신동구 영남대학교의과대학순환기내과학교실 The Diagnosis and Treatment of Hypertension Dong-Gu Shin, MD, PhD Department of Cardiology, Yeungnam University College of Medicine, Daegu, Korea Hypertension is the most common and important risk factor threatening cardiovascular health of peoples, especially in the aged population. The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. All hypertensive patients should be classified not only in relation to the grades of hypertension but also in terms of the total cardiovascular (CV) risk resulting from the coexistence of different risk factors, organ damage and disease. Decisions on treatment strategies (initiation of drug treatment, BP threshold and target for treatment, use of combination treatment, need of a statin and other non-antihypertensive drugs) all importantly depend on the initial level of total CV risk. This document is based on the seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003, and the 2007 guidelines of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). However, new eighth report (JNC 8) will be released soon and expected to include major modifications of JNC 7, incorporating new evidences from clinical trials. Key Words: Hypertension, Diagnosis, Treatment 서론 고혈압은심혈관질환의주요위험인자로서뇌졸중, 심근경색증, 울혈성심부전, 신장병, 말초혈관질환과같은치명적인질환을유발하는질병이다. 고혈압은뇌졸중발생의약 80% 를차지하는허혈성뇌졸중의교정가능한위험인자들중가장중요하면서잘알려진인자로수축기혈압은 115 mmhg 이상에서 20 mmhg 증가할때마다, 그리고이완기혈압은 75 mmhg 이상에서 10 mmhg 증가할때마다뇌졸중의발생률이 2배씩증가한다. 1 미국심장학회 (American College of Cardiology, ACC)/ 미국뇌졸중학회 (American Stroke Association, Dong-Gu Shin, MD, PhD Department of Cardiology, College of Medicine, Yeungnam University Cardiology, Yeungnam University Hospital, 170 Hyeonchungno, Nam-gu, Daegu, Korea Tel: +82-53-620-3843, Fax: +82-53-621-3310 E-mail: dgshin@med.yu.ac.kr ASA) 에서발표한뇌졸중의일차예방가이드라인에의하면, 고혈압으로인한뇌졸중의상대위험도는 8이며, 치료를통하여고혈압을엄격하게조절할경우약 32% 의뇌졸중위험도감소를기대할수있다고한다. 2 이처럼철저한고혈압조절을통하여뇌졸중발생및재발위험을감소시킬수있으므로고혈압의예방과치료는국가가정책적으로관리해야할중요한보건의료문제이다. 국내조사결과고혈압유병률은 26.9% 로나이에따라증가하여 60세이상에서는 2명중 1명이고혈압에해당되었다. 하지만고혈압환자의인지율, 치료율은미국등선진국에비하여매우낮은상황이다 ( 인지율 66.1%, 치료율 59.4%, 조절률 42.4%). 3 고혈압의치료목표는생활요법과약물요법으로혈압을조절하여뇌졸중, 관상동맥질환, 심부전등심혈관계질환및신부전에의한유병률과사망률을최대한감소시키는것이다. 이러한목표를달성하기위해서는상승되어있는혈압을조절하는것은물론흡연, 고지혈증, 당뇨병등의위험인자에대한교정과함께동반질환의적절한조절이필요하다. 본문 52 2013 년대한신경과학회제 32 차학술대회 - 강의록 -
Table 1. 고혈압의정의와분류 Category Systolic Diastolic Optimal <120 mmhg and <80 mmhg Normal 120-129 and/or 80-84 High normal 130-139 and/or 85-89 Grade 1 hypertension 140-159 and/or 90-99 Grade 1 hypertension 160-179 and/or 100-109 Grade 1 hypertension 180 and/or 110 Isolated systolic hypertension 140 and <90 Isolated systolic hypertension should be graded (1,2,3) according to systolic blood pressure values in the ranges indicated, provided that diastolic values are <90 mmhg 에서언급할내용은 2003년에발표된 7차 JNC보고서 (the seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JNC 7) 1, 2007년에발표된유럽고혈압지침 4 과 2011년영국고혈압진료지침 5 에따른것이다. 곧발표될 8차 JNC보고서에서는고혈압의진단과치료지침에대한변경사항이추가되고, 새로운항고혈압약제나비약물치료법등에대한지침이언급될것이다. 본론 1. 고혈압의진단과분류미국국립보건원고혈압합동위원회에서는 1977년처음으로고혈압진료지침을발표한이래 2003년 7차보고서 (JNC 7) 를발표하였다. 1 7차보고서는정상혈압의기준을강화하고혈압이높아지기전에관리를하기위해서 고혈압전단계 (prehypertension) 라는용어를사용하여생활요법의중요성을강조하고있다. 또한혈압은정상범위내에있더라도높을수록합병증발생의위험이높아지기때문에혈압이높아지기전에관리를시작하고고혈압이되면치료를빨리시작하여야하며목표혈압에도달할수있도록적극적인치료를해야고혈압의합병증발생을예방할수있다는점을강조하고있다. JNC 7에서고혈압의분류는간단하지만다양한임상상황에획일적으로적용하기는문제점이있다. 따라서 WHO/ISH classification 에의한고혈압의정의를따르는것이좀더유동적일수있다 (Table 1). 일반적으로첫방문후수주간에걸쳐 2회이상적절히측정한혈압이수축기 140mmHg 이상이거나, 또는이완기 90mmHg 이상이면고혈압으로진단한다. 최근개정된영국고혈압가이드라인 (NICE 2011), 캐나다고혈압가이드라인 (CHEP 2012) 에서는고혈압진단에서활동혈압및가정혈 Table 2. 혈압측정방법에따른고혈압의기준치 (mmhg) SBP DBP Office or clinic 140 90 24-hour 125-130 80 Day 130-135 85 Night 120 70 Home 130-135 85 Table 3. 활동중혈압측정의적응증 When BP shows unusual variability In excluding white coat hypertension In helping with the assessment of patients with borderline hypertension In identifying nocturnal hypertension In assessing patients whose hypertension has been resistant to drug therapy (defined as BP >150/90mmHg on 3 or more antihypertensive drugs) As a guide to determining the efficacy of drug treatment over 24 hours In diagnosing and treating hypertension in pregnancy In diagnosing hypotension and postural hypotension 압의중요성을강조하고있다. 4-6 백의고혈압 (white-coated hypertension) 이나가면고혈압 (masked hypertension) 을진단하거나, 외래측정혈압 (clinic blood pressure) 과비교하여예후와관련된임상적중요성으로서활동혈압 (ambulatory blood pressure monitoring) 및가정혈압 (home blood pressure measurement) 측정이의미를가진다고알려져있어고혈압의진단또는치료감시에있어보조적인역할을했으나, 최근에는본격적인고혈압진단의도구로서가이드라인에서제시되고있다. 7,8 활동혈압은일정시간간격으로측정되기때문의혈압의하루의리듬과혈압변동성의분석이가능하며, 수면시야간혈압과혈압의하루리듬, 혈압변동성등과장기손상과의연과관계가주목을받고있다. 특히주간평균혈압의 20% 이상이야간에감소되는 extreme dipper 의경우허혈성뇌졸중이흔하고, 야간혈압이주간혈압보다오히려높은 reverse dipper 의경우출혈성뇌졸중이흔한특징이 2013 년대한신경과학회제 32 차학술대회 - 강의록 - 53
신동구 있다. 또한허혈성심혈관및뇌혈관질환의발생은일중변동이있어서기상후아침부터오전에걸친수시간에집중적으로발생된다는사실은아침혈압상승의중요성을시사한 Figure 1. 고혈압의예후정량화를위한위험도층별화방법. SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: cardiovascular; HT: hypertension. OD: subclinical organ damage; MS: metabolic syndrome. 다. 9,10 활동혈압측정값은주간평균혈압 135/85 mmhg, 야간평균혈압 120/75mHg, 일일평균혈압 130/80 mmhg를고혈압의진단기준으로제시되고있다 (Table 2). 활동혈압측정의적응증은 Table 3와같다. 여러고혈압치료지침에서환자자신이집에서측정하는자가혈압측정의중요성이강조되고있으며, 또이를권장하고있다. 아침과저녁에한번씩적어도하루두번측정하는것이좋으며, 혈압이안정되지않았을때는 1주일에적어도 5일이상, 혈압이잘조절되는경우에는 1주일에 3일이상측정한다. 자가혈압측정에서고혈압은 135/85 mmhg 이상으로정의하고, 주로백의효과때문에진료실에서측정한혈압보다더낮은값을나타낸다. 진료실혈압보다자가혈압이심혈관계질환의예후를더잘반영하는것으로일부보고되고있으나, 아직까지예후를예측하기위한혈압의측정방법은진료실혈압측정이표준인것으로생각되고있다. 자가혈 Table 4. 총심혈관계위험도평가에사용되는임상변수 Risk factors Subclinical organ damage Systolic and diastolic BP levels Electrocardiographic LVH (Sokolow-Lyon > 38mm; Cornell > 2440 mm*ms) or: Levels of pulse pressure (in he elderly) Echocardiographic LVH o (LVMI M 125g/ m2, W 110g/ m2 ) Age(M>55 years; W>65 years) Carotid wall thickening (IMT > 0.9mm) or plaque Smoking Carotid-femoral pulse wave velocity > 12m/s Dyslipidaemia Ankel/brachial BP index < 0.9 TC > 5.0 mmol/l(190 mg/dl) or: Slight increase in plasma creatinine: LDL-C > 3.0 mmol/l(115 mg/dl)or: M: 115-133 μmol/l(1.3-1.5 mg/dl); HDL-C: M < 1.0 mmol/l(40mg/dl), W < 1.2 mmol/l (46 mg/dl) or: W: 107-124 μmol/l(1.2-1.4 mg/dl) TG > 1.7 mmol/l(150mg/dl) Fasting plasma glucose 5.6-6.9 mmol/l(102-125 mg/dl) Abnormal glucose tolerance test Abdominal obesity (Waist circumference > 102cm (M), >88 cm (W) Family history of premature CV disease (M at age < 55 years; W at age <65 years) Diabetes mellitus Fasting plasma glucose 7.0 mmol/l (126 mg/dl) on repeated measurements, or Postload plasma glucose > 11.0 mmol/l (198 mg/dl) Note: the cluster of three out of 5 risk factors among abdominal obesity, altered fasting plasma glucose, BP>130/85 mmhg, low HDL-cholesterol and high TG (as defined above) indicates the presence of metabolic syndrome Low estimated glomerular filtration rate (<60ml/min/1.73m2) or creatinine clearance o (<60 ml/min) Microalbuminuria 30-300 mg/24h or albumin-creatinine ratio: 22(M); or 31(W) mg/g creatinine Established CV or renal disease Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack Heart disease: myocardial infarction; angina; coronary revascularization; heart failure Renal disease: diabetic nephropathy; renal impairment (serum creatinine M >133, W >124 mmol/l); proteinureia (>300mg/24h) Peripheral artery disease Advanced retinopahy: haemorrhages or exudates, papilloedema M: men; W: Women; CV: cardiovascular; IMT: intima-media thickness; BP: blood pressure; TG: triglycerides; C: cholesterol; o Cockroft Gault formula; MDRD formula; Risk maximal for concentraic LVH (left ventricular hypertrophy): increased LVMI (left ventricular mass index) with a wall thickness/radius ratio >0.42. 54 2013 년대한신경과학회제 32 차학술대회 - 강의록 -
압의심혈관계질환의예후에대한명확한관계를밝히고정상기준치를정립하기위하여대규모장기추적임상연구가필요하다. 11,12 2. 총심혈관계위험도 (Total Cardiovascular Risk) 평가 각환자가지닌심혈관계위험요소 (total cardiovascular risk) 를고려하여고혈압을진단하고치료하여야한다. 예를들어높은정상혈압이측정될경우저위험군에서는문제가되지않지만고위험군에서는치료가필요한고혈압이라고할수있다. 대다수의고혈압환자들은다른심혈관계위험인자들을동반하고있기때문에정확한예후예측과치료를하기위해서총심혈관계위험도 (Fig. 1) 평가를바탕으로치료를시작한다. 혈압의정도뿐만아니라동반위험인자, 장기손상혹은동반질환에따라치료의시작시점, 혹은항고혈압약제의선정, 혈압의목표치가다르다. 총심혈관계위험도평가를위해사용되는임상지표는 Table 4와같다. 증대, 콜레스테롤및포화지방산섭취제한등이있다. 생활요법은혈압을강화시킬뿐아니라강압제의작용을증강시키고심혈관질환이나위험인자의합병을예방하는효과도있어모든환자를대상으로실시한다. 생활습관개선이기본적치료이지만목표혈압에도달하지못하는경우가많아대부분약물요법과의병행이필요하다. 13-15 1) 고혈압치료목표 고혈압치료의중요한목표는심혈관계질환의이환에의한상병율과사망률을줄이는것이다. 치료의시작은수축기및 3. 고혈압의치료 고혈압치료를생활습관개선과약물요법으로구분할수있다. 생활습관을교정하는생활요법에는식염제한, 비만한체중감량, 음주제한, 운동요법, 금연, 과일및채소섭취 Figure 2. 혈압과동반위험인자에따른항고혈압치료의시작 Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmhg) (<130/80 mmhg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling Indications With Compelling Indications Stage 1 Hypertension (SBP 140 159 or DBP 90 99 mmhg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension (SBP >160 or DBP >100 mmhg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Figure 3. JNC 7 에따른고혈압치료알고리듬 2013 년대한신경과학회제 32 차학술대회 - 강의록 - 55
신동구 이완기혈압의정도, 그리고총심혈관계위험도에따라결정하여야한다 (Fig. 2). 혈압을적어도 140/90mmHg이하로줄이고, 당뇨나뇌졸중, 심근경색, 신장기능저하, 단백뇨등이동반된고위험군에서는적어도 130/80mmHg이하로줄이도록한다. JNC 7에서권고하는고혈압치료의알고리듬은다음과같다 (Fig. 3). 2) 고혈압의비약물치료고혈압환자에서비약물치료는잘못된생활습관개선으로, 약물을투여하는중증고혈압환자는물론높은정상혈압에서도시행할필요가있다. 생활습관개선의목적은혈압조절과다른위험인자의개선으로심혈관질환을예방하는데있다. 생활습관개선항목으로금연, 과일및채소섭취증진, 지방 ( 특히포화지방 ) 섭취억제, 금주, 체중조절, 운동및염분섭취제한을들수있다. 철저한생활개선요법은항고혈압약 1알정도에해당하는혈압감소 ( 수축기혈압 10-20 mmhg 정도 ) 효과를볼수있다. 과다한염분섭취는혈압을상승시키며, 특히포타슘섭취가부족할경우영향이더크다. 염분섭취를하루 5g (4.7-5.8 g, 80-100 mmol) 이하로제한하면 4-6 mmhg의혈압강하효과를얻을수있을뿐아니라, 고혈압약제의효과를증대시킬수있다. 고혈압환자는특히조리된음식에소금을더뿌려서섭취하지말고, 포탸슘 Table 5. 생활개선요법에따른혈압강화효과생활개선요법혈압강하정도체중조절 5-20 mmhg/10kg 체중감량저지방, 아채, 과일섭취증가 8-14 mmhg 저염식 2-8 mmhg 운동 4-9 mmhg 절주 2/4 mmhg 이함유된자연적조미료를사용할것을권장한다. 생활개선요법에따른혈압강화효과는 Table 5와같다. 3) 고혈압의약물치료 다음 5가지항고혈압약제로분류할수있다 ; 1) Diuretics, 2) Beta-blockers, 3) Calcium channel blockers (CCBs), 4) ACE inhibitors, 5) Angiotensin-receptor blockers (ARBs). α 수용체차단제의고혈압에치료효과에대한무작위연구는없었다. ALLHAT 연구에서 α수용체차단제 (the doxazosin arm of ALLHAT) 의사용은심혈관사고의증가로조기종료되었기때문에 α수용체차단제를다른항고혈압치료제보다우선적으로추천하지는않지만병합치료요법시추천될수있다. 동반질환에따른주요항고혈압약제의일차선택약은 Table 6와같다. 고혈압의단계에따른일차항고혈압약제의선택은 Table 7과같다. JNC 7권고안은개원의들에게단순화시킨분류를제공함으로써고혈압의관리율을높일려는목적이다. 혈압의정도를제1기와 2기로나누고임상질환, 표적장기손상등에따라특정군을정하고강제적응으로일차선택약제를고르고, 강제적응이아닌일반환자에게는더욱간편하게제1도고혈압 ( 140/90 mmhg) 에서는 thiazide 이뇨제를처음선택하고더필요시다른 5 약제중한가지의병용을권고하고, 제2도고혈압 ( 160/100 mmhg) 에서는처음부터이뇨제를포함한두가지약제를사용하도록권고하였다. 물론고혈압전단계에서도당뇨병, 만성콩팥병이있는경우는목표혈압을 130/90 mmhg 미만으로하고단백뇨가 1일 1g 이상인경우 125/75 mmhg 미만으로권고하였다 (Fig. 3). 1 그러나유럽심장학회및고혈압학회의지침은혈압의높은정도와심혈관계위험인자 0, 1-2개, 3개이상혹은대사 Table 6. 동반질환별항고혈압제의선택 Recommended Drugs Compelling Indication* Diuretic BB ACEI ARB CCB Aldo ANT Heart failure Postmyocardial infarction High coronary disease risk Diabetes Chronic kidney disease Recurrent stroke prevention * Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the BP. Drug abbreviations : ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker. 56 2013 년대한신경과학회제 32 차학술대회 - 강의록 -
Table 7. JNC 7에따른고혈압의분류와치료, 이에따른항고혈압제의선택 BP Classification SBP* mmhg DBP* mmhg Lifestyle Modification Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Encourage Prehypertension 120-139 or 90-99 Yes No antihypertensive drug indicated Drug(s) for compelling indications. Stage 1 Hypertension 140-159 or 90-99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB or combination Drug(s) for the compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension 160 or 100 Yes Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). * Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmhg Figure 4. 2011 년영국고혈압학회의항고혈압제의선택알고리듬. 5 증후군, 표적장기손상, 당뇨병, 또심혈관계및신장질환의동반에따라서평균, 저위험, 중위험, 고위험, 최고위험의 5 단계로나누어고위험군에서부터약물치료를하는것으로적용이복잡하다. 초기치료약제로는다섯가지의약제군, 즉이뇨제, 베타차단제, 칼슘차단제, 안지오텐신전환효소억제제, 안지오텐신수용체차단제가운데하나를경도, 저위험군에서는저용량으로시작할수있으며목표혈압이안되면전용량또는대체약제를권고하며, 2도고혈압이상또는고위험군일경우는처음부터두가지약제의저용량병합요법을시작하고목표가안되면전용량또는세번째약을저용량추가하는순서를권고하였다. 4 또 2011년영국심장학회의지침은유색인종과백인, 또 55세를기준으로고령과유색인에서는칼슘차단제 (C) 를, 백인, 약년자에게는안지오텐신전환효소억제제 (A), 안지오텐신수용체차단제 (A) 를일차약으로권고하고제 2단계로안지오텐신전환효소억제제나안지오텐신수용체차단제에칼슘차단제를병용하고제3단계에서 A+C+ 이뇨제 3자병용을권고하였으며제4단계에서알파차단제나베타차단제를선택하도록해서당뇨병의발생을증가시키는베타차단제를일차약에서제외시켜서많은논란이되고있지만새로운베타차단제의출현으로장기결과가주목된다 (Fig. 4). 5 2013 년대한신경과학회제 32 차학술대회 - 강의록 - 57
신동구 유병률과사망률의위험을줄이는것이다. 따라서정확한진단과적절한치료가중요하며, 환자개개인의특성에따른약제의선택과치료목표가다르게적용되어야할것이다. 또한고혈압지침은임상연구결과에따라변화하고있다. JNC 8에서는지난 10여년간수행된임상연구들을바탕으로새로운항고혈압제의사용지침, 초기약제의선택, 활동성혈압측정의중요성, 저항성고혈압의치료법으로서신장신경절제 (renal nerve denervation) 과같은비약물적치료요법에관한기술이있을것으로예상된다. REFERENCES Figure 5. 항고혈압약제의병용사용방법. 실선은추천되는병용방법이고각무작위임상시험에서효과가입증된약은네모상자안에표시하였다. 4) 병합요법 고혈압환자중단일약에의한강압효과는약반수에서만기대할수있으며혈압을충분히낮추기위해서는 70% 이상의환자에서병용요법이필요하다. 치료시작의혈압이 160/100 mmhg 이상시, 충분한양의 1차약으로효과가없을때, 심혈관계질환 ( 관상동맥질환, 뇌졸증, 말초동맥질환등 ) 이이미생긴경우, 당뇨나신질환이있는경우, 단일약제에부작용이심한경우병용요법을시작할수있다. 서로작용이다른약을소량씩추가하면강압효과와순응도를높이면서부작용은억제할수있는장점이있다. 작용기전상이상적인약제의병용방법은 Figure 5와같다. 4 4. 뇌혈관질환이동반된고혈압환자의치료 고혈압의치료로뇌졸중의재발을 30-40% 감소시킬수있으며, JNC 7보고서에서는과거뇌경색이나일과성허혈을경험하였던환자의경우 ACE억제재나이뇨제를사용하여고혈압치료를권고하였으나, 실제적으로뇌졸중의위험감소는항고혈압제의종류보다는약제의강압효과에정도에따라결정된다고할수있다. 결론 고혈압치료에서가장중요한목표는혈압강하이다. 아울러고혈압의합병증을예방하고조기에적절하게관리하여 1.Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr., et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-2572. 2.Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2011;42:227-276. 3. 질병관리본부, 2008 국민건강통계국민건강영양조사 4.Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007; 25:1105-1187 5. Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34 [Internet]. National Clinical Guideline Centre (UK). London: Royal College of Physicians (UK); 2011 Aug. 6.Daskalopoulou SS, Khan NA, Quinn RR, Ruzicka M, McKay DW, Hackam DG, et al. The 2012 Canadian hypertension education program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy. Can J Cardiol 2012;28:270-287. 7.Group JCSJW. Guidelines for the clinical use of 24 hour ambulatory blood pressure monitoring (ABPM) (JCS 2010): - digest version. Circ J 2012;76:508-519. 8.Kim SG. Clinical implications of ambulatory and home blood pressure monitoring. Korean Circ J 2010;40:423-431. 9.Zis P, Spengos K, Manios E, Vemmos K, Zis V, Dimopoulos MA, et al. Ambulatory blood pressure monitoring in acute stroke: the importance of time rate of blood pressure variation. Blood Press Monit 2012;17:220-221; author reply 221-222. 10. Lip GY, Zarifis J, Farooqi IS, Page A, Sagar G, Beevers DG. Ambulatory blood pressure monitoring in acute stroke. The 58 2013 년대한신경과학회제 32 차학술대회 - 강의록 -
West Birmingham Stroke Project. Stroke 1997;28:31-35. 11.Asmar R, Zanchetti A. Guidelines for the use of self-blood pressure monitoring: a summary report of the First International Consensus Conference. Groupe Evaluation & Measure of the French Society of Hypertension. J Hypertens 2000;18:493-508. 12. Imai Y, Otsuka K, Kawano Y, Shimada K, Hayashi H, Tochikubo O, et al. Japanese society of hypertension (JSH) guidelines for self-monitoring of blood pressure at home. Hypertens Res 2003;26:771-782. 13.Elmer PJ, Obarzanek E, Vollmer WM, Simons-Morton D, Stevens VJ, Young DR, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med 2006;144:485-495. 14. Cornelissen VA, Fagard RH. Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials. J Hypertens 2005;23:251-259. 15. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336:1117-1124. 2013 년대한신경과학회제 32 차학술대회 - 강의록 - 59