, possible side effects importance of
and other lifestyle and co-existing co-morbidities and channel blockers, and importance of medication adherence to
chronic disease (A-II) baseline values (B-II) angiotensin-converting adherence (A-I) diagnostics and
__Make thorough physical enzyme inhibitors and __Lifestyle modifications focusing interventions (A-III)
examination focusing on the Pathway decisions angiotensin receptor on weight control, exercise and
weight/BMI, waist/hip ratio, __ For patients with blocker depending on smoking cessation (A-I)
funduscopy, neurological, cardiac, previously diagnosed co-morbidities or side
renal and peripheral arteries (A-II) co-morbidities, refer effects (A-I) Family interventions
to specific pathway __Inquire and recommend family
Pathway decisions for management of Need to confirm members’ lifestyle activities (A-I)
__If BP is ≥ 140/90 mmHg with co-morbidity (A-III) hypertension
signs and symptoms of acute end- __No medications are Community interventions
organ damage, consider referral to warranted (A-III) __Inquire for community lifestyle
hospital (A-III) activities (A-III)
__If the initial BP is ≥ 180/110 Patients for
mmHg consider hypertension and emergency referral Continuing care
start medication. (A-III) __Consider giving a __Follow-up after 1-2 weeks (A-II)
__IF BP is ≥ 140/90 mmHg single dose of anti- __Offer family wellness package
and with previous history of hypertensive prior to (A-III)
high BP taken by another health transport (A-I)
professional within the month
consider hypertension and start
medication. (A-III)
__If BP is ≥ 140/90 mmHg and first
time high BP confirm with home
BP measurements or second visit
within 4 weeks (A-III)

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146 THE FILIPINO FAMILY PHYSICIAN

 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Second __Review and note any change Diagnosed Diagnosed Patient interventions __Improved BP control
Visit in history focusing on symptoms, hypertension hypertension __Enhance education about (Age 18 to 59: <140/90
family history using the genogram, __Complete request __Start/continue hypertension, risk factors and mmHg;
smoking and other lifestyle and co- for 12-lead ECG, medications with complications (A-I) Age > 60: <150/90
existing chronic disease (A-II) urinalysis, FBS, either or a combination __If medications were prescribed, mmHg) (A-II)
__Repeat and note any change in creatinine, serum of thiazide-type repeat explanation about the dose, __ Body mass index
physical examination focusing on K and lipid profile diuretic, calcium frequency, intended effect, possible between 18.5-24.9 kg/
the weight/BMI, waist/hip ratio, to determine channel blockers, side effects and importance of m2 (A-II)
funduscopy, neurological, cardiac, co-morbidities and angiotensin-converting medication adherence (A-I) __Modification of
renal and peripheral arteries (A-II) baseline values (B-II) enzyme inhibitors and __Enhance advice on lifestyle risk factors i.e. diet,
__Review BP monitoring if angiotensin receptor modifications focusing on weight lifestyle, smoking and
available (A-II) blocker depending on control, exercise and smoking exercise (A-II)
__Review laboratory results and Pathway decisions co-morbidities or side cessation (A-I) __Absence of new
establish the presence of other risk __ For patients with effects (A-I) complications (A-III)
factors and co-morbidities (A-II) previously diagnosed Family interventions __Adherence to
co-morbidities, refer With co-morbidities __Enhance recommendation diagnostics and
to specific pathway __Refer to clinical for family members’ appropriate interventions (A-II)
Pathway decisions for management of pathway of the co- lifestyle activities (A-I) __Agreed plan for
__If home BP and/or second visit co-morbidity (A-III) morbidity (A-III) family intervention
BP are ≥ 140/90 mmHg diagnose as Community interventions (A-III)
hypertension (A-II) __Recommend participation in __Agreed plan
__If home BP and/or second visit appropriate community lifestyle for community
BP are < 140/90 mmHg rule out activities (A-III) involvement (A-III)
hypertension but monitor after 6-12
months (A-III) Continuing care
__Follow-up after 1 month until
BP target is achieved and every
3-6 months if BP target is already
achieved (A-III)

Variations

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 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Continuing __Review and note any change Diagnosed Diagnosed Patient interventions __Improved BP control
Visit in history focusing on symptoms, hypertension hypertension __Enhance education about (Age 18 to 59: <140/90
family history using genogram, __After 6-12 months __Continue/revise hypertension, risk factors and mmHg;
smoking and other lifestyle and co- repeat for 12-lead medications with complications (A-I) Age > 60: <150/90
existing chronic disease (A-II) ECG, urinalysis, FBS, either or a combination __If medications were prescribed, mmHg) (A-II)
__Repeat and note any change in creatinine, serum K and of thiazide-type repeat explanation about the dose, __ Body mass index
physical examination focusing on lipid profile (B-II) diuretic, calcium frequency, intended effect, possible between 18.5-24.9 kg/
the weight/BMI, waist/hip ratio, channel blockers, side effects and importance of m2 (A-II)
funduscopy, neurological, cardiac, angiotensin-converting medication adherence (A-I) __Modification of
renal and peripheral arteries (A-II) Pathway decisions enzyme inhibitors and __Enhance advice on lifestyle risk factors i.e. diet,
__Review laboratory results and __ For patients with angiotensin receptor modifications focusing on weight lifestyle, smoking and
establish the presence of other risk previously diagnosed blocker depending on control, exercise and smoking exercise (A-II)
factors and co-morbidities (A-II) co-morbidities, refer co-morbidities or side cessation (A-I) __Absence of new
to specific pathway effects (A-I) complications (A-III)
Pathway decisions for management of Family interventions __Adherence to
__Enhance/revise pharmacologic co-morbidity (A-III) With co-morbidities __Enhance recommendation diagnostics and
and non-pharmacologic __Refer to clinical for family members’ appropriate interventions (A-II)
interventions until BP control is pathway of the co- lifestyle activities (A-I) __Agreed plan for
achieved (Age 18 to 59: <140/90 morbidity (A-III) family intervention
mmHg; Community interventions (A-III)
Age > 60: <150/90 mmHg) (A-III) __Recommend participation in __Agreed plan
appropriate community lifestyle for community
activities (A-III) involvement (A-III)

Continuing care
__Follow-up after 1 month until
BP target is achieved then every
3-6 months if BP target is already
achieved (A-III)

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148 THE FILIPINO FAMILY PHYSICIAN

Notes on the Recommendations the blood pressure of every patient at every clinic visit. The
Canadian Hypertension Education Program recommended
The subsequent sections discuss the clinical evidences measurement only during appropriate visits that include
to support the recommendations in this clinical pathway. periodic health examinations, urgent office visits for
The recommendations are packages of health care neurologic or cardiovascular-related issues, medication
interventions designed to improve clinical outcomes renewal visits, and other visits where the primary care
of patients with hypertension. This is supposed to be practitioner deems it an appropriate opportunity to monitor
implemented by family and community doctors in their blood pressure.9
outpatient clinics. The recommendations cover history and History and physical examination should be done to
physical examination, laboratory, pharmacologic and non- all patients suspected or diagnosed with hypertension.
pharmacologic intervention. Pharmacologic interventions History should include checking for family history using the
include prescription of anti-hypertensive drugs. Non- genogram. Family history of hypertension, cardiovascular
pharmacologic interventions include health education, and cerebrovascular disease and diabetes should be actively
lifestyle modification, and family and community elicited. The physical examination should focus not only on
intervention. The interventions are designed to achieve the blood pressure measurement but also with the body
patient outcomes that include blood pressure control, mass index. Organ system that may be damaged by high
control of risk factors, prevention of complications and blood pressure should be examined like the central nervous
improved quality of life. system, retina, heart, kidneys and peripheral arteries. All
The current evidences on hypertension treatment look these findings should be clearly written in the patient’s
at the effectiveness of individual intervention. Currently, clinical record.
a package of interventions including: 1) healthy lifestyle
counseling (smoking cessation, and salt, oil, and alcohol Checkbox for History
reduction); 2) prescription of a combination of drugs
(antihypertensives, aspirin, and statin); and 3) adherence • What is your highest/lowest blood pressure in the past? What is
support for drug compliance and healthy lifestyle change is your usual blood pressure?
• When did it start? When did it happen? When were you
now being tested in a cluster randomized controlled trial. The diagnosed as hypertensive?
primary outcome is the incidence of severe cardiovascular • Obtain following information: extent of end-organ damage
events over 24 months of follow-up. This trial will show the (eg, heart, brain, kidneys, eyes), assessment of patients’
effectiveness of the comprehensive cardiovascular event cardiovascular risk status and exclusion of secondary causes of
hypertension
reduction package for hypertensive patients in routine • What happened during that time? What were the triggering/
practice. This will also identify the barriers and facilitators contributory factors? What were you doing that time?
to implementation and get informed advise on policy and • What symptoms did you experience? Headache, dizziness,
practice change.8 blindness/blurring of vision, chest pain/discomfort, difficulty
of breathing/shortness of breath, epigastric pain, difficulty
in urination, hematuria, edema (face, upper and lower
First Visit extremities), leg/foot pain?
• Aside from hypertension what other diseases/illnesses does
the patient have?
History and Physical Examination
• Past Medical History: If the patient is a male, ask if he took
any pill/powder form for protein building? If the patient is a
It is recommended that a blood pressure measurement female, did she take any oral contraceptive pill? Intake of other
should be done to all patients consulting in a family or maintenance drugs/vitamins/herbal medicines/supplements
community clinic. It is however not necessary to measure

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 • Family History: hypertension, coronary artery disease,
The history and physical examination must be written
sudden death, cerebrovascular accident, diabetes mellitus, legibly in a clinical record. A random sample of 18 general
hyperthyroidism, cancer. Draw genogram. practice in London showed that 340 (47%) of 716 patients
• Lifestyle: diet: what do you usually eat? What are you fond of? consulting in a 10 year period had no blood pressure
Do you have food preferences? Do you eat fish, vegetables and
fruits? If yes, how many servings do you get per meal? Do you
readings in their records. Of 84 hypertensive patients with
use condiments? Give a sample menu for a day. Are you taking records, 62 (74%) had no physical examination performed
any supplements? Any weight gain/loss? Exercise/any form of by the physician. Absence of data from the records may
physical activity? Sports? How often? suggest deficiencies in the management of hypertension in
• Substance use/abuse: smoking/tobacco alcohol illicit drugs
energy drinks caffeine/coffee. If yes, ask for the amount, how general practice.10 This should be avoided in the Philippine
often? What does he feel after? family and community medicine practice.
• Occupation: time of work? What are his preparations before Assessment of absolute cardiovascular risk is a rational
going to work? Is he pressured? Do you work overtime? How method of managing hypertension. Determination of the
often? Was there any instance that you were late or absent due
to high blood or any other disease? When was the last time you presence or absence of these factors must be the focus
were on a vacation? of history taking. The CONTROLRISK study was designed
• Last check-up? Last blood chemistry done? What were the to determine how the cardiovascular risk profile of the
results? Increased total cholesterol/LDL and decreased HDL
hypertensive patients were being conducted at primary
care and specialist setting in Spain. In this study, target
organ damage and associated clinical conditions were more
Checkbox for Physical Examination frequently obtained in specialist setting. The most common
• Blood pressure measurement: both arms and if feasible in one
risk factor was age. The most frequently reported target
leg organ damage was left ventricular hypertrophy. Ischemic
• Office reading (clinic): heart disease was the most common associated clinical
• Other vital signs: cardiac rate, respiratory rate, temperature, condition. In this study, physicians tend to underestimate
BMI
• General: conscious, coherent, oriented to time, person and the cardiovascular risk in daily clinical practice.11 A similar
place study in UK also showed that risk was correctly estimated
• Skin: color (cyanosis) in 21% of patients, underestimated in 63% of patients,
• Fundoscopic exam: floaters, arteriovenous nicking, exudates, and overestimated in 16% of patients. It is therefore
hemorrhages, papilledema
• Examine the neck: distended veins, enlarged thyroid gland and recommended that family and community medicine
listen for carotid bruits practitioners use cardiovascular risk charts or tables in the
• Cardiac exam: displacement of apex, sustained and enlarged management of hypertensive patients.12
apical impulse, presence of heaves, thrills, murmurs
Office BP measurement (OBPM) should be performed
• Abdomen: waist circumference, waist to hip ratio,
organomegaly, mass, listen for renal artery bruit using an electronic oscillometric device. Measurement
• Extremity: edema, deformity, palpation of pulses (absent, by aneroid sphygmomanometers has not been found
weak, delayed), mid-upper arm circumference to be accurate. Maintenance of the quality of aneroid
• Neurologic exam: cranial nerves, cerebellar function, motor
and sensory
sphygmomanometers has also been low. A study to check the
• For adults, Beck’s Depression Scale may be used to assess instruments against British Hypertension Society guidelines,
possible psychosocial stressors* only 38.8% of anaeroid instruments were accurate at all test
• For the elderly please do Mini-Mental Status Examination and pressure levels. The defects noted could have an impact on
Geriatric Depression Scale*
diagnosis and monitoring of hypertension.13 If a patient
* These may be done in cases where compliance to medication may has elevated blood pressure reading readings in the office
be affected by these findings. (≥ 140/90), a series of standardized out-of-office blood

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pressure measurements should be performed in order to events in older patients. Similar findings of cardiovascular
rule out white-coat hypertension.14 mortality reduction was also seen in the Swedish STOP-
Hypertension Trial and the British MRC Trial in Older
Laboratory Tests Patients. These studies have in common the use of
diuretics and/or beta blockers. 17
Most studies on hypertension profiling include not In general, the initial antihypertensive treatment
only history and physical examination but also laboratory should include one or a combination of thiazide-
evaluation. In one study, medical examination included type diuretic, calcium channel blocker, angiotensin-
weight, height, blood pressure and laboratory analyses converting enzyme inhibitor, or angiotensin receptor
including fasting blood glucose, serum cholesterol, serum blocker. But angiotensin-converting enzyme inhibitor
triglycerides, electrocardiogram and simple spirometry. 15 and angiotensin receptor blocker cannot be combined. 18
Caution must be raised against over requesting for The choice of drug class will depend on the co-morbid
laboratory tests. In clinics where office chemistry machine condition, cost and patient preference after these have
is available, the test requests increased but the level been explained.
of blood pressure control was the same. 16 Since most After deciding on what drug class to prescribe, the next
outpatient treatment is out-of-pocket, it is better to save is to choose the specific drug. The choice of individual drugs
some money for drugs. depend on efficacy, safety, suitability, and cost. There are
number of options within each class. It may be good for
Pharmacologic Interventions the family and community doctor to narrow their choice
to only 1-2 preferred options for a particular patient based
There is enough evidence that pharmacologic on the above factors. This may be included into a personal
treatment of hypertension prevents stroke, congestive formulary or essential drug list. This will allow the physician
heart failure, and other blood pressure-related to have more experience and become more familiar with the
complications. Even among the elderly, the Systolic expected drug effect, adverse effects, and interactions. A
Hypertension in the Elderly Program (SHEP) also showed new drug also needs to be evaluated before it is added to
a reduction in myocardial infarction and other coronary the personal formulary.19

Table 1. Antihypertensive Drugs for Maintenance

Drugs Dose Indication Adverse Reaction Remarks

ACE Inhibitors (ACEIs)
Captopril* 25 mg tab Heart failure, left Cough, hyperkalemia Contraindicated in pregnancy
25-50 mg per day ventricular (LV) and lactation
BID dysfunction, diabetic,
myocardial infarction
(MI)

Enalapril* 5, 10 and 20 mg tab Headache, dizziness, fatigue,

5-40 mg per day nausea, diarrhea, decreased
BID hgb/hct, cough, hyperkalemia

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 Drugs Dose Indication Adverse Reaction Remarks
Angiotensin II Receptor Antagonists (ARBs)
Candesartan* 8 and 16 mg tab Heart failure and Angioedema, hyperkalemia, Contraindicated in pregnancy
8 – 16 mg per day impaired LV systolic hypoglycemia, acute and lactation
OD function renal failure, hepatic
dysfunction, agranulocytosis,
rhabdomyolysis, interstitial
pneumonia

Irbesartan* 150 and 300 mg tab Diabetics and mild Fatigue, edema, nausea, Contraindicated in moderate
150 – 300 mg per day renal disease vomiting, dizziness, headache to severe renal impairment,
OD pregnancy and lactation

Losartan*+ 50 and 100 mg tab LVH and for renal Diarrhea, abdominal Contraindicated in pregnancy
50 – 100 mg per day protection in Type 2 pain, nausea, headache, and co-administration with
OD diabetic patients dizziness, hyperkalemia, aliskiren in diabetic patients
hypotension, URI symptoms,
angioedema, anemia, liver
function abnormalities,
vomiting, myalgia, arthralgia,
photosensitivity

Olmesartan 10, 20 and 40 mg tab Dizziness Contraindicated in pregnancy

10 – 40 mg per day (2nd & 3rd trimester) and
OD lactation

Telmisartan* 40 and 80 mg tab Prevention of Diarrhea, abdominal pain, Contraindicated in cholestasis,

40 – 80 mg per day cardiovascular nausea, headache, dizziness, biliary tract disorder, severe
OD morbidity and fatigue, light-headedness, hepatic impairment, pregnancy
mortality in patients hypotension, URI symptoms, and lactation
> 55 y/o with high hyperkalemia, intermittent Food decrease bioavailability
CV risk claudication and skin ulcer

Valsartan* 80, 160 and 320 mg tab Heart failure, post-MI, Dizziness, postural dizziness, Contraindicated in pregnancy
80 – 320 mg per day delay of diabetes hypotension, renal failure and
OD for maintenance progression in impairment
BID for HF and MI hypertensives at CV risk
°40 mg per day for and children 6 – 18 y/o
children <35 kg
Cardioselective Beta-blockers (BBs)
Atenolol* 25, 50 and 100 mg Angina, MI or heart Bradycardia, decreased libido Contraindicated in sinus
tablet failure bradycardia, cardiogenic shock,
25 – 100 mg per day acute unstable HF
OD

Metoprolol* 50 and 100 mg tablet Angina, MI or heart Fatigue, weakness, orthostatic Contraindicated in sinus
100 – 400 mg per day failure hypotension, impotence, bradycardia, cardiogenic shock,
BID drowsiness, bradycardia, acute unstable HF
pulmonary edema, CHF

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 Drugs Dose Indication Adverse Reaction Remarks

Propranolol 10 and 40 mg tab Angina, anxiety, Fatigue, weakness, orthostatic Take before meals
160-320 mg per day migraine, post-MI, hypotension, impotence, Contraindicated in patients with
BID arrhythmia drowsiness, bradycardia, history of bronchial asthma
pulmonary edema, CHF or bronchospasm, cardiogenic
shock, tachycardia, 2nd and 3rd
degree block
Calcium Channel Blockers (CCBs)
Nifedipine 5, 30 mg cap Headache, vomiting 5 mg preparation is short-acting
5-30 mg per day 30 mg preparation is extended-
release

Amlodipine*+ 5 and 10 mg tab Peripheral edema, headache, Contraindicated for unstable

5-10 mg per day sleep, urinary, visual and taste angina, uncompensated heart
OD disturbance, abdominal pain, failure, acute MI, pregnancy
nausea, palpitations, flushing

Felodipine* 2.5, 5 and 10 mg tab Peripheral edema, headache, Contraindicated for unstable
2.5 – 10 mg per day flushing, palpitations angina, uncompensated heart
OD failure, acute MI, pregnancy
Combined Alpha & Beta Blocker
Carvedilol* 6.25 and 25 mg tab Angina and mild to Diarrhea, nausea, dizziness, Contraindicated in unstable
6.25 – 50 mg per day moderate heart failure abnormal or blurred vision heart failure, 2nd or 3rd degree
OD - BID AV block, severe bradycardia or
hypotension, history of COPD or
bronchospasm
Thiazide Diuretics
Hydrochlorothiazide 12.5 and 25 mg tab Edema and Dry mouth, thirst, weakness, Contraindicated in renal
12.5 - 100 mg per day nephrogenic diabetes lethargy, muscle pain, cramps, impairment, can cause
OD insipidus hypotension hyperglycemia

Combination drugs
Hydrochlorothiazide- Hydrochlorothizide Dry mouth, thirst, weakness, Contraindicated in renal
losartan (50-100mg)-losartan lethargy, muscle pain, impairment, can cause
(12.5-25mg) cramps, hypotension diarrhea, hyperglycemia, pregnancy
abdominal pain, nausea,
headache, dizziness, URI
symptoms, cough

* Drugs included in PNDF 2008

+ Available at local health centers under the DOH program for noncommunicable diseases

CSAP – Chronic Stable Angina Pectoris

DM – Diabetes Mellitus
HCTZ – Hydrochlorothiazide
HF – Heart Failure
MI – Myocardial Infarction

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Non-pharmacologic Interventions accommodate cultural variations, it is advised that family
and community medicine practitioners should develop a
Knowledge about patient-related determinants of structured non-pharmacologic intervention program. Use
adherence to interventions (pharmacologic and non- of flyers, audio visual presentation at the waiting room and
pharmacologic) is needed to improve the management face-to-face health education may be used.
and outcomes of hypertensive patients. One study The purpose of patient information leaflets is to
tried to measure the association between patient- inform patients about the administration, precautions
related determinants (medication self-efficacy, beliefs and potential side effects of their prescribed medication.
about medication and hypertension, social support, and However, this must be prepared carefully. One study showed
satisfaction with care) and treatment adherence. Medication that current description of potential risk information caused
self-efficacy and fewer concerns about medication use feelings of fear and anxiety to the patients. Flyers need to
were associated with improved pharmacologic and non- convey potential risk information in a language that is less
pharmacologic intervention adherence. Family and frightening while retaining the necessary information.23
community doctors should support medication adherence Dietary fat plays a major role in the development of
by paying attention to patients’ medication self-efficacy, the cardiovascular disease. Modification of fat intake could
concerns they may have about medication use and patients’ have a preventive potential. The guideline of the German
perceptions on hypertension.20 This can be achieved by Nutrition Society recommended to reduce total and
patiently explaining hypertension as a health problem and saturated fat intake. It also recommended increased intake
the risks associated with it. The medication dose, effect, of polyunsaturated fatty acids. A high fat intake increases
potential side effect and cost should also be explained. This the risk of obesity with probable evidence when total energy
will eventually lead to adherence to interventions. intake is not controlled for. When energy intake is controlled
A cross sectional study in family practice clinics showed for, there is probable evidence for no association between
that two-thirds of patients described hypertension based fat intake and risk of obesity.24 There should be a balance
on biomedical definition. Half of them believed that stress between calorie source from fats and carbohydrates.
was a cause of their high blood pressure; two-thirds were There are few randomized controlled trial studies on
aware that stroke and heart attack respectively are possible the effectiveness of dietary intervention for hypertensive
consequences of hypertension. As a result, three-quarters patients in family practice. But family and community
were fully adherent to their medications in the preceding practice is an ideal setting for the provision of lifestyle
month.21 This study showed that appropriate awareness of interventions for patients with hypertension. There is
hypertension and its consequences resulted to an improved currently an ongoing randomized controlled trial that may
adherence to interventions. release its results soon. The trial will test a behaviourally-
Despite the absence of strong evidence, most based, matched prescriptive physical activity and diet
family physicians should still offer non-pharmacological change program. The primary goal is to increase physical
management at the first consultation before prescribing activity and improve dietary intake. The results will provide
medication. However, few offered detailed and structured scientific rationale for the implementation of this lifestyle
interventions. Dietary therapy, restriction of alcohol intervention in primary care.25
consumption and exercise were suggested by most. With regards to advice on exercise, the results of
Restriction of sodium intake and behavioural therapy were a systematic review suggested that physical activity of
less popular non-pharmacological interventions. These moderate intensity involving rhythmic movements with
non-pharmacologic advices were consistent with current the lower limbs for 50-60 minutes, 3 or 4 times per week,
guidelines on the treatment of hypertension.22 In order to reduces blood pressure and appears to be more effective

154 THE FILIPINO FAMILY PHYSICIAN

than vigorous exercise. With this type of exercise, harm is A systematic review of randomized clinical trials was
uncommon and is generally restricted to musculoskeletal conducted to evaluate the acceptability and usefulness
strain. Injury occurs more often with jogging than of computerized patient education interventions. Most
with walking, cycling or swimming. People with mild interventions used instructional programs for educational
hypertension should engage in 50-60 minutes of brisk intervention. Others used information support networks
walking or cycling, 3 or 4 times per week to reduce blood and computer systems for health assessment and history-
pressure. Exercise should be prescribed as an adjunctive taking. Most studies reported positive results for interactive
intervention to pharmacologic therapy for hypertension. educational intervention. Computerized educational
People who do not have hypertension should also participate interventions can lead to improved health status in several
in regular exercise as it reduce the risk of coronary artery major areas of care and serve as a valuable supplement to
disease.26 face-to-face education with physicians.27

Table 2. Patient-directed Non-pharmacologic Interventions.

Goals Recommendations: EDUCATE patients on the following

Health Education Lifetime risk of hypertension

hypertension increases with advancing age
The higher the BP, the greater the chance of heart attack, HF, stroke, and kidney diseases
BP control For those >50 years of age, will reach the DBP goal once the SBP goal is achieved, the primary focus should be on attaining the SBP goal
BP goal In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg
Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications
Goal blood pressure targets should be reached within a month of starting treatment either by increasing the dose of an initial drug or by
using a combination of medications*
BP monitoring Clinicians should provide to patients, verbally and in writing, their specific BP numbers and the BP goal of their treatment
Compliance Emphasize that antihypertensive therapy has been associated with reductions in (1) stroke incidence, (2) myocardial infarction (MI),
and (3) Heart Failure (HF), hence importance of compliance
Target weight Maintain normal body weight (body mass index 18,5-24.9 kg/m2
Weight loss of as little as 10 lbs (4.5 kg) reduces BP and/or prevents hypertension in a large proportion of overweight persons
Diet Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan
Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat
Dietary sodium should be reduced to no more than 100 mmol per day (2.4 g of sodium or 6 g sodium chloride)
Decrease portion sizes for meals and snacks
Decrease frequency and consumption of –containing beverages
Fitness (when able) Engage in regular aerobic physical activity such as brisk walking at least 30 minutes per day most days of the week
or
moderate to vigorous activity 3-4 days a week averaging 40 min per session*
Increase physical activity such as walking, biking, aerobic dancing basketball and other sports
Decrease time in sedentary activities such as watching television, playing videogames or on line
Moderation of alcohol Alcohol intake should be limited to no more than 1 oz (30 mL) of ethanol, the equivalent of two drinks per day in most men and no more
intake and smoking than 0.5 oz of ethanol (one drink) per day in women and lighter weight persons
cessation Patients should be strongly counseled to quit smoking
Others Control blood glucose and lipids*
Follow up most patients should return for follow up and adjustment of medications at monthly intervals or until the BP goal is reached

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 155

Table 3. Family-directed Non-pharmacologic Interventions.

Goals Recommendations

Lifestyle Encourage family meals adhering to DASH eating plan, wherein food served should be
Family Diet HIGH in: Fruits and vegetables (4-5 servings each per day; fiber (7-8 servings per day); low fat dairy products (2-3 servings per day); lean
meat (2 servings per day); calcium; magnesium; potassium
LOW in saturated fat, cholesterol, salt such as unsalted nuts, almonds, peanuts, chocolate, cocoa butter, coconut
Increase intake of polyunsaturated fatty acids such as *Foods and oils including walnuts, sunflower seeds, fish such as salmon, mackerel,
corn oil, soybean oil

Fitness Encourage family members engaging in physical activities

Family members should have physical activity of moderate intensity involving rhythmic movements with the lower limbs for 50-60
minutes, 3 or 4 times per week
Family members with mild hypertension should engage in 50-60 minutes of brisk walking or cycling, 3 or 4 times per week
Family members who do not have hypertension should also participate in regular exercise as it reduce the risk of coronary artery disease.

Table 4. Community-directed Non-pharmacologic Interventions

Goals Recommendations

Lifestyle Inquire if patient and family aware of existing community lifestyle activities
Family Diet

Community Programs Inquire if patient and family aware and willing to participate in existing local health center and programs on hypertension in the
community

Patient Outcomes Second Visit

Awareness by the patient on the diagnosis of

hypertension and its consequences is an important History and Physical Examination and Laboratory Tests
patient outcome during the first visit. A study looked at
the association between patient-related determinants The family doctors should review and complete the
(medication self-efficacy, beliefs about medication and needed information based on the checklist. The needed
hypertension, social support, and satisfaction with care) laboratory and its results should be completed and
and treatment adherence. After follow-up medication reviewed.
self-efficacy and fewer concerns about medication use
were associated with improved medication adherence.
Self-efficacy was also associated with adherence to Pharmacologic Interventions
lifestyle recommendations at baseline.20 Thus an initial and
continuing adequate knowledge about the disease and the Based on the initial response to medications, the
purpose of the interventions lead to better adherence and physician may use the stepped care approach to control the
eventually control of hypertension. blood pressure.

156 THE FILIPINO FAMILY PHYSICIAN

Non-pharmacologic Interventions Patient Outcomes

During the second and continuing visits, repeated During the second visit, the patient should have
delivery of educational intervention should be done. During increased awareness about the diagnosis and potential risks
the first and second visits face-to-face, paper-based or associated with hypertension. As a result of this awareness,
digital method of health education should be done. But adherence to interventions should be achieved. Adherence
when opportunity arise, behavioral intervention such as can be achieved by repeating/enhancing the interventions
counselling may be done later. The use of patient diaries done during the earlier visits.
may be helpful to monitor adherence. Adherence to intervention may be a surrogate outcome
With regards to exercise, once the patient is used to leading to successful management of hypertension. One
rhythmic lower limb exercise, the patient may move up to study evaluated the effect of adherence on cardiovascular
moderate to vigorous aerobic (endurance) activity up to disease mortality, cerebral hemorrhage and cerebral
5 days/week. Resistance training (strength) on 2 or more infarction. Adherence were classified into good (cumulative
non-consecutive days/week. Vigorous exercise training medication adherence, ≥80%), intermediate (cumulative
is generally safe and well tolerated by most people, medication adherence, 50%-80%), and poor (cumulative
including those with hypertension, although some special medication adherence, <50%) adherence groups. The
considerations are required for safety.28 results showed that patients with poor medication
The effectiveness of educational and organizational adherence had worse mortality from ischemic heart disease
strategies used to improve control of blood pressure was (hazard ratio, 1.64; 95% confidence interval, 1.16-2.31;
examined in a systematic review of randomized controlled P for trend=0.005), cerebral hemorrhage (hazard ratio, 2.19;
trials. The following interventions were evaluated: self- 95% confidence interval, 1.28-3.77; P for trend=0.004),
monitoring and educational interventions directed to the and cerebral infarction (hazard ratio, 1.92; 95% confidence
patient. The results showed that a system of regular review interval, 1.25-2.96; P for trend=0.003) than those with
and self-monitoring of antihypertensive drug therapy was good adherence. Similar findings were also noted with
shown to reduce blood pressure and all-cause mortality at hazard ratio for hospitalization.30
5 years follow-up. Antihypertensive drug therapy should be For those already prescribed with medications, the
monitored closely and adopt a stepped care approach when goal should be a blood pressure lower than the baseline.
patients do not reach target blood pressure levels.29 Based on guideline recommendations the goal differ among
patients above or below 60 years old. For patients less than

Table 5. Reinforcement of Goals.

Patient Family Community

Reinforce BP goals, self-monitoring and recording Encourage family members to adhere to healthy Encourage family members to join programs on
lifestyle hypertension in the community

Reinforce compliance to antihypertensives Compliance to healthy family meals Enrolment in existing community lifestyle activities

Reinforce adherence to lifestyle modification Adherence to family fitness activities Actively participating in hypertension support
(targeted weight, diet and fitness) groups in the community

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60 years old, it is less than 140/90 mmHg and for 60 and Non-pharmacologic Interventions
above, the goal is less than 150/90 mmHg towards a normal
of 120/80 mmHg. This goal is also implemented by several During first few visits, the physician is advised to
outpatient Kaiser Permanente cliinics in the US.31 continue repeating and reinforcing health education and
This goal is similar for all other specialties taking non-pharmacologic intervention. During the continuing
care of hypertensive patients. In one study, there was no visit, there may be a shift to peer-led or family treatment
difference in patient outcomes achieved in 2-year or 4-year partner interventions to improve self-management. In one
outcomes for patients with hypertension whether they were randomized controlled trial peer-led interventions were
being treated by endocrinologists, cardiologists or internal found to have similar effect as physician-led intervention.
medicine specialists. These findings must be viewed in However, this may lower the cost of treatment.34
light of the historically higher costs of fee-for-service in Health coaching by medical assistants can also be an
subspecialty physician practice.32 alternative to physician-led health education. In one study,
in-clinic health coaching by medical assistants improves
Continuing Visit control of cardiovascular and metabolic risk factors when
compared with usual care. Patients who were given health
History and Physical Examination coaching were more likely to achieve the treatment goals.
Many coached patients achieved the hemoglobin A1c goal,
During the continuing visit blood pressure monitoring the LDL cholesterol goal and the systolic blood pressure
and continuing review of history and physical examination goal.35
should be done. Changes must be noted. Among those with
co-morbidity, adequate treatment of co-morbid condition Patient Outcomes
using the applicable clinical pathway should be done.
The Eighth Joint National Committee (JNC 8) guidelines
Pharmacologic Interventions for blood pressure management recommend a blood
pressure goal of less than 140/90 mm Hg for all adults
Pharmacologic treatment of hypertension reduces except those 60 years or older. For those who are ≥60 years
risks of stroke, congestive heart failure, renal failure a systolic blood pressure goal of less than 150 mm Hg is
and mortality. However there is a question of once blood recommended.36
pressure is already controlled, can pharmacologic treatment The assessment of the risk of a cardiovascular’ event
be discontinued? A survey of a random sample of practicing is the most reliable and accurate way to measure the
physicians indicated that 79% tried to withdraw treatment. benefits of anti-hypertensive therapy. Most studies that
Studies of antihypertensive medication withdrawal also have examined control of hypertension have relied solely
showed success rates of 40.3 percent after 1 year of follow- on the blood pressure level attained after treatment. Aside
up and 27.7 percent after 2 years of follow-up were achieved. from blood pressure, it is also recommended to control
Similar findings were noted among elderly patients where the other risk factors. This is due to a finding in one study
an average success rate of 26.2 percent was obtained for where 40.9% of the hypertensive still had an absolute risk
periods of 2 or more years.33 It is therefore recommended exceeding 20% of having a cardiovascular event. The factors
that after 1-2 years of follow-up and the blood pressure is independently associated with uncontrolled hypertension
controlled with no symptoms attributed to hypertension or were age, sex, past history of stroke, ischemic heart disease
to a target organ damage, the physician may try step down and transient ischemic attack, a body mass index greater
or withdrawal treatment. than 30, diabetes, and current smoking.37 While age, sex

158 THE FILIPINO FAMILY PHYSICIAN

and past history are non-modifiable, body mass index, Health System Level
blood sugar and smoking can be modified.
The effectiveness of educational and organizational
Recommendations for Implementation strategies at the health system level to improve control
of blood pressure was examined in a systematic review of
Clinic Level randomized controlled trials. The following interventions
were evaluated: (1) educational interventions directed to
Education, training and audit has been used to improve the health professional, (4) health professional (nurse or
the quality of physician’s practice. In one randomized pharmacist) led care, (5) organizational interventions that
controlled trial, an educational intervention designed to aimed to improve the delivery of care, (6) appointment
improve the management of hypertension in the elderly reminder systems. The results showed that an organized
was tested in family practice. Educational visits, discussion system of regular review allied to vigorous antihypertensive
of barriers to implementing change in practice were drug therapy was shown to reduce blood pressure and
done. At the end of the educational visits, there was a all-cause mortality at 5 years follow-up. These findings
significant difference in the stated threshold for treating have important implications for recommendations
systolic hypertension between intervention and control concerning implementation of structured delivery of care in
groups. There was also a statistically significant difference hypertension guidelines.41
between the two groups, in their willingness to treat a
70-year-old male with mild hypertension. The effectiveness
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