Clinical Practice Guidline for

Hypertension

Disease/Condition(s)
/
Hypertension
1958WHO/
160/95 mmHg1999(WHO)
1997 (JNC)6
140/90mm Hg1993WHO
1.18
2140mm Hg/90mm Hg
2.
130mmHg80mmHg2003
JNC7120-139/80-89 mmHgprehypertension
140-159mmHg
90-99mmHg160mmHg
100mmHg()
180mmHg
110mmHg
175/85mmHg
140mmHg90mmHg

12~13 35 15~16 35

5-10mmHg

20mmHg2-4mmHg
Korotkoff
Korotkoff

DC

Guideline Category

Counseling
Evaluation
Management
Prevention

Clinical Specialty

Family Medicine
Internal Medicine
Cardiology
Gerontology
Preventive Medicine

Intended Users

()

Guideline Objective(s)

[1-3]
(disease burden)[4]
(disease burden)[4]

[1-3,5,6]

Target Population

2-4 160/110mmHg 50 5
2.5~5%
3

(
1-3
)
( TIA)
55

65

1.
(1.2~2.0mg/dl)

2.
(
240mg/dl
()
LDL 160mg/dl
1.5mg/dl)

300mg/day

50

HDL 40
45mg/dl

(
)
J Hypertension 2003;21:1984, WHO/ISH statement on hypertension

3
JNC7 120/80mmHg
140/90mmHg

(Coronary heart disease)

2002

mmHg

140/90

1 130/80
g/d
1 g/d

125/75

20~25%

()

140-159 160-179
180
90-99mmHg 100-109mmHg 110mmHg

II 1-2

III()3

J Hypertension 2003;21: 1985, WHO/ISH statement on hypertension

1.

0.5
1 mm-Hg
5-6mmHg40%10mmHg
2.

720cc300cc60cc

3.

4.

5.

6.

7.

8.

25~10

16

14

52.5

62.4

30%
10mmHg

5~6

3 ~5

1.
6

2.
(A)(B)
(C)

(1)

30g

15 mmHg710 mmHg

(2)
(licorice)carbenoxolone (
)
(mineralocorticosteroid)

(3)
(corticotropin, ACTH)

(4)
(nonsteroid anti-inflammatory drug,NSAID)
indomethacin
(5)
phenylpropanolamine
(catecholamine)

(MAO inhibitor)pargyline
(tyramine)

3.

4.
ductus arteriosus

5.
Conn's syndrome

ATP III

ATPIII)

()

CAD
55 65

45
55

140/90mmHg

Interventions and Practices Considered

()
()
() (target organ)

1.

(cyclosporine)(erythropoietin,
EPO)(MAO inhibitor)
9

2.
(1)

(2)

(3)

180/110mmHg/

30
3.

10

FriedwaldATPII
ATPIIIATPII1999chronic actable angina pectoris
LDLC

(1)
a.

Sokolow-LyonV5
V6RV1S35(mV)

QT
b.

c.
126mg%
/

d.

e.

T
f.

g.
11

(2)

a.

(3)

a.

(Doppler)

b.

12

(renin)

24
(catecholamine)
(norepinephrine)(epinephrine)
(dopamine)

13

1.

2.

3.

hypertension in adults in primary

care

NICE clinical guideline 34

Hypertensionmanagement of

NICE clinical guideline 34-hypertension

14

BB

1/4

ABC
720c.c.300c.c.60c.c.
B

()5 45
30%10mmHg
B

1. DThiazideThiazide-likeLoopPotassium-sparing agents
aldosterone-receptor blocker
2. ACE
3. ARB
4. CDihydropyridinenon-DHP(DiltiazemVerapamil)
15

5. Hydralazine(
)
6.
a. prazosin(
)
b.
PropranololNadolol(Corgard)Timolol
Atenolol.
LabetalolCarvedilol
7. O
ReserpineIsmelin
2 ClonidineMethyldopa
Carvedilol Clonidine

1997 ARCH INTERN MED Carvedilol

Carvedilol
C

1. 180/1101

130/802003 WHO/ISH
140/902004 BHS IVNICE2006
2. 160/1002 2004
BHS TVNICE2006
3. 1~2 140/90
2 (2003 WHO/ISH)
4. 140~159/90~992
140~149/90~94
140/90 (WHO/ISH)

2003 WHO/ISH

16

()

I.
(1)Thiazide diuretics
Chlorthalidone(G)
Hydrochlorothiazide(G)

Hygroton
Hydrodiuril

12.5-50 (1)
12.5-50 (1)

Indapamide
Metolazone

Dichlotride
Natrilix
Mykrox

1.25-2.5 (1)
0.5-1.0 (1)

(2)Loop diuretics
Bumetanide(G)
Ethacrynic acid
Furosemide(G)

Bumex Busix
Edecrin
Lasix

0.5-4 (2-3)
25-100 (2-3)
40-240 (2-3)

(3)Potassium-sparing agents
Amiloride hydrochloride(G)
Triamterene(G)
(4)Adosterone-receptor
blockers Spironolactone(G)
II.
(1)
Guanethidine monosulfate
Reserpine (G)
(2) 2
Clonidine hydrochloride(G)
Guanfacine hydrochloride(G)

Methyldopa(G)
(3)1
Prazosin hydrochloride(G)
Doxazosin mesytate
Terazosin hydrochloride

()

(,)
()
(,)

Midamor
Dyrenium

5-10 (1)
25-100 (1)

Aldactone

25-100 (1)

()

Ismelin
Serpasil

10-150 (1)
0.05-0.25 (1)

(:)
(,,)

Catapres
Tenex
Aldomet

0.2-1.2 (2-3)
1-3 (1)
500-3000 (2)

()
()
()

( prazosin)
Minipress
Doxaben
Hytrin

2-30 (2-3)
1-16 (1)
1-20 (1)

ISA

(4)

Propranolol hydrochloride(G)
Nadolol(G)
Timolol maleate(G)

(blood
dyscrasias)

Inderal
Corgard
Blocadren

10-480 (2)
40-320 (1)
20-60 (2)
17


Atenolol (G)
Betaxolol hydrochloride
Bisoprolol fumarate
Metoprolol tartrate(G)
Metoprolol succinate

Tenormin
Kerlone
Zebeta Concor
Betaloc
Toprol-XL

25-100 (1-2)
5-20 (1)
2.5-10 (1)
50-300 (2)
50-300 (1)

Sectral
Cartrol
Visken

200-800 (1)
2.5-10 (1)
10-60 (2)

intrinsic sympathomimetic activity

Acebutolol 
Carteolol hydrochloride 
Pindolol (G) 
(5)

Carvedilol
Labetalol hydrochloride (G)
III.

Dilatrend
Trandate

Hydralazine hydrochloride (G)

Minoxidll (G)
IV.

Apresoline
Loniten

12.5-50 (2)
200-1200 (2)
50-300 (2)
5-100 (1)

(A) Nondihydropyridines(non DHP)

Diltiazem hydrochloride
Verapamil hydrochloride

Cardizem SR
Cardizem CD
Isoptin SR
Verelan

120-360 (2)
120-360 (1)
90-480 (2)
120-480 (1)

(B) Dihydropyridines (DHP)

Amlodipine besylate
Felodipine
Isradipine
Nicardipine hydrochloride
Nifedipine
Nisoldipine

Norvasc
Plendil
DynaCirc
Cardene SR
Procardia XL
Sular Syscor

2.5-10 (1)
2.5-20 (1)
5-20 (2)
60-90 (2)
30-120 (1)
20-60 (1)

()
()

V.
Benazepril hydrochioride
Captopril (G)
Enalapril maleate
Fosinopril sodium
Lisinopril
Moexipril
Quinapril hydrochloride

()
()

Lotensin
Capoten
Vasotec
Monopril
Prinivil, Zestril
Univasc
Accurpril
18

50-40 (1-2)
25-150 (2-3)
5-40 (1-2)
10-40 (1-2)
5-40 (1)
7.5-15 (2)
5-80 (1-2)

Ramipril
Trandolapril
VI.(ARB)

Altace
Mavik

Losartan potassium
Valsartan
Inbesartan
Telmisartan
Oimesartan
Camdesartan

Cozaar
Diovan
Aprovel
Micardis
Olmetec
Blopress

1.25-20 (1-2)
1-4 (1)

25-100 (1-2)
80-320 (1)
150-300 (1)
20-80 (1)
20-40 (1)
4-16 (1)

JAMA 2003;289:2565

 ISA

19


ANTIHYPERENSIVE COMBINA COMBINATIONS TIONS IN TAIWAN

mg

Benazepril+ Hydrochlorothiazide

Captopril+ Hydrochlorothiazide

Cilazapril+ Hydrochlorothiazide

Enalapril+ Hydrochlorothiazide

Fosinopril+ Hydrochlorothiazide

Imidapril+ Hydrochlorothiazide

Lisinopril+ Hydrochlorothiazide

Moexipril+ Hydrochlorothiazide

4/1.25

Perindopril+ Indapamide

2/0.625
-

Quinapril+ Hydrochlorothiazide

-+

-+

II
+

BI
PRETERAX
PRETERAX

Benazepil+Amlodipine

Enalapril+Felodipine

Ramipril+Felodipine

Trandolapril+Verapamil

Atenolol+Chlorthalidone

100/25

SHPYNJA
TARGET

Bisoprolol+ Hydrochlorothiazide

Metoprolol+Chlorthalidone

Metoprolol+ Hydrochlorothiazide

Nadolol+Bendroflumethiazide

Pindolol+Clopamide

Propranolol(LA)+Hydrochlorothiazide

Timolol+Hydrochlorothiazide

Atenolol+Amlodipine

Atenolol+Nifedipine (SR)

Metoprolol+Felodipine

Candesartan+ Hydrochlorothiazide

Eprosartan+ Hydrochlorothiazide

Irbesartan+ Hydrochlorothiazide

150/12.5

COAPROVEL

Losartan+ Hydrochlorothiazide
Olmesartan medoxomil+
Hydrochlorothiazide
Telmisartan+ Hydrochlorothiazide

50/12.5

HYZAAR

40/12.5,80/12.5

MICARDIS
PLUS

20

Valsartan+ Hydrochlorothiazide

80/12.5,160/12.5 CO-DIOVAN

Amiloride+ Cyclopenthiazide

+Thiazide
/

Amiloride+ Hydrochlorothiazide

5/50

Spironolactone+Butizide(thiabutazide)

ALOZIDE
,
AMITON
,
AMIZIDE

MODURETIC
TIADEN

Spironolactone+ Hydrochlorothiazide

25/25

Spironolactone+Hydroflumethiazide

50/50

SLOSAT
,

,
,
ALDACTIDE
,
,

Triamterene+ Hydrochlorothiazide

50/25

Methyldopa+ Hydrochlorothiazide

ANJAL
DYAZIDE
TRIAZIDE
-

0.1/4

BEHYD RA

Reserpine+Chlorthalidone

Reserpine+Chlorothiazide

0.1/0.5/5

BRINERDIN

0.1/10/10

ESIDRI
RELAZIDE

0.1/25/15

LISEIPIN

Reserpine+Benzylhydrochlorothiazide

Reserpine+Dihydroergocristine+Clop
amide
Reserpine+Hydralazine+
Hydrochlorothiazide
Reserpine+ Hydrochlorothiazide
MINS

21

----------------------

A+CA+D A+C+D

22


1.
2.
atenolol
(head-to-head)

3. Cost-effective(LIFE
15%)()

80%
1.5~2
(1)(2)(3)
(4)

a.1997 JNC6

b. Thiazide (TZ) 12.5mg

Hydrochlorothiaze HCTZ
2004BHS IV
(JNC7)
4. ()

5.

6.
B

7. ACE
ARB ACE D
8.
ACE ( Renin- angiotensin )
ARB
23

9.

10.

Thiazide
1. 1997 JNC6 HCTZ 6.25mg~ 2.5mg
2. 2003JNC7Thiazide
JNC6?JNC7
3. 2003 WHO/ISH
4. 2004 BHS IV HCTZ 12.5mg
HCTZ JNC7

TZ 12.5mg HCTZ

28% 16
Indapamide

JNC7 JNC7
2003 JNC7 2002 ALLHAT

4~5 Chlorthalidone 50~100mg( 48~72 )

(:) Doxazosin
Lisinopril
19% Amlodipine 38%
1,?2.
Lisinopril Amlodipine ?, 4~5
20~30
JNC7 Thiazide

24

1. CAD B + C
A
CHF D
+ A +
C FelodipineAmlodipine
DM
A C2003JNC7
CVD D A
BPH -blocker
2.A+C A+D()
3.A+C+D()
A AC
A ACE ARB
B
C
D

JNC7,2003

25





- ACE

ARB CCB

ACC/AHA
MERIT-HF

COPERNICUS CIBIS

SOLVD AIRE TRACE

ValHEFTRALES
ACC/AHA

BHATSAVECapricom
EPHESUS
ALLHATHOPEANBP2

LIFECONVINCE
NKF-ADA ; UKPDS

ALLHAT
NKF ; Captopril

RENAALINDNTREIN
AASK

PROGRESS
JNC7 JAMA 2003,289:2568
AASKACC/AHA /ACE
AIRE Ramipril ALLHAT
ANBP2ARBBHAT-
CCBCIBIS Bisoprolol CONVINCE
Onset Verapamil COPERNICUSCarvedilol
EPHESUSEplerenone HOPE
IDNTInbesartan LIFE Losartan
MERIT-HF Metroprolol CR/XL
NKF-ADA-PROGRESSPerindopril
RALES Aldactone REIN Ramipril RENAAL
Losartan SAVE
SOLVDTRACETrandolapril UKPDS
ValHEFTValsartan

[2]

26


1.39
2.JNC7 JNC7
2003
WHO/ISH 2003
2004 BHS IV WHO/ISH BHS IV
25mg Hydrochlorothiazide

JNC7 ALLHAT

3.JNC7

2004 WHO/ISH
2003 2004
BHS IV

non-Dihydropyridine

z1997 JNC6
z1999 WHO/ISH
(2003 JNC7TZ ()
(2003 WHO/ISH
(2003 ESH-ESC
(2004 BHS IV A(B) CD

(2006 NICE clinical guideline34-hypertension 2004 BHS IV

(1) ()

55 ()C D (BHS IV200NICE2006)

27

D1. 12.5mgHCTZ
2.BHS IV2004
3. (JNC7)
C
TZ

()
(2) ()
55 A( B)(BHS IV2004NICE2006)
A ACE ARB
(B)
(B) 1.
2.
3.
4.ACE
D
ACE 15~20% 1.ARB
2.3. C ()
A(B)
1. CAD (B)
z CAD A C
z A
2. CAD (B)
z DM D
z DM non-DHP (B)
non-DHP Af wpw Vf

28


(1)
55
1.
2.
A+CA+D Indapamide
B+C CA+OB+A D
z B
zJNC7
(2)
55 ()
A+CA+DC+D D
D+OC+BC+O D
z-blocker

z-blocker BPH A 2~3 C

1 50% 75%
140/90mmHg
2

1.A+C+D DJNC6
2.A+B+C C
3.Thiazide A+C+O C
Othe others() Reserpine 0.25mg 1/2
1/4 GuanethidineClonidine-methyldopa (19992003 WHO/ISH)

4. O A+C+-blocker (2005 ASCOT)

29


1.A+B+C+D (-blocker
2. u Hyperaldosteronism
Spironolactone
3.80mg

4.Central (2 agonist ClonidineReserpine

(-methyldopa
5. BP 140/90 160mm(NICE2006)
2003WHO/ISH 140mmHg

z
z

z
adolsteronism pheochromocytoma

z
z(
(codeine)(erythropoietin)
(cyclosporins)(Nasal decongestants)
z

THE JNC7 REPORT JAMA 2003,289:2569

:

30


140/90mmHg

55

55 ()

or

A ACE ACE
ARB,
(B)

+ or +

+ +

2006 NICE clinical guideline 34-hypertension

1.(Isolated systolic hypertension)

2. 80 55

3.

1. Indapamide
WHO/ISH 1999

31

2.

3. Verapamil Diltiazem(
) VerapamilDiltiazem()
4. Verapamil
5. -blocker B
6. ACEI ARB A
7. ACEI ARB Spironolactone

8.

9. Prazosin
D Guanethidine (
)
20mmHg D
10.
1999 WHO/ISH B
11.(ED)
ED (1)-blocker (2) (3) A (4)-blocker ED
ED
ED
(1) Thiazides
Spironolactone
Acetazolamide
Amiloride
Chlorthalidone

Impotence
Decreased libido, and impotence
Decreased libido, and impotence
Decreased libido, and impotence
Decreased libido, and impotence

(2) -blocker
Propranolol, and Labetalol
Decreased libido, and impotence
(3) Sympatholytics
Methyldopa
Decreased libido, and impotence
Clonidine
Impotence, and ejaculatory dysfunction
Reserpine
Decreased libido, and ejaculatory dysfunction
Guanethidine
Ejaculatory dysfunction

12.

32

(1)()
(2)

Vioxx
Procaterol(meptin)meptin FDA

13. ACE (angioedema)

aspyrin C
Histamin
Histamin
15
anaphylatic shock
decadnon A

Bosmin
D NS
D
14 ACE
HyporeninemicHypoaldosteronicHyperkalemic Syndrome B
1. (Hyporenin)
2.

3.

4. ()

Intra-atrialIntra-nodal &
Intra-Ventricular conduction delaySine
wave
(1)
(2)A B

1. B
aspirin(75mg)

aspirin
33

HOT 50
aspirin
aspirin
aspirin
aspirin aspirin
aspirin
2.
/(CHO)
(TG)(1)(VLDL)(2)
(LDL)(3)(HDL)(TotalC)
(HDLC)(LDLC)(VLDLC.
TG/5)ATP III20
HDLCLDLCATP IIIATP IIATP II
LDLCFriedewaldLDLCTotalCHDLC
VLDLCTG/5LDLC1999Guideline for the
management of patients with chronic stable angina
Calculated LDL()TG400mg%LDLC
LDLC94~99%TG
LDLC
LDLCTotalCHDLC+LDLC+VLDLC
(TG/5)TGLDLC/HDLC
Friedewald2013
LDLC
LDLC
LDLC
FraminghamATP III

10~20%
20%100
10200~1
10%ATP IIIII

ATP
(1)(2)140/90mmHg(3)HDL40mg/dl
60mg/dl(4)
5565(5)4555
HDL40mg/dl
34

TC200mg/dl

TC240mg/dl

LDL-C 130mg/dl

160mg/d>
TC200mg/dl(
TC/HDL-C5
HDL-C40mg/dl

TG200mg/dl

LDL-C130mg/dl

200 mg/dl

240 mg/dl

130 mg/dl

160 mg/dl

200 mg/dl

160 mg/dl

100 mg/dl

150 mg/dl

150 mg/dl

TG200mg/dl
(TC/HDL-C

5HDL-C40mg/dl

TG
200~499mg/dl

HDL-C130mg/dl
500mg/dlfibric
(3)
()
*1. 2.45 3. 4.55
5. 6.HDL40mg% (
56)
ATP III
A.
(1)LDLC130mg/dl(CHO 200mg/dl)Statins
LDLC100mg/dlCHO 160mg/dl(2)
LDLC100~129mg/dlTGHDLfibric acid
LDLC24~48
35

LDLC
LDLCLDLC100mg/dl
B.
C.0~1
LDLC
130mg/dlLDLC160mg/dl
LDLC130mg/dlLDLC
160mg/dlCHO 240mg/dl

LDLC190mg/dl

StatinsBile acid sequestrants

LDLCStatinsLDLC18~55%
Statin

ATP III
Statins

(GPT)33~12
Statins
Bile acid sequestrant Cholestyamine(Questran)
LDLC15~30%

TG200mg/dl
TG500mg/dlfibric acid
TG200~499mg/dlATP III
LDLCHDL
TG
HDLC40mg/dlTotal/HDLC5HDLC
3540535/40=4.384.38HDLC=TotalC
HDLC=LDLC+VLDLC (TG/5)ATP III
TG200mg/dlHDLC130mg/dl

ATP IIIHDLC130mg/dlLDLC100mg/dl
TG150/5TG200mg/dl0~1
ATP IIIHDLC
36

190mg/dlHDLC
()160mg/dl160mg/dl
TG200mg/dl
TG150mg/dlfibric aid
20~50
Nicotinic acidTG20~50%
/

TG(TG)
HDLCTG
TGTG
(fatty liver)VLDLC
(IDLC)50%LDLCVLDLC

HDLC

trans fatty acid

LDLC
LDLCNCEP
7%
LDLC

LDLC200(
300)
HDLCLDLC

3.
37

1 2 ACE-I ARB

1
125/75mmHg130/80mmHg
3 3
ACE-I ARB 2.5mg
Thiazide loop loop diuretics

4.
1.5 2
2
80%

2 2
insulin resistant stateSyndrome X
HDLC
ATP3
metabolic syndrome130/85 mmHg
(110mg/dl)(9080
)(150mg/dl)(40mg/dl)
ACE-I ARB

ARB

HOT

80mmHg
130/80mmHg
ACE-IARBThiazide
HbA1C7%

5.

38


ACE ARB
ACE ARB Hydralazine
minoxidilACE ARB

6.

(ISA )

()(ISA)ACE
ACE
aspirin
7.
Framingham ()

(idiopathic
dilated cardiomyopathy)ACE
/
ACE
(ARB )1
(CarvedilolBisoprolol Metoprolol)
()

ACE
ACE
Hydralazine Isosorbide
dinitrate ACE ARB Dihydropyridine
amlodipine
ACC/AHA Guidelines for themanagement of HF 2001Felodipine
ACE /Arch
Intern Med/Vol 157,Nov24,1997
8.
BP>140/90mmHg
10mmHg90mmHg
39

3 1
25mmHg 15mmHg
8-10%(300mg/
)1.
2.:pre-eclampsia
20 3.

170/110mmHg
()
nifedipine
labetalol hydralazinemagnesium sulfate

oxprenololpindololatenolol
labetalolmethyldopaprazosinhydralazine
nifedipine isradipineACE
II

40

9.
2002 Framingham 55
90
160/95mmHg 50%60
140/90mmHg 70%65
65%
JNC7 50 140 mmHg

80

(Baroreceptor)
7%20%

()

Dihydropyridine ACE
ARB

prazosinTamsulosin
15%

41


1. , , . . .
2. . .
3. . .
4. World Health Organization. The World Health Report 2002: Risks to
Health 2002. Geneva: World Health Organization
5. Psart BM, Manolio TA, Smith NL, Heckbert SR, Gotdiener JS, Burke GL,
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1998.Hypertension 2001; 38:827-832.
7. Blood Pressure Lowering Treatment Trialists Collaboration. Effects of
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8. The Heart Outcomes Prevention Evaluation Study Investigators. Effects
of an angiotensin-converting-enzyme inhibitor, ramipril, on
cardiovascular events in high-risk patients. N Engl J Med 2000;
342:145-153
9. Progress Collaborative Group. Randomized trial of a perindopril based
regimen on blood pressure lowering among 6105 individuals with
previous stroke or transient ischaemic attack. Lancet 2001;
358:1033-1041.
10. PARS Collaborating Group. Post-stroke antihypertensive treatment
study. A preliminary result. Chin Med J [Engl] 1995; 108:710-717.
11. Parving HH, Lenhert H, Brochner-Mortensen J, Gomis R, Andersen S,
Arner P. Irbesartan in patients with type 2 diabetes and
Microalbuminuria Study Group. The effects of Irbesartan on the
development of diabetic nephropathy in patients with type 2 diabetes. N
Engl J Med 2001; 345:870-878.
12. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving
HH, et al. for the RENAAL Study Investigators. Effects of Losartan on
renal and cardiovascular outcome in patients with type 2 diabetes and
nephropathy. N Engl J Med 2001; 345:861-869.
13. Lewis EI, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al.
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42

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