(JM test)Insightful CONversations (ICONs) on Hypertension

SUMMARY

With a local incidence rate of 37%, hypertension continues to be a clinically relevant disease among Filipinos. Unfortunately, despite high rates of treatment compliance, blood pressure control rates among hypertensives in the country remain low.¹

In a luncheon symposium held on February 22, 2024 at the EDSA Shangri-La Hotel, thru an educational grant from Servier Philippines Inc, the country’s key opinion leaders on the topic of hypertension management discussed how local barriers continue to hinder optimal blood pressure control in patients with hypertension.

Aside from many other factors, the quality of physician’s prescriptions was identified as among the most important. The persistently high local prevalence of monotherapy prescribed by physicians puts patients at a disadvantage by denying them the proven benefits of combination treatment. Beyond improving compliance, combination therapy significantly impacts clinical endpoints like major adverse cardiovascular events.

Combination therapy, especially RAASi-based treatments like Perindopril-based combinations, is at the core of international and local hypertension management guidelines. Several landmark clinical trials have established that Perindopril decreases relative risk of fatal stroke and recurrent stroke, risk of heart failure as well as cardiovascular and total mortality. In conclusion, the symposium established that single-pill combinations especially ACEi-based treatments, and enhanced adherence can improve hypertension management outcomes.

INTRODUCTION

Grounding current medical evidence and guidelines with the realities of day-to-day medical practice bring to focus clinical issues that are often overlooked or disregarded. “You will hear from us something we thought we all knew, but (did) not really know,” said Dr. Agnes Mejia, nephrologist, and former chair of the Department of Medicine, University of the Philippines – Philippine General Hospital (UP-PGH) as well as the Department of Adult Nephrology, National Kidney and Transplant Institute (NKTI), as she opened the scientific luncheon symposium attended by almost 300 medical doctors. The educational grant from Servier Philippines Inc, happened during the 29th Joint Annual Convention of the Philippine Lipid and Atherosclerosis Society and the Philippine Society of Hypertension held at the EDSA Shangri-La Hotel last February 22,2024.

The session, entitled “Insightful CONversations (ICONs) in Hypertension, brought together some of the most respected medical authorities in hypertension management. Joining Dr. Mejia as panelists were Dr. Jose Donato Magno, cardiologist, and current chair of the ASEAN Society of Echocardiography, Dr. Nemesio Nicodemus, Jr., endocrinologist, and Immediate Past President of the Philippine Association for the Study of Overweight and Obesity and Dr. Leilani Nicodemus, family medicine specialist, and Executive Member-at-large of the World Association of Family Doctors (WONCA), Asia Pacific Region.

The discussions revolved around key questions currently confounding hypertension management in the local practice.

Why is Control of Hypertension not Optimized?

The burden of hypertension in the Philippines, as summed up by Dr Mejia, has a 37% incidence rate with a blood pressure control rate of 37% on a remarkable treatment compliance rate of 86%.¹ Local barriers to optimal blood pressure control were identified, with Dr. N. Nicodemus, Jr. citing a study showing a patient’s lack of understanding and knowledge of their medication as an important patient-related factor affecting treatment.² He stressed that the quality of physician prescription and instruction were equally important factors on treatment success. Dr Magno, on the other hand, shared new data on genetic resistance of Filipinos to beta blockers.³ For her part, Dr. L. Nicodemus cited the poor availability and accessibility of antihypertensive medications nationwide in both public and private outlets despite legal and administrative measures that seek to ensure the same.^4,5



What Etiologies Account for the Burden of Hypertension in the Young?

Obesity and renal disease were the highlighted etiologies of hypertension in the young. Dr N. Nicodemus, Jr. emphasized the growing problem of overweight and obesity that now affects 1 in 3 adult Filipinos.⁶ He pointed out that obesity alone, even without metabolic abnormalities, is associated with increased risk of coronary and cerebrovascular disease as it affects the integrity of vascular endothelium and activates the renin-angiotensin system that in turn increases blood pressure.^7-9 He emphasized that treating obesity is important as weight loss can lower blood pressure and that the ESH – EASO consensus recommends pharmacologic treatment for BMI equal to or greater than 30, or 27 for those with comorbidities. He underscored the guideline recommendation of RAS blockers,¹⁰ including angiotensin converting enzyme inhibitors (ACEi) like PERINDOPRIL, as the recommended first-line medication for hypertension in obese patients. Dr. Mejia then presented a clinical scenario that emphasized the importance of the early detection and management of renal causes of hypertension in the young. In addition, Dr. L. Nicodemus discussed the importance of an annual physical examination and risk assessment and pointed out some areas that can be improved in health financing, including diagnostic test coverage.

What Strategies Can Improve Diagnosis and Treatment of Hypertension?

Local prescribing patterns of antihypertensive medication were cited as key determinants of treatment effectiveness. The persisting high prevalence of monotherapy puts patients at a disadvantage by denying them the proven benefits of combination treatment. Dr. Magno emphasized that combination therapies, especially RAASi-based treatment like Perindopril-based combinations, are at the core of international and local hypertension management guidelines. The benefits of these treatments extend beyond improving compliance on top of effective blood pressure control as it significantly impacts clinical endpoints like major adverse cardiovascular events, compared to monotherapy.¹¹ ACEi-based combinations have been shown by studies to mitigate prothrombotic processes and provide better blood pressure control with less variability as well as proven added protection from cardiovascular events.¹² These were not consistently seen in other RAASi-based treatments like ARBs.^13,14 Perindopril-based therapy was singled out by Dr. Magno as data from various studies show the protection it provides across the cardiovascular continuum.

Several landmark clinical trials have established that Perindopril decreases relative risk of fatal stroke and recurrent stroke, risk of heart failure and rate of cardiac remodeling,¹² the incidence of combined macro- and microvascular outcomes as well as cardiovascular and total mortality.

The spectrum of patients of hypertension, including the concepts of white coat and masked hypertension, were also recognized as important diagnostic pitfalls further emphasizing the importance of annual risk assessments and blood pressure monitoring across settings.



Open Forum

The interesting topics discussed during the session triggered a highly interactive discussion that followed, further highlighting practical concerns in local practice like the importance of priming the patient about medication side effects and improving the interface between public and private healthcare providers. The clamor from the participants for the inclusion of perindopril and its combinations in the coverage of national health insurance was evidence of their appreciation of the potential impact of perindopril on the local hypertension treatment landscape.

CONCLUSION

The symposium established that patient, physician and health policy-related factors contribute to poor control of hypertension, obesity and renal conditions are important etiologies of hypertension in the young, and that early detection, single-pill combinations, especially ACEi-based treatment, and enhanced adherence can improve hypertension management outcomes.