BACKGROUND: Hypertension is an important risk factor of coronary heart disease. A new guidelines for hypertension prevention and management in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in the United States recommended lifestyle modification or medical treatment for subjects with prehypertension. However, whether prehypertension increases the risk of coronary atherosclerosis in the Japanese population is still unknown.METHODS: A cross-sectional study in a clinical setting was conducted. The subjects were 705 patients  aged 30 years and older who underwent a first-time coronary angiography for suspected or known coronary heart disease at 5 major cardiology departments in the Fukuoka metropolitan area between September 1996 and August 1997.RESULTS: Compared to subjects with normal blood pressure, those with prehypertension had an increased risk of coronary atherosclerosis even after adjusting for other factors.CONCLUSION: Prehypertension may be an important clinical entity which requires treatment in the Japanese population. In the United States, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provided guidelines for hypertension prevention and management.8 They recommended lifestyle modifications for subjects with prehypertension .Coronary heart disease is the single most important disease entity in many industrialized countries,9 They recommended that blood pressure should be controlled under 140/90 mmHg among middle-aged hypertensive patients. The guidelines for treatment of hypertension in the elderly , 2002 revised version10 recommended that blood pressure should be controlled under 140/90 mmHg for those aged 60-69 years, under 150/90 mmHg for ages 70-79 years and under 160/90mmHg for those 80 years or over. The Tanno-Sobetsu Study11 demonstrated that cumulative survival rates with cardiovascular mortality decreased as systolic blood pressure increased, with a significant decline in elderly Japanese aged 60 years or over . We have already shown that hypertension defined as either systolic blood pressure of 160 mmHg or higher, diastolic blood pressure of 95 mmHg or higher, or with administration of anti-hypertensive agents is a significant risk factor of coronary atherosclerosis among the Japanese population.12 The purpose of the present study was to evaluate the relation of prehypertension to the severity of coronary atherosclerosis in the Japanese population.The Japanese Society of Hypertension Guidelines Subcommittee for the Management of Hypertension provided guidelines for the management of hypertension for general practitioners.Study subjects were patients aged 30 years and older who underwent the first-time angiographic examination at five major cardiology departments in the Fukuoka metropolitan area  during the period from September 1996 through August 1997. All patients were referred due to clinical signs of coronary heart disease. The following patients were excluded from the study: those with known myocardial infarction, valvular disease, or cardiomyopathy; and those who had undergone aorto-coronary bypass operation or percutaneous transluminal coronary angioplasty.A total of 733 (85.7%) of 838 eligible patients agreed to take part in this study and answered a questionnaire about lifestyle and other factors; 38 patients refused to participate in this study, 16 were severely ill, and 51 were discharged before the interview was arranged. Among the 733 participants, 28 were excluded; 2 of these had a single coronary artery, for 2 information about the duration of chest pain was not obtained, 23 received medication for angina pectoris more than 6 months before the onset of chest pain, and 1 answered that chest pain had lasted more than 20 years. Thus, the remaining 705 patients (417 men and 288 women), who were 62.4±10.8 (mean±standard deviation) years old, participated in the present study.13 The luminal diameter was measured by calipers at one hospital and was approximated at the other hospitals. The lumen diameter reduction in each 15 coronary artery segments was classified as 0% , 25%, 50%, 75%, 90%, 99%, or 100% according to the maximal narrowing. Coronary artery stenosis was defined when 50% or greater luminal narrowing occurred in one or more coronary arteries. To examine agreement of the angiographic evaluation across departments, randomly chosen cinefilms for 10 patients  from one teaching department were assessed in the other 4 departments in a masked fashion; the presence or absence of coronary artery stenosis agreed completely, and the interclass correlation coefficient for Gensini’s score was 0.92.15Coronary angiography was performed by the percutaneous transbrachial or transfemoral technique. The interpretation of angiograms was done by experienced cardiologists at each hospital in conformity with American Heart Association methods.After informed consent was obtained, interviews were started. Research physicians or nurses asked patients to answer questions about lifestyle factors such as smoking habits and alcohol drinking. The coronary heart disease-related symptom or abnormal electrocardiogram leading to coronary angiography was elicited, and lifestyle and other factors prior to the onset of the event were ascertained. All clinical and laboratory data as well as the medical history were obtained from medical records just before and during admission for coronary angiography.8 hypertension was defined as present if patients had systolic blood pressure of 140 mmHg or higher and/or diastolic blood pressure of 90 mmHg or higher. Normal blood pressure was defined as present if patients had systolic blood pressure of less than 120 mmHg and diastolic blood pressure of less than 80 mmHg. The remaining patients were defined as having prehypertension.Blood pressure was measured by hospital nurses or physicians using standard mercury sphygmomanometers on the right arm of the seated patient after more than 5 minutes of bed rest in the ward. Korotkoff phases I and V were considered to represent systolic and diastolic blood pressures, respectively. According to the new guidelines for hypertension prevention and management in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,Diabetes mellitus was defined as present if patients were under dietary or drug treatment for diabetes mellitus or when they had fasting plasma glucose of 140 mg/dL or higher, or casual plasma glucose of 200 mg/dL or higher. Dyslipidemia was defined as present when patients received lipid-lowering agents, or their serum cholesterol levels were 220 mg/dL or higher, or their HDL cholesterol levels were less than 40 mg/dL.®) . All the p-values quoted were two tailed, and values less than 0.05 were regarded as statistically significant.Logistic regression analysis was used to adjust for potential confounding factors. Age was categorized into 5-year age groups. Exposure to cigarette smoking was expressed as cigarette-years, i.e., the number of cigarettes smoked per day multiplied by years of smoking, which was categorized into 0, 1-399, and 400+. Alcohol consumption (mL/day) was calculated for current drinkers, categorized into 0, 1-49, and 50+ mL/day. Age, cigarette smoking, and alcohol use were treated as continuous variables, and indicator variables were used for hospital, blood pressure, and other factors. Odds ratios (OR) and their 95% confidence interval (CI) were obtained from the logistic regression coefficients and their standard errors. All the statistical analyses were performed using the Statistical Analysis System  had hypertension and 246 patients (34.9%) had prehypertension while only 148 patients (21.0%) were categorized into the normal blood pressure group. Mean (± standard deviation) systolic blood pressure was 135±22 mmHg for all patients  while mean diastolic blood pressure was 76±13 mmHg for all patients . Among the 705 patients, 288 (40.9%) were treated with antihypertensive agents. Diabetes mellitus was found in the 126 patients (17.9%) while 440 patients (62.4%) had dyslipidemia. A total of 370 patients (52.5%) were smokers, and 322 patients (45.7%) were current drinkers.2,3,4,17,18,19 as well as stroke.4,16,18 Ueda et al.19 reported that the management of mild hypertension with a diastolic blood pressure of 90 to 104 mmHg was more effective in reducing stroke than coronary heart disease in Japan. In western countries, however, high normal blood pressure with a systolic blood pressure between 130 and 139 mmHg or a diastolic blood pressure between 85 and 89 mmHg increases the risk of coronary heart disease.6 Furthermore, in the Hypertension Optimal Treatment Study,20 the most prominent protection against cardiovascular events by lowering blood pressure was observed in patients with systolic blood pressure in the range of 130-140 mmHg and diastolic blood pressure in the range of 80-85 mmHg. Lewington et al.21 demonstrated that vascular mortality decreased most when blood pressure was reduced to 115 mmHg for systolic blood pressure and 75mmHg for diastolic blood pressure.Hypertension is associated with an increased risk of cardiovascular disease18 demonstrated that systolic hypertension increased the risk of acute myocardial infarction in both middle-aged and elderly Japanese while mild hypertension  did so only in the elderly. In the present study, however, prehypertension showed an increased OR for coronary artery stenosis even after controlling for age and other factors.The Hisayama study18 the different results of the two studies may be partly explained by the fact that the prevalence of obesity has rapidly increased due to the westernization of the Japanese lifestyle, including dietary habits,22 which has brought on other coronary heart disease risk factors associated with insulin resistance syndrome such as hypertension, dyslipidemia, diabetes mellitus and hyperuricemia.22Because our study was conducted more than one decade after the Hisayama Study,23 demonstrated that body mass index was significantly associated with hypertension, diabetes mellitus, and hypercholesterolemia in the Japanese population. Handa et al.24 reported that the combination of hypertension and hypercholesterolemia appeared to be important in the development of coronary atherosclerosis. Kaplan proposed the term “deadly quartet” as a profile of a person having a very high risk of coronary heart disease with a combination of upper body obesity, hypertension, hypertriglyceridemia, and impaired glucose tolerance.25 The combination of prehypertension and other borderline diseases such as impaired glucose tolerance and a high normal lipid profile may increase the risk of coronary heart disease. Because a change to a westernized life-style was associated with an increased risk of coronary heart disease among Japanese immigrants,26 the results of our study may indicate that blood pressure control of prehypertension may be important for the prevention of coronary heart disease in the Japanese population.Liu et al.27,28 and the prevalence of diabetes mellitus29 are increasing in the Japanese population. Very recently, Nakanishi et al.30 reported that the accumulation of coronary heart disease risk factors was highly associated with the increased risk of hypertension among Japanese men. Our results may give us useful information to prevent the increase of coronary heart disease among the Japanese population in the future.There are certain limitations in the current study. First, the participants were not randomly selected from the general population. Most of the participants had risk factors of coronary heart disease other than high blood pressure such as diabetes mellitus (17.9%), dyslipidemia (62.4%) or smoking (45.7%). However, the total cholesterol level31The second limitation is that the blood pressure might have been higher than the usual blood pressure regardless of the degree of coronary atherosclerosis because all patients might have waited with anxiety for their first-time angiographic examinations. However, the nondifferential misclassification of ‘normal blood pressure to prehypertension’ and ‘prehypertension to hypertension’ may lead to underestimation of the effect of high blood pressure on coronary atherosclerosis because the nondifferential misclassification underestimates the risk of exposure.32 Because we collected the information about blood pressure and coronary artery stenosis at the same time, the sequence of high blood pressure and coronary artery stenosis cannot be necessarily determined in the present study.Third, our study was a cross-sectional one.Finally, we could not evaluate the contents of antihypertensive treatment because we did not obtain information about antihypertensive drugs such as diuretics, beta-blockers, calcium channel blockers, and angiotensin converting enzyme inhibitors.15On the other hand, our study has strengths as well. First, this cross-sectional study is one of the largest studies to evaluate the effect of prehypertension on angiographically defined coronary atherosclerosis among Japanese population. Second, the participating hospitals were five major cardiology departments in the Fukuoka metoropolitan area. Third, we confirmed that the angiographic evaluation of coronary artery stenosis agreed very well among these five cardiology departments.8 recommended lifestyle modifications as well as medical treatment for prehypertensive subjects with high coronary heart disease risk. Prehypertension appeared to be an important clinical entity which requires medical treatment in the Japanese population as well, especially when patients have other risk factors for coronary heart disease.In summary, the present findings should be interpreted with caution because the patients in the present study were a high-risk group for coronary heart disease. However, the present study clearly showed that, compared with normal blood pressure, prehypertension was associated with an increased risk of coronary artery stenosis even after adjusting for other risk factors. Our results indicate that maintaining normal blood pressure levels with systolic pressure of less than 120 mmHg and diastolic pressure of less than 80 mmHg should be recommended to prevent coronary artery stenosis among Japanese. In the United States, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure


Overall, 40-50% of affected children have kidney involvement ranging from microscopic hematuria to rapidly progressive glomerulonephritis, contributing to 1-2% of all chronic kidney disease (CKD) stage 5.IgAV is considered a benign disease in children (around 94% of affected children achieve full and spontaneous recovery within two years), but its prognosis depends on the extent and the progression of kidney involvement,Genetics plays a role in determining the appearance of the disease and its severity, although there is no clear genetic correlation with primary IgANCurrently, the hypothesis of an abnormal immune response to various antigens in genetically susceptible individuals is acceptedet al., published in the current issue of Braz. J. Nephrol., used stringent criteria to select participantsThe study by Kara Most patients were under 10 years of age, predominantly male, with skin and gastrointestinal involvement, and had hematuria and proteinuria at onset. Kidney biopsies were classified mostly as grade II and III according to ISKDC. Most patients were grade B  and grade A , respectively, on short- and long-term outcomes. The authors divided the patients in two groups (group I: grade I - II and group II: grade III - IV) according to ISKDC criteria and age group (≤10yr and >10yr). There was no difference between the groups (p=0.744).et al., the scrotal involvement occurred in almost one fifth of IgAV patients, mostly as acute subtypeThe authors found significant correlation between scrotal involvement and unfavorable outcome in seven patients (14.8%). Only neutrophil/lymphocyte ratio was found significantly higher in those with scrotal involvement, which may be attributed to disease severity and inflammationet al. in a meta analysis showed that older age at onset, lower glomerular filtration rate, initial renal features of nephrotic syndrome and nephritic-nephrotic syndrome, and renal biopsy with crescentic nephritis were predictive of poor prognosis in children with IgAVet al. report a significant correlation between hypertension and kidney impairment with unfavorable outcomeKidney dysfunction, proteinuria, hypertension, and crescentic nephritis at onset were significantly associated to unfavorable outcome,et al. treated all patients with steroidsThe recent European consensus (SHARE initiative) on diagnosis and treatment of IgAV provides a severity definition for IgAVN and recommends the prompt start of oral steroids (first-line) and IV pulses or immunosupression as second line treatmentet al. contributes to the knowledge of IgAV and may change clinical practice. The three main messages are: (a) scrotal involvement in pediatric patients with IgAV can be associated with unfavorable outcome, (b) Cy-A and cyclophosphamide may be effective in steroid unresponsive IgAV pediatric patients, and (c) the disease has a good prognosis in children. However, other studies found that some children can progress to end-stage kidney disease. It seems reasonable that all IgAV pediatric patients, with no exception, should be periodically screened for urinalysis, blood pressure, and kidney function. Identifying children at greatest risk for progressive loss of kidney function is key to reducing the incidence of irreversible CKD. Hopefully, future studies will address these important questions.The study by Akbalik Kara


Lower quartile of proteinuria  was significantly associated with male, older age, and history of atherosclerotic CVD including coronary artery disease, peripheral arterial disease, and cerebral infarction (Ptrend<0.05). Kidney size was smaller in patients with lower levels of proteinuria. Patients with higher levels of proteinuria were more likely to have proliferative diabetic retinopathy (Ptrend<0.05). Multivariate competing risk analysis revealed that the first quartile of proteinuria was associated with a greater risk of atherosclerotic CVD than the third quartile . This association was attenuated after additional adjustments for history of atherosclerotic CVD. Furthermore, patients with lower quartiles of proteinuria were more likely to die of atherosclerotic CVD than those with non-atherosclerotic CVD (Ptrend = 0.01). Diabetic patients with lower proteinuria at dialysis initiation were characterized by severer macroangiopathy, as shown by a more atrophic kidney and higher prevalence of past atherosclerotic CVD. Hence, they are at a high risk of developing atherosclerotic CVD.Diabetic kidney disease (DKD) is heterogeneous in terms of proteinuria. Patients with DKD who present with low-grade proteinuria are more likely to have nephrosclerosis rather than traditional diabetic nephropathy. The amount of proteinuria might reflect the underlying pathology of renal failure and influence the prognosis after dialysis initiation. Clinical implications of proteinuria at the start of dialysis have not been confirmed, while greater proteinuria is associated with higher risk of cardiovascular disease (CVD) in the predialysis stages of chronic kidney disease. We performed a retrospective multicenter cohort study enrolling incident hemodialysis patients with diabetes. Patients were stratified using proteinuria quartiles. We examined the association of proteinuria quartiles with types of subsequent CVD. Among the enrolled 361 patients, the estimated mean glomerular filtration rate and proteinuria was 5.4 mL/min/1.73 m All patients started dialysis after admission to the hospital in our cohort. The primary outcome was fatal atherosclerotic CVD and re-hospitalization for atherosclerotic CVD. Atherosclerotic CVD consists of myocardial infarction, unstable angina, non-hemorrhagic stroke, peripheral vascular disease (including amputation), and aortic dissection or rupture. The rest of the CVD cases were non-atherosclerotic CVD, which includes heart failure, arrhythmia, hemorrhagic stroke, sudden death, fatal pulmonary embolism, and death due to unspecified causes of CVD. The outcomes were obtained from medical records or common questionnaires sent to each dialysis facility. Patients were censored at the date of kidney transplantation or when they were lost to follow-up.Patients were categorized into quartiles of UPCR, with cut-offs at 3.0, 5.4, and 8.8 g/gCr. For continuous variables, the mean (standard deviation) was presented, while percentages were presented for categorical variables. We examined linear trends of baseline characteristics across quartiles of UPCR using linear or logistic regression, as appropriate. To explore a potentially non-linear relationship between UPCR and renal length, we adopted restricted cubic spline models adjusted for age, sex, eGFR, height, body mass index at discharge, and modality for measurement of renal length (CT or ultrasonography).We examined the association between quartiles of UPCR and first atherosclerotic CVD events using competing risk regression models with death from diseases other than atherosclerotic CVD as the competing risk. After conducting a univariate analysis, we constructed several multivariate models: model 1 adjusted for age, sex, eGFR, body mass index at discharge, systolic blood pressure, glycated hemoglobin A1c (HbA1c), smoking status, and prescription ; and model 2 adjusted for covariates in model 1 plus history of atherosclerotic CVD . Additionally, we examined the association between quartiles of UPCR and fatal atherosclerotic CVD using competing risk regression models with death from other diseases than atherosclerotic CVD as the competing risk.Statistical significance was set at P < 0.05. All statistical analyses were performed using Stata/IC 14 .2. Patients in the lower quartile of UPCR were more likely to be male and elderly. They were more likely to have a history of atherosclerotic CVD, including coronary artery disease, peripheral arterial disease, and cerebral infarction , 103 patients (28.5%) developed atherosclerotic CVD. In univariate competing risk analysis, the first quartile (Q1) of UPCR was a significant risk factor for atherosclerotic CVD (subhazard ratio (SHR) [95% confidence interval (CI)]: 1.84 [1.06–3.17] compared to quartile 3)  Fig 3A)Fig 3A). In this multicenter retrospective cohort study enrolling incident dialysis patients with diabetes, we showed that patients with severe proteinuria were more likely to have advanced diabetic retinopathy (microangiopathy) and to receive insulin at dialysis initiation. In contrast, patients with moderate proteinuria were more likely to have atrophic kidneys and a history of atherosclerotic CVD (macroangiopathy) . FurtherPatients with more severe proteinuria had lower serum albumin and higher LDL levels. In other words, patients with massive proteinuria showed nephrotic syndrome. They were more likely to receive statins, probably because of their high LDL levels. Furthermore, these patients also had lower eGFR at dialysis initiation and higher OH-R. They might have withstood more severe overhydration without suffering from congestive heart failure. This is probably because edema rather than increased intravascular volume contributed to overhydration since they have low serum osmotic pressure accompanied with vascular hyperpermeability, as it is often observed in patients with diabetes . In addiPatients with massive proteinuria were more likely to receive insulin and have advanced diabetic retinopathy. Although we cannot prove causality in our study, insulin therapy was unlikely to cause microangiopathy because multiple insulin injection treatments (three times per day) are more effective to prevent the progression of microangiopathy than conventional insulin injection therapy (one to two times per day) . FurtherAnother possibility is that the necessity of insulin prescription at dialysis initiation might reflect severely decreased insulin secretion due to β-cell dysfunction, which was caused by islet microangiopathy driven by long-term hyperglycemia. In db/db mice, signs of islet microangiopathy have been reported. The observed findings include increase in the average and diversity of islet capillary size, pericapillary edema and fibrosis, and hypertrophy of the pericyte with abundant actin-like microfilaments, which suggest capillary hyperperfusion, hypertension, and secondary vascular response . HemodynPatients with modest proteinuria were more likely to have a history of atherosclerotic CVD. In addition, they were more likely to be elderly and male, which have been reported as risk factors for atherosclerosis , 24. PatIt should be noted that more than 95% of patients in our study had proteinuria corresponding to A3 levels of albuminuria (>300 mg/g) according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Our findings indicate that the link between severe proteinuria and worsening prognosis advocated by the KDIGO guidelines cannot be extrapolated to those patients with end-stage renal disease who are new to dialysis. Proteinuria accelerates kidney function loss  that has2, a J-shaped association between proteinuria and all-cause mortality has been reported [Few studies have investigated the association between proteinuria at the initiation of dialysis and prognosis. The findings of our study are consistent with those of previous studies that enrolled patients with advanced CKD. In pre-dialysis patients with eGFR < 30 mL/min/1.73 mreported , 29. AmoPatients in the fourth quartile of proteinuria had a greater risk of future atherosclerotic CVD than those in the third quartile of proteinuria. This might be explained by long-term effects of glycemic control. Patients in the fourth quartile of proteinuria might have had poor glycemic control as shown in the high prevalence of insulin users. In the UK Prospective Diabetes Study, intensive glucose control decreases the risk of microvascular complications, but not macrovascular complications during the first 10 years after diagnose of diabetes . HoweverThis study had several strengths. First, this is the first study to examine the association between the amount of proteinuria at the initiation of dialysis and the characteristics of patients with diabetes. Second, we recorded kidney length at the initiation of dialysis. No study has examined the association between the amount of proteinuria and kidney size in incident dialysis patients. In contrast, this study also had several limitations. First, the outcomes were not adjudicated. The indications for hospitalization might vary among physicians. Second, we enrolled only patients with diabetes, so our results cannot be extrapolated to patients without diabetes. Third, the method of measuring renal length was not standardized among the technicians.In conclusion, patients with diabetes and with lower levels of proteinuria at dialysis initiation were more likely to have prevalent atherosclerotic CVD at the initiation of dialysis and a higher risk of developing atherosclerotic CVD after the initiation of dialysis. The amount of proteinuria at dialysis initiation might be useful in determining the heterogeneous pathologies of patients with diabetes: the dominance of microangiopathy and macroangiopathy.S1 TableAbbreviations: eGFR, estimated glomerular filtration rate; HbA1c, glycated hemoglobin A1c; LDL, low density lipoprotein; OH-R, overhydration rate; RAAS, renin-angiotensin-aldosterone system; UPCR, urinary protein creatinine ratio.(PDF)Click here for additional data file.


P < 0.001), 0.712 , and 0.760 , respectively, with threshold values of ≤ 74 mmHg, ≥ 42.5 mL/m2, and ≤ 1.08 mmHg/mL, respectively. If patients have MAP < 75 mmHg with SVI ≥ 42.5 mL/m2 or Ea ≤ 1.08 mmHg/mL before postural change from T-off during RALP, prompt management for ensuing hypotension should be considered.Postural change from a steep Trendelenburg position to a supine position (T-off) during robot-assisted laparoscopic prostatectomy (RALP) induces a considerable abrupt decrease in the mean arterial pressure (MAP). We investigated the variables for predicting postural hypotension induced by T-off using esophageal Doppler monitoring (EDM). One hundred and twenty-five patients undergoing RALP were enrolled. Data on the MAP, heart rate, stroke volume index (SVI), cardiac index, peak velocity, corrected flow time, stroke volume variation, pulse pressure variation, arterial elastance (Ea), and dynamic arterial elastance were collected before T-off and at 1, 3, 5, 7, and 10 min after T-off using EDM. MAP < 60 mmHg within 10 min after T-off was considered to indicate hypotension, and 25 patients developed hypotension. The areas under the curves of the MAP, SVI, and Ea were 0.734 . However, a specific physiologic condition is required for RALP: pneumoperitoneum with carbon dioxide (CO2) insufflation and a steep Trendelenburg position of ≥ 30°5. These combined effects can result in considerable hemodynamic alterations, including > 30% increase in the mean arterial pressure (MAP) and a threefold increase in the central venous pressure (CVP)4. Furthermore, resuming a supine position with cessation of CO2 insufflation afterward induces considerable abrupt decreases in the MAP and CVP5.Robot-assisted laparoscopic prostatectomy (RALP) has become a more favorable surgical technique than open prostatectomy based on postoperative complications, perioperative outcomes, and functional outcomes6. However, this hemodynamic change may differ from that in patients undergoing a postural change from a steep Trendelenburg position to a supine position during RALP. Moreover, that previous study only included patients younger than 65 years, with a mean age of approximately 45 years, whose compensatory responses were likely more adequate than those of elderly patients. Elderly patients, especially those with comorbidities, such as hypertension and diabetes mellitus, are susceptible to hypotension after sudden upright postural change because of autonomic system dysfunction and impairment of cardiovascular responses to sudden changes in pathologic states8. Patients undergoing RALP are mostly elderly (mean age > 60 years) with various comorbidities2, which may increase the risk of hypotension when resuming a supine position from a steep Trendelenburg position.However, data on the prediction of hypotension following a postural change in patients under general anesthesia are limited. Only one study investigated the variables that can predict hypotension after a postural change from the supine to the beach chair position (70° upright position)10. This technique is a safe, quick, and less invasive method compared with the thermodilution technique with a pulmonary artery catheter10. Numerous studies have shown that EDM can be a useful supplementary part of standard perioperative hemodynamic monitoring that could reduce postoperative morbidity and length of hospital stay9. Therefore, we investigated the variables that could predict postural hypotension induced by changing a patient’s position from a Trendelenburg position to a supine position (T-off) during RALP using EDM.Esophageal Doppler monitoring (EDM) allows for continuous monitoring of cardiac output (CO) and other advanced hemodynamic variables, including preload, afterload, and contractilityOf the 127 patients enrolled, 2 patients were excluded from the analysis because of incomplete data. Among 125 patients, 25 patients developed hypotension after T-off . The MAP significantly decreased in both groups after T-off; however, the changes in the MAP over time were significantly different between the groups (PGroup×Time < 0.001). The stroke volume index (SVI) was significantly higher (Bonferroni-corrected P = 0.004), whereas arterial elastance (Ea) was significantly lower in the hypotension group (Bonferroni-corrected P = 0.005) than in the non-hypotension group before T-off. During 10 min after T-off, the hypotension group maintained significantly higher SVI values and lower Ea values than the non-hypotension group. The heart rate (HR), cardiac index (CI), peak velocity (PV), corrected flow time (FTc), stroke volume variation (SVV), pulse pressure variation (PPV), and dynamic arterial elastance (Eadyn) were comparable between the groups before and after T-off, except for a significantly higher PV value at 10 min after T-off in the hypotension group than in the non-hypotension group (Bonferroni-corrected P = 0.025).Changes in hemodynamic variables are presented in Table P < 0.001; AUC 0.712; 95% CI 0.598–0.825; P < 0.001; AUC 0.760; 95% CI 0.646–0.875; P < 0.001, respectively). The optimal threshold values of the MAP, SVI, and Ea were 74 mmHg , 42.5 mL/m2 , and 1.08 mmHg/mL , respectively  of each index for predicting hypotension after T-off are presented in Table 2) and low Ea (threshold of 1.08 mmHg/mL) can be used to predict postural hypotension during RALP.This prospective observational study was the first to investigate the hemodynamic variables for predicting hypotension after T-off during RALP. With the use of EDM, we found that a high SVI  within 10 min after resuming the supine position, and considering the patients’ age (mean age: approximately 65 years) and comorbidities (> 80% of patients with comorbidities), this percentage is enough to warrant attention. According to a recent systematic review, there were moderately or highly elevated risks of any end-organ injury after non-cardiac surgery when patients had MAP < 65–60 mmHg for ≥ 5 min or MAP < 55–50 mmHg for any duration12. In the present study, 3 of 25 patients developed MAP < 55 mmHg, despite the administration of ephedrine when the MAP was < 60 mmHg (data not shown). Therefore, predicting postural hypotension may be crucial for administering prompt management as needed, especially in elderly patients with comorbidities.Laparoscopic surgery with CO8. The physiologic condition when resuming a supine position suddenly after a prolonged Trendelenburg position may be similar to that with a sudden change to the upright position. Orthostatic intolerance in elderly individuals is associated with age-related impairment in baroreflex-mediated vasoconstriction and an increase in the HR along with medical conditions such as hypertension and diabetes mellitus8. Moreover, older age, pre-induction high blood pressure, and the presence of diabetes mellitus were associated with an increased risk of general anesthesia induction-related hypotension13. Therefore, we anticipated that the patients developing postural hypotension would be older and with more comorbidities. However, the mean age and incidence of hypertension or diabetes mellitus were not different between the patients who developed hypotension and those who did not  and Hemosonic 10. The probe of CardioQ is 6 mm in diameter, which is smaller than that of Hemosonic and approximately the same as that of a nasogastric tube10. Along with the small diameter, the probe has an internal spring coil that provides an optimal balance between flexibility and rigidity for easier insertion10. The CardioQ probe emits a 4-MHz continuous-wave ultrasound signal at a fixed angle of 45° and measures descending aortic blood flow velocity at the midthoracic level (between the fifth and sixth thoracic vertebrae), at which the aorta and esophagus run approximately parallel10.EDM offers minimally invasive continuous real-time hemodynamic monitoring with an extremely low incidence of complications10. A low FTc with a normal PV, a low FTc with a low PV, and a normal FTc with a low PV may indicate low preload, increased afterload, and decreased contractility, respectively10. The values of FTc and PV before T-off were not different between the non-hypotension and hypotension groups 6. However, FTc, SVV, and PPV, which are known to be closely related to preload, did not predict postural hypotension induced by T-off in our study.Monitoring of CO itself may be insufficient for therapeutic decision-making. For example, a low CO level can result from hypovolemia, increased systemic vascular resistance (SVR), and decreased contractility. With the use of CardioQ, assessment of preload, afterload, and contractility is possible with the values of FTc and PVps Table , resultips Table . In addion Table . In a pr2) was a predictor of hypotension in the beach chair position 6, a high SVI (≥ 42.5 mL/m2) was a predictor of hypotension after resuming the supine position. Meanwhile, Ea ≤ 1.08 mmHg/mL before T-off was also revealed as a predictor of hypotension. Ea is the ratio of the left ventricular end-systolic pressure to the stroke volume (SV)15, and Ea is calculated by the equation /SV in CardioQ. Therefore, the finding that a low Ea being a predictor is in concordance with a high SVI being a predictor because Ea is inversely related to SV. Ea reflects arterial tone variation and is an expression of the complex association of different arterial properties, such as wall stiffness, compliance, and outflow resistance15. Ea has a strong correlation with SVR and is inversely related to compliance; Ea decreases with a lower SVR and higher compliance17. Therefore, we can deduce that patients with reduced Ea, in other words, those who have a more compliant artery, developed postural hypotension. In a previous study investigating etomidate-induced hypotension, patients who developed hypotension showed a decrease in Ea with an increase in arterial compliance after etomidate injection, whereas patients who did not develop hypotension showed no changes in these values17. When a 50-μg bolus of phenylephrine was compared with a 5-μg bolus of norepinephrine in patients with general anesthesia-induced hypotension, phenylephrine led to an increase in the MAP with a larger decrease in the SV and arterial compliance than norepinephrine18. In our study, MAP ≤ 74 mmHg before T-off was also a predictor of postural hypotension after T-off. Therefore, a bolus of phenylephrine can be considered if patients have MAP < 75 mmHg before a postural change because phenylephrine can increase the MAP along with decreasing the SV and arterial compliance . However, further studies are required to determine the beneficial effect of the prophylactic administration of a vasopressor on the prevention of postural hypotension.An SVI value before T-off was found to be a predictor of postural hypotension after T-off. Contrary to a previous result showing that a low SVI  compared with those in the usual care group19. Secondly, all patients in our study were placed in a constant setting of 30° Trendelenburg position with pneumoperitoneum at the pressure of 12 mmHg. Therefore, the effects of different settings of head down angle and intra-abdominal pressure on postural hypotension after T-off was not explored. In addition, since T-off with cessation of CO2 insufflation was done in a routine, concurrent manner at our center, each individual effect of postural change and cessation of insufflation could not be determined. Therefore, further studies focusing on the effects of postural change and insufflation pressure separately are needed for more detailed conclusions. Lastly, we collected the data within a limited time interval (from before T-off to 10 min after T-off); therefore, we could not determine the occurrence of post-induction hypotension, which may be correlated with postural hypotension. However, this is beyond the scope of our study because we focused only on hemodynamic variables for predicting postural hypotension.The present study has some limitations. First, we used only one definition of hypotension (MAP < 60 mmHg). Previous studies used various definitions of intraoperative hypotension, including a threshold based on the absolute blood pressure or relative blood pressure (a percentage-wise or absolute decrease from the baseline blood pressure)2 or Ea ≤ 1.08 mmHg/mL before a postural change.In conclusion, EDM with CardioQ can be used to predict postural hypotension induced by T-off during RALP. The high SVI and low Ea values before postural change can be used to predict the occurrence of postural hypotension. Prompt management for ensuing hypotension should be considered if patients have MAP < 75 mmHg with SVI ≥ 42.5 mL/mThis prospective observational trial was approved by the Institutional Review Board and Hospital Research Ethics Committee  and was performed in accordance with relevant guidelines and regulations. Between March 2019 and December 2020, 127 patients with an American Society of Anesthesiologists physical status of I–III, aged ≥ 20 years, and with prostate cancer who were scheduled for RALP were enrolled after written informed consent was obtained from each patient. Patients were excluded if they had left ventricular ejection fraction < 40%, pre-existing severe vascular disease, implanted pacemaker, autonomic nervous system impairment, or a history of esophageal varices.2/air) and remifentanil (0.02–0.1 µg/kg/min) by targeting a PSI of 25–50. Neuromuscular blockade was achieved with the administration of 1.2 mg/kg of rocuronium, and its depth was maintained at 0–2 train-of-four by continuous infusion of rocuronium during pneumoperitoneum. Mechanical ventilation was delivered with an air–oxygen mixture (fraction of inspired oxygen = 0.4) at a tidal volume of 7–8 mL/kg and a positive end-expiratory pressure of 5 cmH2O. Following cannulation of the radical artery, the probe of EDM was inserted, and CO was continuously monitored. A single surgeon performed all RALPs. When pneumoperitoneum was induced by CO2 insufflation, the patients were placed in a 30° Trendelenburg position, and the intra-abdominal pressure was maintained at 12 mmHg. With cessation of CO2 insufflation, T-off was performed. Hypotension, defined as MAP < 60 mmHg, was recorded during 10 min after T-off and treated with a bolus of ephedrine in 4-mg increments.After arrival in the operating room, the patients were monitored with electrocardiography, and data on the peripheral oxygen saturation, non-invasive blood pressure, and Patient State Index (PSI) were collected using a SedLine® electroencephalograph sensor . Following intravenous administration of 0.1 mg of glycopyrrolate as a premedication, anesthesia was induced with a bolus of propofol (1.5–2 mg/kg) and remifentanil (0.5 µg/kg) and maintained with sevoflurane /SV, Eadyn which was calculated as SVV/PPV. The values of SVI, CI, PV, and FTc were obtained in the flow monitoring mode, whereas PPV, Ea, and Eadyn were obtained in the pressure monitoring mode. All variables before T-off were derived from the average of three consecutive measurements every 30 s and last measurement was done 30 s before T-off. The position of the probe was continuously monitored and adjusted for the best signal for descending aorta.P value of < 0.05 was considered to be significant. All analyses were conducted using SAS version 9.4 .In a preliminary study with 50 patients, the incidence of hypotension was 12% after T-off. A sample size of 125 patients achieved a power of 90%, which allowed us to demonstrate a difference of 0.25 in the AUC under the null hypothesis of 0.5 and an AUC under the alternative hypothesis of 0.75 using a two-sided z test at a significance level of 0.05. To evaluate the ability of variables to predict hypotension after a postural change, quantification was performed by calculating the AUCs of the hypotension group using the DeLong method. After the receiver-operating characteristic curve was constructed, the optimal threshold value was determined by choosing the maximum value of the Youden index, which was calculated as sensitivity + specificity − 1. All values are presented as mean ± standard deviation, median [interquartile range], or number of patients (proportion). Close-to-normal continuous variables were analyzed using an independent t-test, and the other continuous variables were analyzed using a Mann–Whitney U test. Categorical variables were analyzed by the chi-square test or Fisher exact test as appropriate. For repeated-measure variables, a linear mixed model analysis was performed to determine group and time effects, and a compound symmetry covariance structure was used for the within-subject effect. To adjust for multiple comparisons for post-hoc analysis, the Bonferroni correction was applied. A


Pulmonary hypertension is a dreaded disease associated with considerable morbidity and mortality. The pulmonary hypertension developing due to chronic respiratory disease is a unique subset with symptoms often getting masqueraded by the underlying respiratory condition. The importance of early detection of this complication has been realized worldwide, and recently, the definition of pulmonary hypertension was revised to set the cutoff of mean pulmonary artery pressure (mPAP) at 20 mmHg instead of 25 mmHg at rest. In our study, we have tried to estimate the difference this new definition brings to the prevalence of pulmonary hypertension among interstitial lung disease patients at our centre. n = 239) attending the outdoor and indoor Department of Respiratory Medicine, King George's Medical University, India, for the duration of one year were subjected to transthoracic echocardiography along with measurement of serum pro-B-type natriuretic peptide (BNP) and troponin T values. The data were analyzed using the different definitions, and the prevalence was compared.  This was a cross-sectional study in which all the patients of ILDs ( Incidence of pulmonary hypertension among ILD patients at mPAP cutoff ≥ 25 was 28.9%, while that at value ≥20 mmHg, incidence of pulmonary hypertension increased to 46.0%. An increment of 15–20% in incidence of pulmonary hypertension was observed among different types of ILD when cutoff of mPAP was changed.  The new definition helps in a significant increase in the detection of pulmonary hypertension, which certainly helps in earlier detection and better management of patients. The hemodynamic definition was given as mean pulmonary artery pressure > 25 mmHg at rest measured by right heart catheterization [≥20 mmHg , 5. This≥20 mmHg . In our st September, 2018, to 31st August, 2019. Consecutive patients diagnosed with interstitial lung diseases who provided written informed consent were included in the study. Approval was obtained from Institutional Ethics Committee. Patients who did not provide consent or had left-sided heart disease were excluded.This cross-sectional study was conducted in the Department of Respiratory Medicine, KGMU, UP, Lucknow, from 12. TAPSE indicated the longitudinal function of right ventricle. Its normal value was >1.6 cm [∗PAT) [2 + right atrial pressure, where V is the TR velocity. The severity was defined as mild if mPAP was 20–40 mmHg in new definition or 25–40 mmHg in the previous one and moderate and severe when mPAP was 41–55 mmHg and >55 mmHg, respectively [t-test, analysis of variance (ANOVA), and logistic regression.239 subjects were enrolled in the study. All were subjected to transthoracic echocardiography, and the following parameters were recorded: tricuspid regurgitation (TR) velocity, right ventricular systolic pressure (RVSP), pulmonary artery acceleration time, right atrial area, right atrial and right ventricular enlargement, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), interventricular septum (IVS) flattening, pericardial effusion, and left ventricular ejection fraction. Right atrial enlargement was said to occur when right atrial area > 18 cmm [∗PAT) . RVSP waectively . Diameteectively . Pro-B-t2, mean RVSP was 54.7 mmHg, and mean diameter of IVC was 21.57 mm  and CTD-ILD (n = 75) comprised most of the study group. Prevalence of other major groups is shown in β type of estrogen receptors increases the arterial tone and raises the pressure, while the α type has a protective role and prevents fibrosis. The balance between these two types of receptors seems to be responsible for female preponderance [Among the 239 ILD patients, hypersensitivity pneumonitis (nderance . Both thILD n = 7 comprisenderance –27. All nderance . Pulmonanderance –31. In oA high prevalence has been reported previously in CPFE and other rare ILDs such as LCH and lymphangioleiomyomatosis in advanced cases –34. OlivIn sarcoidosis, pulmonary hypertension has been reported in up to 20% of patients, and the mechanisms involved are different. Often, the ones with advanced disease are involved –44. ConcThe mean TR velocity in mild cases was 1.83 m/s, which decreased to 1.63 m/s on applying the new definition . EchocarThus, in our study, we could conclude that there were a considerable number of subjects with interstitial lung diseases who had their mPAP in the range of 20–25 mmHg, and with application of the new definition, the pulmonary hemodynamics got the attention earlier which is likely to impact the management and overall quality of life of such patients.We have ascertained the prevalence of pulmonary hypertension among patients of interstitial lung diseases utilizing two different international definitions. The new definition certainly unmasks a large number of subjects who previously fell in the range of elevated pulmonary artery pressure but could not qualify the criteria for diagnosis.


Hypertension is the most common cause of death and disability worldwide with its prevalence rising in low to middle income countries. It remains to be an important cause of morbidity and mortality in the Philippines with poor BP control as one of the main causes. Different societies and groups worked and collaborated together to develop the 2020 Philippine Clinical Practice Guidelines of hypertension arising for the need to come up with a comprehensive local practice guideline for the diagnosis, treatment, and follow up of persons with hypertension. A technical working group was organized into six clusters that analyzed the 30 clinical questions commonly asked in practice, looking into the definition of hypertension, treatment thresholds, blood pressure targets, and appropriate medications to reach targets. This guideline also includes recommendations for the specific management of hypertension among individuals with uncomplicated hypertension, hypertension among those with diabetes, stroke, chronic kidney disease, as well as hypertension among pregnant women and pediatric populations. It also looked into the appropriate screening and monitoring of patients when managing hypertension, and identification of groups who are at high risk for cardiovascular (CV) events. The ADAPTE process was used in developing the statements and recommendations which were then presented to a panel of experts for discussion and approval to come up with the final statements. This guideline aims to aid Filipino healthcare professionals to provide evidence‐based care for persons with hypertension and help those with hypertension adequately control their blood pressure and reduce their CV risk This, therefore, is the reason for the urgency of developing local practice guidelines for the management of this common disease. While there are many international practice guidelines which can be adopted in its totality, this guideline is meant to address issues that are unique and relevant to the Filipino population and when available, include local research in the development of the recommendations.This guideline is a collaborative work of different specialties in the interest of curbing the morbidity and mortality due to hypertension in the country, by providing a set of recommendations that could guide the Filipino physician in the management of elevated blood pressure.The objective of the guidelines is to present evidence‐based recommendations on the diagnosis and treatment of hypertension that are adapted from international practice guidelines, but which take into consideration local realities and the practice of doctors in the Philippines. It is intended to help physicians make sound clinical decisions in the management of hypertension by presenting the latest information about diagnosis, treatment, and follow‐up of persons with hypertension. The primary targets for these guidelines are physicians in general practice, but these recommendations are also useful for all healthcare professionals in the Philippines.The guideline includes statements and recommendations on the definition of hypertension, treatment thresholds, and blood pressure targets, appropriate medications to reach targets, and specific management of hypertension among individuals with uncomplicated hypertension, hypertension among those with diabetes, stroke, chronic kidney disease, as well as the hypertension among pregnant women and pediatric populations. It also includes statements on the appropriate screening and monitoring when managing hypertension, and identification of groups who are at high risk for cardiovascular (CV) events.2The project to develop the Philippine Practice Guideline was spearheaded by the Philippine Society of Hypertension and the Philippine Heart Association, in collaboration with experts from various fields including pediatricians and pediatric cardiologists, obstetrician‐gynecologists, endocrinologists, nephrologists, and neurologists/stroke specialists. The administrative group organized a technical writing group comprised of these experts who decided in consensus to use the ADAPTE process in developing the 2020 Clinical Practice Guidelines (CPG) on Hypertension.https://g‐i‐n.net . The process of adaptation is systematic, allowing for transparent and explicit reporting and typically allows the use of multiple guidelines and their contents, to develop a new set of guidelines, that is, locally relevant.The rationale for guideline adaptation rather than de‐novo guideline development is to allow efficient use of current information, that is, already available in existing practice guidelines, abbreviating the process of identifying individual studies that apply to specific research questions, appraising them, evaluating individual study quality and finally, developing specific recommendations. This methodology also still allows for customizing or modifying existing guideline recommendations to suit the local context, and to add any local researches or new information on the question as they become available. The methodology for guideline adaptation using the ADAPTE process is available on the website of the Guidelines International Network at Each of the organizations involved in the process of guideline development nominated a group of experts who will comprise the technical working group (TWG). The TWG was organized into clusters that developed the six areas that were covered by the CPG: general recommendations for adults with hypertension; blood pressure management among persons with diabetes, chronic kidney disease; and stroke; and hypertension among Pregnant women and children.2.1The TWG searched for all published guidelines, both local and international, pertaining to the clinical questions, with the use of electronic search engines and manual search. Literature search was done by each of the working groups using search engines such as Pubmed (Medline), Google Scholar, other medical search engines using key words relevant to each clinical question. The full listing of guidelines that were retrieved, appraised and included for each research question for each of the TWG clusters can be found in the full guideline.2.2Each cluster then developed and presented their draft recommendations for approval to the panel of experts for discussion and approval by consensus of the majority. These draft recommendations were then revised and presented again to the panel and were finalized. Several public presentations have also been made to further elicit feedback from various stakeholders on the details of the guidelines. The recommendations presented here are the result of these iterative processes.3I. Diagnosis and management of hypertension in adult populationClinical question 1. Among adult Filipinos, what is the definition of hypertension?Statements:1.1Hypertension is defined as an office blood pressure (BP) of 140/90 mm Hg or above, typically at least twice taken on two separate days.1.2It is recommended that office BP be classified as Normal, Borderline, Hypertension.1.3Out of office BP measurements are recommended to confirm the diagnosis of hypertension, with ambulatory blood pressure monitoring (ABPM) as the preferred method, and home blood pressure monitoring (HBPM) as an acceptable alternative.The TWG also decided to adopt the joint position statement of the Philippine Heart Association (PHA) and the Philippine Society of Hypertension (PSH)This guideline defines hypertension as an office BP of 140/90 mm Hg or above taken in accordance with the proper standard BP measurement. A cut‐off value has been set to simplify the diagnosis of hypertension and to rationalize the treatment decisions surrounding it. The continuum between BP level and the occurrence of CV and renal events is not clear, making the setting of a cut off value arbitrary. Nevertheless, hypertension is defined here as the level of BP at which the benefit of pharmacologic treatment supported by lifestyle interventions far outweigh the risks/costs of treatment as documented by clinical studies.All the guidelines reviewed define hypertension as a BP level of ≥140/90 mm Hg, except for the AHA/ACC guideline which pegs hypertension at a BP level of ≥130/80 mm Hg. All the guidelines except for NICE and the Indian guideline include different stages and grades for hypertension. This Philippine recommendation opted to keep it simple, and the definition of hypertension remains unchanged from the 2011 Philippine guidelineClinical question 2. Among adult Filipinos, what device is recommended for accurate blood pressure determination and monitoring?Statements:2.1A properly validated automated oscillometric sphygmomanometer  is recommended for in office or out of office use.2.2The aneroid sphygmomanometer  may be used in office or out of office provided the examiner is efficient and well trained, and the device is periodically checked according to standard maintenance procedures.2.3The aneroid sphygmomanometer is recommended for special cases like the presence of arrhythmias or extremes in BP levels.The guideline acknowledges the greater accuracy of a validated digital sphygmomanometer. However, the aneroid sphygmomanometer is still a widely available, cheaper, and accessible device for which many health care professionals have been trained. Thus, it may still be used in areas of the country where the digital device is not available, provided that there is proper training of personnel, and calibration and maintenance of the device is done regularly.Clinical question 3. Among adult Filipinos, what are the blood pressure thresholds for treatment and BP targets for the prevention of CV disease?Statements:3.1A therapeutic threshold of 140/90 mm Hg to achieve a goal of less than 130/80 is recommended for most adults with hypertension.3.2For the very elderly, defined as 80 years old and above, a therapeutic threshold of 150/90 mm Hg to achieve a goal BP of less than 140/90 mm Hg is recommended.All guidelines agree that patients with hypertension should receive anti‐hypertensive treatment on top of diet and lifestyle modification to reduce blood pressure to treatment targets. Lowering blood pressure to less than 140/90 has been shown repeatedly to reduce morbidity and mortality.We recommend these interventions to achieve a blood pressure of < 130/80 mm Hg in Filipino adults with hypertension.This local guideline takes a practical approach to BP targets in recommending a threshold of greater than 140/90 mm Hg to start therapy. This can be addressed with diet and lifestyle modifications alone in low‐risk hypertensives or concomitant lifestyle changes with medical treatment in high‐risk individuals. Clinical question 4. Among Filipinos with hypertension, what are the general treatment recommendations?Clinical question 4.1. What non‐pharmacologic approaches are recommended for persons with hypertension?Statements:4.1Lifestyle modification remains the cornerstone for the management of hypertension. Robust clinical trial evidence has shown that it can prevent or delay the onset of high blood pressure and can reduce CV risk. Healthy lifestyle choices are the first line of antihypertensive treatment and of course are synergistic to the effects of antihypertensive medications. Lifestyle modifications should include the following:4.1.1Dietary Approaches to Stop Hypertension (DASH) meal plan which is low in sodium and high in dietary potassium, can be recommended for all patients with hypertension without renal insufficiency.4.12Aerobic physical activity and (dynamic) resistance exercises4.13Abstinence from alcohol or moderate alcohol intake4.14Significant weight loss of ≥ 5% of the baseline weight for those who are overweight or obese4.15Smoking cessationSodium restriction to as low as 1500 mg/day. The American Heart Association recommends that sodium intake be limited to 2300 mg/day  in most healthy individuals and 1500 mg/day in people with prehypertension or hypertension.Effective CV protection for hypertensive patients requires achievement of blood pressure targets with appropriate lifestyle measures and anti‐hypertensive medications. The goal of treatment strategies is to reduce excess CV morbidity and mortality from chronically elevated blood pressure.Clinical question 4.2. What are the preferred drugs for the treatment of hypertension among adult Filipinos for prevention of CV diseases?Statements:4.2.1Among persons with uncomplicated hypertension, angiotensin‐converting enzyme (ACE) inhibitors or angiotensin‐receptor blockers (ARBs), calcium channel blockers, thiazide/thiazide‐like diuretics are all suitable first‐line antihypertensive drugs, either as monotherapy or combination.4.2.2Ideal combination therapy includes renin‐angiotensin‐system (RAS) blocker with calcium channel‐blocker (CCB) or thiazide/thiazide‐like diuretics. Other combinations of the five major classes may also be used in patients with compelling indications for the use of specific drug classes.4.2.3ACE inhibitors & ARBs are not recommended to be used in combination. Likewise, combinations of ACE‐I or ARBs with direct renin inhibitors should not be used.4.2.4The use of free combinations is recommended if single‐pill combination therapy is not available or not affordable.4.2.5Beta blockers are suitable as initial therapy in hypertensive patients with coronary artery disease, acute coronary syndrome, high sympathetic drive and pregnant women. Beta blockers for those with congestive heart failure was specified to be bisoprolol, carvedilol, metoprolol succinate or nebivolol.4.2.6Among patients with BP > 150/100 mm Hg (or >160/100 mm Hg in the elderly), a combination of two agents, preferably combination of a RAAS inhibitor (ARB/ACE‐is) and CCB or diuretic, should be given initially since it is unlikely that any single agent would be sufficient to achieve the BP target.Guideline recommendations include risk‐factor identification to stratify hypertensive patients since the presence of one or more additional CV risk factors proportionally increases the risk of coronary, cerebrovascular, and renal diseases. Risk stratification directs the degree of aggressiveness in setting BP targets and in using pharmacologic treatment on top of diet and lifestyle modifications. Risk stratification involves identification of risk factors, presence of hypertension‐mediated organ damage (HMOD) and established CV and related diseases.2), diabetes, high LDL‐C (>130 mg/dl) and high triglyceride (>150 mg/dl), family history of CVD, family history of hypertension, early‐onset menopause, smoking, and various psychosocial or socioeconomic factors (poverty). HMOD include LVH (LVH with ECG), moderate‐severe CKD , and any other available measure of organ damage. Finally, take note of established CV and related diseases such as previous coronary heart disease (CHD), heart failure, stroke, peripheral vascular disease, atrial fibrillation, and CKD stage 3+.Cardiovascular risk factors include advanced age (>65 years), male sex, increased body weight  be initiated at a blood pressure of ≥ 140/90 mm Hg.Consistent then with the section on general guidelines for treatment, plus the recommendations of majority of the international guidelines on the management of hypertension among persons with diabetes, the threshold for treatment continues to be 140/90 mm Hg.Clinical question 6: Among persons with diabetes and hypertension, what non‐pharmacologic therapy is recommended?Statement:6. The general advice for non‐pharmacologic therapy for hypertension among persons with diabetes is similar to the general population. Additionally, screening for obstructive sleep apnea may be worthwhile as randomized studies of people with diabetes have shown that treatment of OSA (by Continuous Positive Airway Pressure or CPAP) reduces blood pressure.Clinical question 7. Among persons with diabetes and hypertension, what are the blood pressure targets for prevention of CV diseases ?Statement:7. A blood pressure target of <130/80 mm Hg is recommended for most persons with diabetes mellitus and hypertension; however, do not lower down the blood pressure below 120/70 due to an increased risk for adverse events.While CV risk reduction  is already significant for BP <140/90 mm Hg , a lower blood pressure target of <130/80 mm Hg has additional benefit for stroke reduction and decreased risk for nephropathy.Clinical question 8. Among persons with diabetes, what are the preferred drugs for the treatment of hypertension?Statements:8.1low‐dose combination of a RAAS blocker (ACE‐I or ARB) with a CCB or thiazide/thiazide‐like diuretic, preferably using a single‐pill combination (SPC). Free tablet combinations may also be given if SPCs are not available.It is recommended to initiate treatment with a 8.2The combination of ACE and ARB is not recommended due to a higher risk of hyperkalemia and renal failure.As already stated in the general guidelines, the choice for starting on initial combination therapy results in greater achievement of BP lowering at the shortest amount of time. Low‐dose combination therapy has been shown to be more effective than maximal dose monotherapy in the general population of persons with hypertension.III. Management of hypertension in persons with chronic kidney diseaseHypertension is highly prevalent in individuals with chronic kidney disease The prevalence of hypertension increases from 36% in stage 1 to 84% in chronic kidney disease stage 4 and 5. Needless to say, blood pressure control is fundamental to the care of patients with chronic kidney disease and is relevant at all stages of chronic kidney disease regardless of underlying cause.Clinical question 9. Among patients with CKD who are pre‐dialysis, what is the level of blood pressure to start pharmacotherapy to prevent CV complications and renal progression?Statement:9. Patients with BP ≥140/90 mm Hg should have prompt initiation and timely titration of pharmacotherapy to achieve blood pressure goals.Clinical question 10. Among patients with CKD who are pre‐dialysis, what is the target blood pressure to prevent CV complications and renal progression?Statements:10.1routine office blood pressure measurement, maintain a BP target consistently <140 mm Hg systolic and <90 mm Hg diastolic in patients with low risk of CV disease and CKD grade 4 and 5, or if with adverse effect on intensive target of <130/80 mm Hg. CKD patients with high CV risk or CKD grade 3 or earlier is recommended to have a blood pressure target of <130/80 mm Hg.For 10.2standardized office BP measurement is targeted, when tolerated, among adults with high BP and non‐dialysis CKD (ND‐CKD). An individualized treatment target is recommended for the following patient populations: Diabetic Kidney Disease patients, CKD grade 4 and 5ND patients, patients with proteinuria of more than 1 g/day, individuals with baseline SBP of 120 to 129 mm Hg, those with very low diastolic BP of less than 50 mm Hg with CAD, those with white coat or severe hypertension, stroke patients, those with age less than 50 with low absolute risk for CV disease or those individuals above 90 years of age, very frail patients, those with limited life expectancy and those with symptomatic postural hypotension. For these patient populations, a specialist referral is suggested.A systolic BP of <120 mm Hg using a 10.3If unable to obtain a standardized BP measure, maintain a blood pressure target consistently ≤130 mm Hg systolic and ≤80 mm Hg diastolic in patients with urine albumin excretion of >30 mg per 24 h unless adverse event occurs with achievement of this target.Clinical question 11. Among patients with CKD, what is the level of blood pressure to start initiation with two antihypertensive drugs to prevent CV complications and renal progression?Statement:11. Patients with confirmed office‐based blood pressure or ≥160/100 mm Hg should, in addition to lifestyle modification, have prompt initiation and timely titration of two drugs or a single‐pill combination of drugs demonstrated to reduce CV events.A two‐drug combination should consider these mechanisms in the choice of anti‐hypertensives: calcium channel blockers and diuretics to address volume dependent type of hypertension, and ACE, ARB and beta blockers for the renin dependent type.Clinical question 12. Among patients with CKD, what is the anti‐hypertensive of choice to prevent CV complications and renal progression?Statement:12. Treatment for hypertension should include drug classes demonstrated to reduce CV events in patients with CKD such as ACE inhibitors, Angiotensin Receptor Blockers, Thiazide‐like diuretics, and dihydropyridine calcium channel blockers.Clinical question 13. Among patients with CKD with albuminuria/proteinuria, what is the anti‐hypertensive of choice to prevent CV complications and renal progression?Statements:13.1These medications should not be discontinued unless serum creatinine level rise above 30% over baseline during the first 2 months of treatment or hyperkalemia (serum potassium level   ≥ 5.6 mmol/L). If the patient is intolerant to both ACE inhibitor and angiotensin receptor blocker, a non‐dihydropyridine calcium channel blocker (verapamil or diltiazem) may be used as first line treatment in this setting.An ACE inhibitor or Angiotensin receptor blocker, at maximally tolerated dose is the recommended first‐line treatment for hypertension in CKD patients with urinary albumin‐to‐creatinine ratio ≥30 mg/g . If one class is not tolerated, the other is substituted. 13.2Combinations of ACE inhibitor and Angiotensin receptor blocker and of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used.Clinical question 14. Among patients with CKD with resistant hypertension, is the addition of mineralocorticoid receptor antagonist beneficial in reducing albuminuria and CV events?Statement:14. CKD patients with resistant hypertension not meeting blood pressure targets on three classes of anti‐hypertensive medications (including diuretic) should be considered for mineralocorticoid receptor antagonist therapyClinical question 15. Among patients with CKD, is giving anti‐hypertensive at bedtime more beneficial in reducing CV event?Statement:15. Administer one or more antihypertensive medications at bedtimeIV. Blood pressure management among persons with strokeThe relationship between hypertension and stroke is very dynamic and multifaceted. Management of hypertension during the acute onset of stroke (whether ischemic or hemorrhagic) and during the secondary prevention phase poses a challenge due to the intricacies of how elevated BP must be handled.Clinical question 16.1. For adults with acute ischemic stroke (AIS) who are eligible for intravenous (IV) thrombolysis but not for mechanical thrombectomy, what is the threshold for pharmacological treatment and the target blood pressure (BP)?Statement:16.1For adults with AIS who are eligible for IV thrombolysis but not for mechanical thrombectomy, a referral to a neurologist or stroke specialist is advised. It is recommended that the BP be maintained to <185/110 mm Hg prior to treatment and during infusion. For the next 24 h after treatment is given, the BP is recommended to be maintained at <180/105 mm Hg.Clinical question 16.2. For adults with AIS who are eligible for IV thrombolysis but not for mechanical thrombectomy, what are the pharmacologic agents of choice to reach the target BP?Statement:16.2It is recommended to use a titratable intravenous medication to allow dynamic adjustment of the drug depending on the current BP. For patients with acute ischemic stroke otherwise eligible for intravenous thrombolysis with BP > 185/110 mm Hg before or during infusion, or BP > 180/105 mm Hg after treatment, the recommended pharmacologic agent is Nicardipine 1–5 mg/h. IV, titrated up by 2.5 mg/h. every 5–15 min, with maximum of 15 mg/h. If available, labetalol 10 mg IV over 1–2 min followed by continuous IV infusion of 2–8 mg/min may also be used.Clinical question 17.1. For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, what is the target BP and threshold for pharmacological treatment?Statement:17.1For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, it is recommended to maintain a target mean arterial pressure (MAP) of 110–130 mm Hg.For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, the threshold for urgent antihypertensive treatment is with severe hypertension of Systolic BP >220 mm Hg or Diastolic BP >120 mm Hg. If with severe hypertension, it might be reasonable to reduce the BP by 15% during the first 24 h after the onset of stroke.Clinical question 17.2. For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, what pharmacological agent may be used to achieve target BP, when needed?Statement:17.2For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, the use of IV nicardipine to achieve the target BP may be considered.Clinical question 18.1. For adult patients with acute hypertensive parenchymal intracerebral hemorrhage (ICH), what is the threshold for BP lowering in the first few hours upon presentation at the emergency room?Statement:18.1For adult patients with acute ICH, the threshold for BP lowering is SBP ≥ 180 mm Hg.Clinical question 18.2. What would be the target BP when lowering the blood pressure in acute ICH?Statement:18.2The target SBP is <180 mm Hg. In patients with SBP ≥180 mm Hg, careful BP lowering to 140 to 160 mm Hg should be considered. The magnitude of BP reduction is dependent on the clinical context. It should be careful SBP lowering (avoiding reductions ≥60 mm Hg in 1 h).■It is recommended to keep the blood pressure stable and avoid variability.■It is also recommended not to lower the BP acutely to <140 mm HgClinical question 18.3. What are the pharmacologic agents of choice and manner of administration?Statement:18.3st line drug of choice is IV Nicardipine. Alternative treatment choice would be labetalol, when available.It is recommended to use intravenous antihypertensive agents that can easily be titrated to lower the BP to the desired level. The 1Clinical question 19. For adults who have a history of stroke, what is the target blood pressure level for secondary prevention?Statement:19. For adults with history of stroke, the target blood pressure level for secondary prevention is ≤ 130/80 mm Hg. RAS blockers, CCBs and thiazide diuretics remain to be the first‐line pharmacologic agents in hypertension management for secondary stroke prevention.A patient with a history of stroke will most likely have another stroke in his lifetime. In the United States, recurrent strokes make up almost 25% of the nearly 800,000 strokes annually.V. Management of hypertension in pregnancyHypertensive disorders of pregnancy constitute one of the major causes of maternal and perinatal morbidity and mortality worldwide. It has been estimated that preeclampsia complicates 2–8% of all pregnancies globally.Clinical question 20. What are the different types of hypertensive disorders of pregnancy (HDP) and what are the criteria for each?and proteinuria.1.11.1.1Systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on two occasions at least 4 h apart after 20 weeks of gestation in a woman with a previously normal blood pressure.1.1.2Systolic blood pressure of 160 mm Hg or more diastolic blood pressure of 110 m Hg or more.  to facilitate timely antihypertensive therapy).Elevated blood pressure defined as1.21.2.1300 mg or more per 24 h urine collection (or this amount extrapolated from a timed collection), or1.2.2Protein/creatinine ratio of 0.3 mg/dl or more or1.2.3Dipstick reading of 2+ (used only if other quantitative methods not available)Proteinuria (26)1.31.3.19/LThrombocytopenia: Platelet count < 100,000 × 101.3.2Renal insufficiency: Serum creatinine concentrations >1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of other renal disease1.3.3Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration1.3.4Pulmonary edema1.3.5New‐onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptomsOr in the absence of proteinuria, new onset hypertension with the new onset of any of the following:1.4Eclampsia‐ New‐onset tonic‐clonic, focal, or multifocal seizures in the absence of other causative conditions such as epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, or drug use.1.5Chronic Hypertension‐ Hypertension of any cause, that predates pregnancy. BP ≥ 140/90 mm Hg before pregnancy or before 20 weeks gestation or both.1.6Chronic Hypertension with Superimposed Pre‐eclampsia‐ Chronic hypertension in association with preeclampsia. Others define it as worsening baseline hypertension accompanied by new‐onset proteinuria or other findings supportive of preeclampsia.Pre‐eclampsia‐ Elevated blood pressure Acute, severe, and persistent elevations in blood pressure.Sudden increase in baseline hypertension.1.71.7.1Systolic blood pressure 140 mm Hg or more or a diastolic blood pressure of 90 mm Hg or more, or both, on two occasions at least 4 h apart after 20 weeks of gestation, in a woman with a previously normal blood pressure.1.7.2Hypertension without proteinuria or severe features develops after 20 weeks of gestation and blood pressureGestational Hypertension –New‐onset proteinuria or sudden increase in proteinuria.For patients with chronic hypertension, it can be difficult to differentiate worsening of the hypertension from superimposed preeclampsia. Conditions that may indicate superimposed preeclampsia, that warrants a referral to a maternal fetal medicine specialist/perinatologist, include the following:Clinical question 21. What blood pressure threshold is used to define hypertension in pregnancy?Statement:21. Hypertension is diagnosed empirically when appropriately taken blood pressure is 140 mm Hg systolic or 90 mm Hg diastolic or above. Korotkoff phase V is used to define diastolic pressure.Clinical question 22. What antihypertensive agents can be used for urgent blood pressure control in pregnancy?Statement:22. Acute‐onset severe hypertension  can occur in the prenatal, intrapartum and postpartum period. It is accurately measured using standard techniques and is persistent for 15 min or more. The first line of treatment is intravenous (IV) hydralazine and labetalol; intravenous nicardipine is also an option. Extended release oral nifedipine also may be considered as a first line therapy, particularly when IV access is not available. Use of these drugs does not require cardiac monitoring.Clinical question 23. When do we treat hypertension during pregnancy?Statement:23. Treatment of severe hypertension (blood pressure of ≥ 160/100 mm Hg) is always recommended as it prevents serious maternal and fetal complications to set in.Initiating therapy in non‐severe disease, however, is a patient of controversy. The NICE, ISSHP and SOGC recommends therapy when the blood pressure remains above 140/90 mm Hg but SOGC suggests a lower threshold in patients with other co‐morbidities.Clinical question 24. What are the pharmacologic treatment options in the OPD management of hypertension in pregnancy?Statement:24. The choice of antihypertensive drug for initial therapy should be based on the characteristics of the patient, contraindications to a particular drug and physician and patient preferences. The first line drugs are methyldopa, calcium channel blockers or beta blockers, and ACE‐inhibitors and angiotensin‐receptor blockers (ARBs) are generally not recommended. Antihypertensives may be used to keep systolic blood pressure at 130 to 155 mm Hg and diastolic blood pressure at 80 to 105 mm Hg.Clinical question 25: How is hypertension managed during the immediate postpartum and breastfeeding periods?Statement:25. Blood pressure should be recorded shortly after birth and if normal again within 6 h.In hospital stay for at least 24 hCheckup within 48–72 h of the birth and again 7–14 days and at 6 weeks post‐partum.All women should be reminded of the danger signs of preeclampsia following birth including headaches, visual disturbances, nausea, vomiting, epigastric or hypochondrial pain, feeling faint or convulsions.All women should have BP recorded and discharge deferred for at least 24 h or until vital signs are normal and/or treated or referred. Any woman with an obstetric complication and/or newborn with complications should stay in the hospital until both are stable.VI. Blood pressure management in the pediatric populationClinical question 26. Among pediatric patients, what is the threshold for commencing pharmacologic treatment for Hypertension?Statements:26.1 Pharmacologic treatment for hypertension (HTN) should be started for children with the following conditions:26.1.1 Children who remain hypertensive even after 6 months of lifestyle modification strategies* (see Table 26.1.2 Symptomatic hypertension or Stage 2 hypertension26.1.3 Presence of co‐morbidities like chronic kidney disease (CKD) or diabetes mellitus (DM), or any evidence of target organ involvement .26.2. The goal of pharmacologic therapy should be a reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) to <90th percentile for age, sex and height and <120/80 mm Hg in adolescents ≥13 years of age.26.3. For children with CKD, BP targets should be less than or equal to 50th percentile for age, sex and height.26.4. The goal of treatment of hypertension in the pediatric population is not only to reduce BP to <90th percentile for age, sex and height and <130/80 mm Hg, but also to reduce CV risk factors, and prevent target organ damage.26.5. Follow‐up every 4–6 weeks is recommended for monitoring and evaluation of therapy.Clinical question 27. What advice regarding nonpharmacologic treatment is recommended for pediatric patients?Statements:27.1 Non‐pharmacologic therapy of lifestyle modification which include Dietary Approaches to Stop Hypertension (DASH) and engaging in 30–60 min of moderate to vigorous physical activity at least 3–5 days a week should be initiated in all pediatric patients consulting for the first time for hypertension.27.2 All children with hypertension should have their body mass index (BMI) measured during each visit.27.3 Weight loss intervention is recommended for identified overweight and obese children until a normal BMI is attained through dietary counselling and exercise (weight loss of 1 to 2 kg per month).27.4 All children diagnosed to have hypertension or elevated BP should be advised to do the following:27.4.1 Decrease intake of high sodium content and calorie‐dense food and beverages, and to increase intake of fruits and vegetable to 3–5 servings per day.27.4.2 Engage in moderate‐to‐vigorous exercise 30–60 min at least 3–5 times a week but preferably daily, unless with medical contraindication.27.4.3 Avoid smoking including electronic cigarettes and exposure to tobacco smoke.27.4.4 Avoid alcohol intake and caffeinated energy drinks.Clinical question 28. What are the BP targets for prevention of target organ complications?Statements:28.1 The target BP for children is <90th percentile for age, sex and height or <120/<80 mm Hg whichever is lower.28.2 For CKD patients, BP target is less than or equal to the 50th percentile for age, sex and height.Clinical question 29. What are the preferred medications for children?Statements:29.1 Any of the following drugs may be used as initial treatment for children with hypertension: ACE inhibitors , ARBs , or calcium channel blockers (Amlodipine).29.2 For children with co‐existing chronic kidney disease, proteinuria or diabetes mellitus, an ACE‐inhibitor or ARB is recommended as the initial antihypertensive drug unless with absolute contraindications. Referral to a specialist is highly recommended.29.3 Therapy should start with a single drug at the lowest possible dose and titrated up every 2–4 weeks until target BP is achieved, or the maximal dose reached, or adverse effects occur.29.4 If BP is not controlled with a single agent , a second agent can be added to the regimen and titrated as with the initial drug. Because the use of other anti‐hypertensive agents can lead to compensatory salt and water retention, the addition of a thiazide diuretic to an initial drug for uncontrolled hypertension is prudent.29.5 In combining agents from different drug classes, it is preferable to give those with complementary modes of action. Ideally, no two drugs which act separately on the RAAS, should be used in combination because of the risk of hyperkalemia, impaired kidney function and hypotension.Clinical question 30: What is the recommended technique and BP device for accurate BP measurement in pediatric patients?Statements:30.1 The use of proper technique and appropriately‐sized cuff is critical for the accurate measurement of BP in children.30.2 An auscultatory device using an aneroid non‐mercury sphygmomanometer is recommended for children.30.3 An oscillometric device is a suitable alternative to auscultation for initial BP screening and monitoring in the pediatric population.30.4 Ambulatory BP monitoring (ABPM) is recommended in children (> 5 years old) and adolescents with the following conditions:30.4.1 Elevated office BP measurements for one or more years, or if with stage 1 hypertension over 3 clinic visits, for confirmation of hypertension.30.4.2 Those with high‐risk conditions  to document masked hypertension.suspected white coat hypertension (WCH).30.4.3 Those with 30.5 Home BP monitoring should not be used to diagnose hypertension, MH, or WCH but may be a useful adjunct to office and ambulatory BP measurement if clinically validated oscillometric apparatus and appropriate‐sized cuffs are used.4The clinical questions and statements in this clinical practice guideline allow us to holistically manage the Filipino hypertensive individual. We recommend that the diagnosis of hypertension among adults should be based on a BP reading of equal or more than 140/90 mm Hg. The target BP should be less than 130/80 mm Hg to prevent hypertension‐mediated organ damage. We also recommend that lifestyle modification be advised to all persons with hypertension. The use of appropriate anti‐hypertensive medications depending on the co‐morbidity of the individual is recommended. We also recommended management for the pediatric and the pregnant hypertensive. Simplified algorithms are provided to serve as a quick reference guide to clinicians. There was limited Filipino data, particularly in the pediatric population thus, local studies are needed to collect real‐world data on the use of various medications in various populations, and even of the utility of this practice guideline.The 2020 CPG is designed to be a guide for clinicians in managing hypertension for the Filipino patient. This, however, should not replace sound clinical judgment, and the ultimate decision for treatment should be shared by both clinician and the patient.Dr. Gilbert C. Vilela (Philippine Heart Association)Dr. Alberto A. Atilano (Philippine Society of Hypertension)Dr. Aurelia G. Leus (Philippine Heart Association)Dr. Felix Eduardo R. Punzalan (Philippine Society of Hypertension)Expert Panel(Cardiology Group)Joanna Cosare‐San Pedro, MDJulius Caesar D. De Vera, MDRamanaya D. Garcia, MDJoanna Teresa Margarita L. Manalo, MDIrma Marie P. Yape, MDChristian Michael H. Pawhay, MDEduardo O. Yambao Jr., MD(Nephrology Group)Christine V. Pascual, MDMarichel Pile‐Coronel, MDGelen Vestalez Umali‐Sunga, MD(Pediatrics Group)Emely G. Anupol, MDJuliet J. Balderas, MDJose Jonas D. Del Rosario, MDBee Jane T. Martinez, MDLeah Patricia A. Plucena, MDAndrea Orel S. Valle, MDEleanor C. Du, MD (Philippine Society of Pediatric Metabolism and Endocrinology)Sylvia C. Estrada, MD (Philippine Society of Pediatric Metabolism and Endocrinology)Maria Rosario F. Cabansag, MD (Pediatric Nephrology Society of the Philippines )Lorna Lourdes L. Simangan, MD (Pediatric Nephrology Society of the Philippines )Dorothy M. Ann Calma, MD (Obstetrics Gynecology Group)Joseph U. Olivar, M.D.Kristine S. Sese, M.D.Irene B. Quinio, M.D.Ma. Geraldine Assumption Gavina C. Torralba, M.D.Zarinah G. Gonzaga, M.D.Amaryllis Digna O. Yazon, M.D.Nerissa Gracia G. Nano‐de Guzman, M.D.Drs. Leilanie Mercado‐Asis, Vimar Luz, Aurelia Leus, Alejandro Bimbo Diaz, Allan Belen, Roberta Maria Cawed‐Mende, Arnel Chua, Anne Marie Joyce Javier, Dan Neftalie Juangco, Juan Miguel Ortiz, Christia Padolina, Maria Concepcion Sison, Jonnie Bote‐Nunez, Carmela Madrigal‐Dy, Marlon Manicad,Ninfa Villanueva have nothing to disclose.Dr. Deborah Ignacia Ona receives honoraria as part of the speaker's bureau of Upjohn, Viatris, Astra‐Zeneca, Sanofi, Servier, MSD, Getz, Advisory Board of Sanofi, research grant from St. Luke's Medical Center, outside the submitted workDr. Cecilia Jimeno is the vice editor of JAFES; reports speaking engagements of Natrapharm, Novartis, Servier Philippines, LRI‐Therapharma; CME grant from OEP, Cathay; Advisory board of MSD, outside the submitted work.Dr Gabriel Jasul reports honorari as part of the speaker's bureau of Boehringer Ingelheim , MSD, Sanofi‐Aventis, Novo Nordisk, LRI‐Therapharma, Abbott Nutrition, Umed, Astra Zeneca, and J &JDr. Ma. Lourdes Bunyi receives speaking grants from Omron.Dr. Raymond Oliva reports connection to Astellas Pharma Philippines, outside the submitted work.Dr. Lourdes Ella Gonzalez‐Santos reports personal fees for speaking engagements from LRI‐Therapharma, Sanofi‐Aventis, Servier Philippines, Merck Sharpe and Dohme, Astra Zeneca, Menarini, Novartis, Natrapharm, Pascual, Amgen; research grant from Cardinal Santos Medical Center, outside the submitted work.Dr. Dolores Bonzon is receiving speaking grants from Viatris.Substantial contributions to the conception or design; or the acquisition, analysis or interpretation of data for the workDrafting the work or revising it critically for important intellectual contentFinal approval of the version to be publishedAgreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are properly investigated and resolvedAll authors of this manuscript fulfilled the ICMJR criteria for authorship: