740 J Formos Med Assoc | 2010 • Vol 109 • No 10
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J Formos Med Assoc 2010;109(10):740–773
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Formosan Medical Association
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Volume 109 Number 10 October 2010
New Delhi metallo-b-lactamase-1
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Guideline
2010 Guidelines of the Taiwan Society of Cardiology
for the Management of Hypertension
Chern-En Chiang,1 Tzung-Dau Wang,2 Yi-Heng Li,3 Tsung-Hsien Lin,4 Kuo-Liong Chien,5 Hung-I Yeh,6
Kou-Gi Shyu,7 Wei-Chuen Tsai,3 Ting-Hsing Chao,8 Juey-Jen Hwang,2 Fu-Tien Chiang,9 Jyh-Hong Chen3*
Hypertension is one of the most important risk factors for atherosclerosis-related mortality and morbidity.
In this document, the Hypertension Committee of the Taiwan Society of Cardiology provides new guide-
lines for hypertension management. The key messages are as follows. (1) The life-time risk for hyperten-
sion is 90%. (2) Both the increase in the prevalence rate and the relative risk of hypertension for causing
cardiovascular events are higher in Asians than in Caucasians. (3) The control rate has been improved sig-
nificantly in Taiwan from 2.4% to 21% in men, and from 5% to 29% in women in recent years
(1995–2002). (4) Systolic and diastolic blood pressure (BP) ≥ 130/80 mmHg are thresholds of treatment
for high-risk patients, such as those with diabetes, chronic kidney disease, stroke, established coronary
heart disease, and coronary heart disease equivalents (carotid artery disease, peripheral arterial disease,
and abdominal aortic aneurysm). (5) Ambulatory and home BP monitoring correlate more closely with
end-organ damage and have a stronger relationship with cardiovascular events than office BP monitoring,
but the feasibility of home monitoring makes it a more attractive alternative. (6) Patients with masked hy-
pertension have higher cardiovascular risk than those with white-coat hypertension. (7) Lifestyle changes
should be encouraged in all patients, and include the following six items: S-ABCDE (Salt restriction;
Alcohol limitation; Body weight reduction; Cessation of smoking; Diet adaptation; Exercise adoption).
(8) When pharmacological therapy is needed, physicians should consider “PROCEED” (Previous experi-
ence of patient; Risk factors; Organ damage; Contraindication or unfavorable conditions; Expert or doctor
judgment; Expense or cost; Delivery and compliance) to decide the optimal treatment. (9) The main ben-
efits of antihypertensive agents are derived from lowering of BP per se, and are generally independent of
©2010 Elsevier & Formosan Medical Association
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1Division of Cardiology and General Clinical Research Center, Taipei Veterans General Hospital and National Yang-Ming
University, 2Division of Cardiology, Department of Internal Medicine and 9Department of Laboratory Medicine, National
Taiwan University Hospital and National Taiwan University College of Medicine, 5Institute of Preventive Medicine, College of
Public Health, National Taiwan University, 6Department of Internal Medicine, Mackay Memorial Hospital and Mackay
Medical College, and 7Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Graduate Institute of Clinical
Medicine, Taipei Medical University, Taipei, 3Division of Cardiology, Department of Internal Medicine, National Cheng Kung
University College of Medicine and Hospital, Tainan, 8Department of Medicine, National Cheng Kung University Hospital
Dou-Liou Branch, Yun-Lin, and 4Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kaohsiung
Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
Received: April 7, 2010
Revised: May 29, 2010
Accepted: May 31, 2010
*Correspondence to: Dr Jyh-Hong Chen, Division of Cardiology, Department of Medicine,
National Cheng Kung University Medical College and Hospital, 138 Sheng Li Road, Tainan, 704
Taiwan.
E-mail: jyhhong@mail.ncku.edu.tw
Taiwan hypertension guidelines
J Formos Med Assoc | 2010 • Vol 109 • No 10 741
The writing group of the 2010 Guidelines of the
Taiwan Society of Cardiology for the Management
of Hypertension: Jyh-Hong Chen (Chairperson),
Chern-En Chiang (Co-Chairperson), Tzung-Dau
Wang, Yi-Heng Li, Tsung-Hsien Lin, Kuo-Liong
Chien, Hung-I Yeh, Kou-Gi Shyu, Wei-Chuen Tsai,
and Ting-Hsing Chao
Taiwan Society of Cardiology Committee for
Hypertension: Jyh-Hong Chen (Chairperson),
Chern-En Chiang (Co-Chairperson), Tzung-Dau
Wang, Chun-Yi Wu, Li-Ping Chou, Tsung-Hsien
Lin, Kwan-Lih Hsu, Jaw-Wen Chen, Chuen-Den
Tseng, Chao-Hung Yang, Wei-Chuen Tsai, Po-
Ming Ku
Taiwan Society of Cardiology Executive Board
Members: Fu-Tien Chiang (President), Gwo-Ping
Jong, Chern-En Chiang, Chang-Chyi Lin, Charles
Jia-Yin Hou, Jyh-Hong Chen, Jun-Jack Cheng,
Shih-Chung Huang, San-Jou Yeh, Chiau-Suong
Liau, Wen-Ter Lai, Ji-Hung Wang, Kuo-Yang Wang,
Shih-Ping Wu, Jiunn-Ren Wu, Chiung-Jen Wu, Mei-
Hwan Wu, Li-Ping Chou, Chin-Lon Lin, Yu-Lin
Ko, Kou-Gi Shyu, Tsui-Lieh Hsu, Wei-Hsian Yin,
Chih-Kuang Chang, Chung-I Chang, Chi-Tai Kuo,
Chung-Huo Chen, Thay-Hsiung Chen, Tsuei-
Yuan Huang, Be-Tau Hwang, Chao-Hung Yang,
Hung-I Yeh, Liang-Miin Tsai, Cheng-Ta Chung,
Jeng Wei
Taiwan Society of Cardiology Control Boards:
Dr. Nen-Chung Chang, Ruey-Jen Sung, Chung-
Sheng Lin, Chi-Ren Hung, Sheng-Hsiung Sheu,
Ming-Fong Chen, Morgan Mao-Young Fu, Chuen-
Den Tseng, Wen-Jin Cherng, Cheng-Ho Tsai,
Hung-Shun Lo
Preface
Hypertension is the most important risk factor for
cardiovascular morbidity and mortality.1 Since
the Seventh Report of the Joint National Com-
mittee Guidelines (JNC 7) on hypertension in
20032 and the European Society of Hypertension
and European Society of Cardiology Guidelines
for the Management of Arterial Hypertension
in 2007,3 there have been many new data from
the drugs being used, except that certain associated cardiovascular conditions might favor certain classes of
drugs. (10) There are five major classes of drugs: thiazide diuretics; β-blockers; calcium channel blockers;
angiotensin-converting enzyme inhibitors (ACEIs); and angiotensin receptor blockers (ARBs). Any one of
these can be used as the initial treatment, except for β-blockers, which are only indicated in patients with
heart failure, a history of coronary heart disease, and hyperadrenergic state. (11) A standard dose of any
one of the five major classes of antihypertensive drugs can produce an ∼10-mmHg decrease in systolic BP
(rule of 10) and a 5-mmHg decrease in diastolic BP (rule of 5), after placebo subtraction. (11)
Combination therapy is frequently needed for optimal control of BP, and the amount of the decrease in
BP by a two-drug combination is approximately the same as the sum of the decrease by each individual
drug (∼20 mmHg in systolic BP and 10 mmHg in diastolic BP) if their mechanisms of action are independ-
ent, with the exception of the combination of ACEIs and ARBs. (13) An ACEI or ARB plus a calcium chan-
nel blocker or a diuretic (A + C or A + D) are reasonable two-drug combinations, and A + C + D is a
reasonable three-drug combination, unless patients have special indications for β-blockers. (14) Single-
pill (fixed-dose) combinations that contain more than one drug in a single tablet are highly recom-
mended because they reduce pill burden and cost, and improve compliance. (15) Very elderly patients
(≥ 80 years) should be treated without delay, but BP should be reduced gradually and more cautiously.
Finally, these guidelines are not mandatory; the responsible physician’s decision remains most important
in hypertension management.
Key Words: blood pressure, disease management, drug therapy, hypertension
C.E. Chiang, et al
742 J Formos Med Assoc | 2010 • Vol 109 • No 10
epidemiological studies and randomized control
trials. The Hypertension Committee of the Taiwan
Society of Cardiology believes it is an appropriate
time to provide updated guidelines for the man-
agement of hypertension. This report serves as a
guide, and the Committee continues to recognize
that the judgment of the responsible physician
remains paramount.
Classification
According to the largest meta-analysis of obser-
vational data carried out to date, cardiovascular
morbidity and mortality have a continuous rela-
tionship with both systolic (down to 115 mmHg)
and diastolic (down to 75 mmHg) blood pres-
sure (BP).4 For every 20 mmHg difference in sys-
tolic BP, or 10 mmHg difference in diastolic BP,
there is a twofold increases in the stroke death rate,
and twofold differences in the death rates from
coronary heart disease (CHD) and from other vas-
cular causes.4 However, for descriptive purpose
and therapeutic guidance, hypertension needs to
be classified. The definition and classification of
hypertension in these guidelines is based on of-
fice BP, as shown in Table 1. For patients with high
Framingham risk (≥ 20% in 10 years), such as pa-
tients with diabetes, chronic kidney disease, stroke,
established CHD, and CHD equivalents (carotid
artery disease, peripheral arterial disease, and ab-
dominal aneurysm), a target of < 130/80 mmHg
is recommended.5
Epidemiology
Hypertension is one of the most important risk
factors for atherosclerosis-related mortality and
morbidity. According to the Prospective Studies
Collaboration, hypertension produced the great-
est mortality burden in 2001, accounting for more
than 7 million deaths worldwide, more than any
other known risk factors.1 About 54% of stroke
and 47% of ischemic heart disease worldwide are
attributable to high BP.6 Overall, about 80% of the
attributable burden occurred in low- and middle-
income economies.6
The life-time risk of having hypertension is
about 90%.7 The prevalence rate of hypertension
is also growing. There were 972 million patients
(26.4%) with hypertension in 2000 and the num-
ber will reach 1.56 billion (29.2%) in 2025, a 60%
increase in 25 years.8,9 The rampant increase in
prevalence is most serious in Asia. For men, there
will be a 65.4% increase in Asia compared with a
51.2% increase for men in the rest of the world. It
is even more severe in women; an 81.6% increase
in Asia compared with a 54.4% increase in the rest
of the world.8 In a recent survey in Taiwan, the
nationwide prevalence rates of hypertension, de-
fined by systolic BP > 140 mmHg or diastolic BP
>90mmHg, were 25% in men and 18% in women,
and the rate increased to 47% among individuals
of age ≥ 60 years.10 The community-based data on
a 10-year follow-up cohort in Taiwan have shown
that the incidence rates have increased among
individuals with prehypertension, obesity and
metabolic syndrome.11 Furthermore, baseline BP
categories play an important role in predicting
cardiovascular risks; the hazard ratios of prehy-
pertension and hypertension increased from 1.73
to 4.52, compared with baseline normotensive
subjects.11
The impact of hypertension on cardiovascular
events in Asian is higher than that in Cau-
casian.12 With the same increase in systolic BP of
15 mmHg, the hazard ratio for CHD and stroke is
Table 1. Definition and classification of hypertension
by office blood pressure*
Stage
Systolic BP Diastolic BP
(mmHg) (mmHg)
Normal < 120 and < 80
Prehypertension 120–139 or 80–89
Stage 1 hypertension 140–159 or 90–99
Stage 2 hypertension ≥ 160 or ≥ 100
Stage 3 hypertension ≥ 180 or ≥ 110
*Systolic BP ≥ 130 or diastolic BP ≥ 80 is considered hypertension for
patients with coronary heart disease, coronary heart disease equiva-
lent (carotid artery disease, peripheral arterial disease, abdominal
aortic aneurysm), stroke, diabetes and chronic kidney disease. BP =
Blood pressure.
Taiwan hypertension guidelines
J Formos Med Assoc | 2010 • Vol 109 • No 10 743
higher in Asian than in Caucasian.12 The hazard
ratio of hypertension for fatal vascular events is
higher for men in China and Japan, compared to
men in Australia and New Zealand.13 In 6105 pa-
tients with a history of stroke or transient ischemic
attack, treatment of hypertension resulted in a
38% reduction in the risk of recurrent stroke in
Asian patients, compared with a 20% reduction in
Caucasian patients with a similar decrease in BP.14
In a recent survey from 10 developed countries,
the prevalence rate of hypertension was higher in
men than in women before the age of 60 years.8
After that, it was higher in women. An epidemio-
logical study in Taiwan has shown similar find-
ings, in that the age-related rise in systolic BP was
steeper in women than in men between ages 40
to 80 years.10 Despite the mean systolic BP in
men being higher than that in women before the
age of 60 years, it becomes lower than that in
women after 60 years.10
The control rate for hypertension, defined by
office BP < 140/90 mmHg in non-high-risk pa-
tients and < 130/80 mmHg in high-risk patients,
is generally low. No single country has an overall
control rate > 40%.2,15 In Taiwan, compared with
the national survey in 1993,16 there was a signif-
icant improvement in the awareness, treatment,
and control rate in the 2002 survey,10 a finding
that could be attributable to the implementation
of the National Health Insurance system since
1995.10 Hypertension control rate increased from
2.4% to 21% in men, and from 5% to 29% in
women.10 In fact, the control rate in Taiwan is
higher than that in Korea (10.7%),17 Japan (12%)18
and China (5%).19 The control rate of hyperten-
sion varies in different areas in Taiwan; it reaches
about 50% for women in the northern area, but is
< 10% for men in eastern parts, which reflects the
disparity in medical resources.20
Etiology
Blood pressure is a product of the interaction be-
tween genetic determinants and environmental in-
terfering factors, where the causes of hypertension
arise. Currently, the etiology of hypertension is
divided into two categories: essential and second-
ary hypertension.
Essential hypertension
In patients with high BP, essential hypertension is
diagnosed after secondary causes of hypertension
are excluded.21 Essential hypertension accounts
for nearly 95% of all cases of hypertension. The
development of study into human genetics has
lead to the recognition of several genes that are
involved in regulation of BP.22–24 These associa-
tions between common variants and BP and hy-
pertension offer mechanistic insights into the
regulation of BP, and point to novel targets for
interventions to prevent cardiovascular disease.
However, genetic analysis for most patients with
hypertension is not practical at present. In con-
trast, detection of environmental interfering fac-
tors is useful for BP control. These factors include:
(1) obesity; (2) insulin resistance; (3) high alco-
hol intake; (4) high salt intake (in salt-sensitive
patients); (5) aging; (6) sedentary lifestyle; (7)
stress; (8) low potassium intake; and (9) low cal-
cium intake. Many of these factors occur in clus-
ters and the effects are additive, such as obesity,
insulin resistance, and sedentary lifestyle.
Secondary hypertension
Secondary hypertension is a potentially curable
condition if the cause is eliminated.25 The most
common form is secondary to renal parenchymal
disease; the causes of which include acute and
chronic glomerulonephritis of varying causes,
autosomal dominant polycystic kidney disease,
diabetic nephropathy, and hydronephrosis sec-
ondary to obstructive uropathy. Renovascular
disease is also a common cause of secondary hy-
pertension related to the kidneys, which is due to
renal artery stenosis, which is often caused by
atherosclerosis in elderly patients. Apart from the
kidneys, other common causes of secondary hy-
pertension are endocrine-related, due to either
hyperactivity or hypoactivity, depending on the
glands involved. Table 2 summarizes the causes
of secondary hypertension.
C.E. Chiang, et al
744 J Formos Med Assoc | 2010 • Vol 109 • No 10
Office Blood Pressure, Ambulatory Blood
Pressure, Home Blood Pressure, and
Other Blood Pressure Parameters
Blood pressure can be measured by doctors or
nurses in the office or clinic (office BP), by auto-
matic machine over 24 hours (ambulatory BP
monitoring; ABPM), or by the patient or a relative
at home (home BP monitoring; HBPM). Although
office BP is used for staging of hypertension, there
is increasing evidence that it might not reflect the
true cardiovascular risk for hypertensive patients.26
ABPM and HBPM have become increasingly im-
portant for the management of hypertension.26,27
They both make use of automated, validated oscil-
lometric devices, and the BP values are operator-
independent.28 They also eliminate the alarm
reaction and the “white-coat” effect associated
with office BP measurement, and provide more
stable and reproducible readings of BP values.29
A new electronic device for HBPM, which imp-
lements an algorithm for the diagnosis of atrial
fibrillation, has an excellent diagnostic accuracy.30
A much larger number of values than office BP
measurements make HBPM and ABPM more ac-
curate estimates of future cardiovascular events.31
Office blood pressure
The measurement of BP is likely to be the clinical
procedure of greatest importance that is performed
in the sloppiest manner. Blood pressure measure-
ment should follow the guidelines outlined by
Pickering et al,32 and is not mentioned further in
this paper. In brief, the diagnosis of hypertension
should be based on multiple measurements on
separate occasions over a period of time. The pa-
tients should be seated with their back supported
and both feet lying flat on the floor for at least
5 minutes in a quiet room, with an empty bladder.
At least two measurements of BP should be taken
each time, separated by at least 1 minute. Blood
pressure can be measured by a mercury sphyg-
momanometer or other noninvasive electronic
devices. The latter is becoming an important mo-
dality because of its simplicity of use and the pro-
gressive banning of the medical use of mercury.
For mercury sphygmomanometry, phase I and V
Korotkoff sounds are taken to identify systolic
and diastolic BP, respectively. The BP should be
taken in both arms at first visit and the higher
value is used as reference. For follow-up, one
only needs to measure the BP in the arm with the
higher value.
Although the data from the Framingham Heart
Study have shown that diastolic BP is a stronger
predictor for future coronary events than systolic
BP in patients aged < 50 years,33 it is generally
believed that systolic BP is a more important
Table 2. Causes of secondary hypertension
Acute stress Isolated systolic
related secondary hypertension due to an
hypertension increased cardiac output
Diseases of the aorta Neurological causes
Coarctation of the Guillain–Barre
aorta syndrome
Rigidity of the aorta Idiopathic, primary, or
familial dysautonomia
Drugs and exogenous Increase intracranial
hormones pressure
Endocrine Quadriplegia
Acromegaly Obstructive sleep apnea
Adrenal cortical Pregnancy induced
hypertension
Apparent Renal
mineralocorticoid
excess
Cushing syndrome Increased intravascular
volume
Primary Primary sodium
aldosteronism retention
(Liddle’s syndrome)
Adrenal medulla Renal parenchymal
disease
Carcinoid syndrome Renin-producing
tumors
Pheochromocytoma Renal vascular
disease
Hyperparathyroidism
Hyperthyroidism
Hypothyroidism
Taiwan hypertension guidelines
J Formos Med Assoc | 2010 • Vol 109 • No 10 745
predictor for overall