2013 Korean Society of Hypertension guidelines for the management of hypertension. Part II—treatments of hypertension
© Shin et al.; licensee BioMed Central. 2015
Received: 2 December 2014
Accepted: 23 December 2014
Published: 8 April 2015
Treatment strategies are provided in accordance with the level of global cardiovascular risk, from lifestyle modification in the lower risk group to more comprehensive treatment in the higher risk group. Considering the common trend of combination drug regimen, the choice of the first drug is suggested more liberally according to the physician’s discretion.
KeywordsAntihypertensive treatment Cardiovascular risk Guidelines Hypertension Lifestyle Organ damage
Treatments of hypertension
The purpose of hypertension (HTN) treatment is to prevent cardiovascular disease (CVD) caused by increased blood pressure (BP) and decrease mortality by controlling high BP. In patients who already have established CVD, treatment aims to control BP to prevent progression or recurrence of disease in order to decrease mortality and improve quality of life. HTN treatment provides greater benefit in patients who are at higher risk for CVD. Most clinical studies of HTN have found that lowering systolic blood pressure (SBP) by approximately 10 to 20 mm Hg or diastolic blood pressure (DBP) by approximately 5 to 10 mm Hg can reduce the occurrence of stroke by 30% to 40% and that of ischemic heart disease by 15% to 20% . Because most clinical studies were performed over a relatively short period, the benefits of HTN treatment over a period of 5 years or more seem to be much more pronounced than the treatment efficacy observed in clinical studies. The benefits of HTN treatment are not affected by sex or age and are also similar for the treatment of systolic HTN in the elderly. HTN treatment was found to be the most cost-effective intervention for prevention of CVD.
Strategy for hypertension treatment
Initiation of hypertension treatment
Prehypertension stage II
Treatment for hypertension according to the risk
Blood pressure (mm Hg)
Stage 2 prehypertension (130–139/85–89)
Stage 1 hypertension (140–159/90–99)
Stage 2 hypertension (≥160/100)
Risk factors 0
Lifestyle modificationa or drug therapy
Lifestyle modification or drug therapy†
Risk factors 1–2 other than DM
Lifestyle modificationa or drug therapy
Lifestyle modification and drug therapy
Risk factors ≥3, subclinical organ damage
Lifestyle modification and drug therapy
Lifestyle modification and drug therapy
DM, cardiovascular disease, chronic kidney disease
Lifestyle modification or drug therapyb
Lifestyle modification and drug therapy
Lifestyle modification and drug therapy
Hypertension stage I
Patients with stage 1 HTN without other risk factors are in the low-risk group and would not be expected to obtain a greater benefit from treatment . However, their overall risk will increase over time, and the window in which treatment could reverse progression might be missed. Modern drugs are generally inexpensive and safe, and drug therapy has been found to be cost-effective given that patients generally fail to accomplish lifestyle changes. Drug therapy is recommended only after measurement of the out-of-clinic BP in order to exclude the possibility of white coat HTN [12,13]. The effect of medical therapy on white coat HTN has not yet been proven; however, as white coat HTN poses increased metabolic risk and risk for CV events over the long term, lifestyle modification is recommended at first, and patients should be observed periodically for development of persistent HTN. Drug therapy should be instituted immediately in patients with high-risk stage I HTN [14,15].
Hypertension stage II
Hypertension in the elderly
The effect of drug therapy against HTN is clear irrespective of age . Drug therapy can be initiated in elderly patients when the SBP is 160 mm Hg or higher; consistent drug therapy can be considered if the SBP is 140 to 159 mm Hg and the patient tolerates the drug well.
Target blood pressure in the treatment of hypertension
Target blood pressures in hypertension treatment
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Coronary artery disease
Chronic kidney disease
Hypertension in the elderly
The effects of decreasing BP in elderly patients with HTN are clear, but it is difficult to lower BP to less than 140 mm Hg in such patients , and there is no difference in prognosis between BP targets of 140 and 150 mm Hg. Therefore, the target SBP is approximately 140 to 150 mm Hg with a DBP that is not excessively low, i.e., less than approximately 60 mm Hg [20,21].
Hypertension in patients with diabetes
Reduction of BP in patients with HTN and diabetes is very important for reducing CV complications . Few studies have shown reduction of SBP to below 130 mm Hg. Even reduction of SBP to less than 120 mm Hg did not demonstrate any additional preventive effect on CVD but rather showed a deleterious effect on renal function; therefore, the recommended target BP is an SBP below 140 mm Hg  and a DBP below 85 mm Hg .
Hypertension in patients with stroke
HTN is a most important causative risk factor for stroke. HTN treatment can reduce the recurrence of stroke and CV events [25-27], but there are no distinct benefits from reducing SBP to below 130 mm Hg . In particular, a recent clinical study in patients with cerebral infarction showed no additional benefit from controlling SBP below 140 mm Hg . Considering the clinical studies to date, a target SBP below 140 mm Hg is recommended in patients with stroke.
Hypertension in patients with coronary artery disease
Hypertension in patients with chronic kidney disease
The major purpose of controlling BP in patients with chronic kidney disease (CKD) is to prevent deterioration of renal function and reduce the occurrence of CVD. Further control of SBP to below 140 mm Hg has shown no additional benefit in patients with HTN and CKD without diabetes [33-35]. However, the data on the goal of treatment in patients with HTN and CKD with diabetes is even more insufficient [36,37]. Meta-analysis has not proven that a target BP of less than 140 mm Hg is any more effective at preventing cardiac and renal events [23,38,39]. Therefore, on the basis of recent clinical data, a target SBP of less than 140 mm Hg is recommended regardless of the presence of diabetes. However, a target SBP below 130 mm Hg can be recommended in patients with HTN with prominent albuminuria .
Low threshold of hypertension treatment
As BP increases, the CV risk also increases, whereas as BP decreases, the risk of the occurrence of a CV event decreases to some extent. There is insufficient clinical data to prove the J-curve hypothesis (a hypothesis that excessive lowering of SBP and DBP will increase rather than decrease CV events and mortality), but post hoc analysis of clinical studies suggests the possibility of such a J-curve effect and a pathophysiological detriment of excessively low BP . Therefore, it is not recommended to target BP too low, but additional studies are needed to determine how low a BP is desirable.
Nondrug therapy and lifestyle modification
Blood pressure reduction by lifestyle modification
BP reduction (systolic/diastolic BP, mm Hg)
Restriction of salt intake
Less than 6 g of salt per day
Body weight reduction
Each reduction of 1 kg
Moderation in drink
Less than two glasses per day
30–50 min per day for more than 5 days in a week
Vegetables-based healthy diet habit
Restriction of salt intake
According to the 2010 KNHANES data, it is estimated that Korean consume 12.2 g (4.9 g sodium) of salt daily, which is a higher amount than western (10 g) or Japanese (10.7 g) populations . Salt intake can increase the risk for CV events because of the association of central hemodynamics with the estimated 24-h urinary sodium in patients with HTN . Halving the daily salt intake of 10.5 g will decrease SBP by 4 to 6 mm Hg [45,46]. However, there have been variable and confusing reports about the relationship between salt restriction and CV events [47-50]. Despite the absence of randomized large-scale trials, some reports of a J-curve phenomenon for salt intake and CV events, and lack of Korean data, there is no clear evidence that salt restriction is harmful, especially among Koreans with their high-salt intake. Therefore, we must recommend decreasing salt intake in accordance with other guidelines .
The daily recommended amount of salt is less than 6 g (sodium [g] × 2.5). Salt reduction has many benefits, including lowering of BP and reducing the need for diuretics, which cause detrimental urinary loss of potassium and calcium. The avoidance of urinary calcium loss prevents the development of osteoporosis and renal calculi.
Sensitivity to salt tends to be higher in patients who are elderly, obese, or have diabetes or family members with HTN. Greater salt sensitivity means a greater reduction in BP in response to salt restriction. The dietary habits must be modified. Some recommendations are not to put additional salt on the table during the meal and to avoid high-salt processed foodstuffs. Some frequently eaten foods, such as kimchi, stew, soup, salted fermented seafood, instant ramen, and dry bar snacks containing meat and fish, are very salty. When cooking foods, natural ingredients should be used instead of synthetic flavoring agents. The patient should not only reduce absolute salt intake but also try to consume more low-salt foods.
HTN is closely related to obesity, and weight reduction decreases BP. Central obesity in particular is closely associated with HTN, dyslipidemia, diabetes, and CV death. In a patient heavier than 110% of ideal body weight, weight reduction of only 5 kg can decrease BP. The beneficial effects of weight reduction are higher in patients with diabetes, dyslipidemia, and left ventricular hypertrophy (LVH). The combination of weight reduction with exercise, moderation of alcohol consumption, and reduction of salt intake has synergistic effects on BP. The recommended initial goal of weight reduction is 4 to 5 kg, with an additional 5 kg reduction after the initial goal has been achieved.
The ideal body mass index (BMI) (weight [kg]/height [m]2) varies among reports and according to nationality. A collaborative analysis reported that BMI either above or below the apparent optimum of approximately 22.5 to 25 kg/m2 is itself a strong predictor of overall mortality . Another meta-analysis found that both overweight and grade 1 obesity were associated with significantly lower all-cause mortality . A report on data from 1.2 million Koreans revealed that the risk of death from any cause was lowest among patients with a BMI of 23.0 to 24.9 kg/m2 and recommended a BMI of less than 25 kg/m2 . Unfortunately, there are no Korean-specific data on appropriate waist circumference. A waist circumference of less than 90 cm for men and 80 cm for women is recommended for Asian individuals .
The recommendations for weight reduction are to eat breakfast every morning, eat slowly, and avoid a high-carbohydrate diet, alcohol, snacks such as bread and cookies, and sweetened beverages. A high-fiber diet is recommended, and a high-fat diet including food fried with oil is prohibited. Patients should try to eat as many fruits and vegetables as possible and to avoid meals containing large amounts of cholesterol and saturated fatty acids.
Moderation of alcohol consumption
BP tends to increase in patients who drink excessive amounts of alcohol, and such patients are also resistant to antihypertensive drugs. An appropriate moderate daily amount of alcohol is less than 20 to 30 g for men or 10 to 20 g for women. A man or woman with lower-than-average body weight is more sensitive to alcohol and is therefore permitted half of the recommended amount. Heavy drinkers should be warned that they are high risk for stroke. One bottle of beer (720 mL), one glass of wine (range, 200 to 300 mL), one glass of sake (200 mL), two shots of whisky (60 mL), or two to three glasses of soju corresponds to 30 g of alcohol.
The benefits of regular exercise are lowering of BP, improvement of cardiopulmonary function, reduction of body weight, improvement of the lipid profile (including elevation of HDL cholesterol), and reduction of emotional stress. Aerobic exercises such as brisk walking, jogging, bicycling, swimming, jumping rope, playing tennis, and aerobic dancing are recommended for patients with HTN. The appropriate intensity of exercise is 60% to 80% of the maximal heart rate (220—age in years). Such exercise should be performed five to seven times per week. Aerobic exercise should begin at low intensity for 10 to 20 min and then increase to appropriate intensity for another 30 to 60 min. Every exercise session should start with 5 min of warm-up exercise and end with 5 min of cool-down exercise. In addition to aerobic exercise, isometric exercise such as weight lifting can reduce BP, produce metabolic benefits, and increase muscle power. Isometric exercise is recommended two to three times per week . Isotonic exercise such as lifting a heavy object (anaerobic metabolism) can increase BP and may be dangerous in patients with poorly controlled HTN. Most patients with uncomplicated HTN can begin regular exercise without an initial evaluation and increase the duration and intensity to appropriate levels as possible. However, patients with known CVDs or other risk factors are recommended to start the exercise only after complete evaluation by an exercise consultant and to follow a program.
During smoking, the BP increases temporarily in response to nicotine. Among patients with white coat HTN, smokers maintain a higher daytime ambulatory SBP than do nonsmokers with a similar office BP . Smoking, like HTN, is a powerful risk factor for CVD , and CV events are inevitable in patients who continue smoking regardless of BP control. Second-hand smoking is also harmful. Smoking cessation should be advised at every opportunity. Low-nicotine-containing replacement materials do not increase BP and can be recommended in combination with behavior therapy. During smoking cessation, regular exercise and diet therapy should be emphasized in order to prevent weight gain.
Healthy diet management
BP is lower in vegetarians than in people who mainly eat meat, and maintaining a vegetarian diet can reduce BP. The BP-lowering effect results not from decreasing the intake of animal protein but from increasing the intake of vegetables and fruits in combination with decreasing the intake of saturated fatty acids. In a study in elderly people, BP decreased by 3/1 mm Hg when intake of vegetables and fruits was increased alone but by 6/3 mmHg when it was combined with a decrease in fat intake [59-61]. In patients with HTN, a combined diet with greater intake of calcium, magnesium, and potassium decreased BP by an additional 11/6 mm Hg [59,61,62]. A regular diet composed mainly of fish reduces BP and improves the lipid profile in obese patients with HTN. The Dietary Approaches to Stop HTN (DASH) diet, which is rich in vegetables, fruits, and fish and low in fat, is recommended for patients with HTN .
Caffeine from various foods rapidly increases BP, but the effect does not progress to HTN because tolerance to caffeine develops. Emotional stress increases both BP and the risk for CVD, making the control of emotional stress important for the management and patient compliance of HTN. Further studies are required to examine the long-term effects of stress control on HTN and CVD. The effectiveness of various methods of stress management, such as relaxation and biofeedback, for the management of HTN remains uncertain. There is still no clear evidence for the effects of micronutrients, calcium, magnesium, and supplementary fiber on BP.
The occurrence of CV events in patients with HTN can be decreased by reducing the BP. Currently available antihypertensive drugs are more effective than placebo for prevention of CVD. This preventive effect is relatively larger for stroke than for coronary artery disease. The extent to which CV events are reduced depends on the degree of BP reduction. All major classes of antihypertensive drugs, including beta-blockers and diuretics, are suitable for first-line treatment. However, the individual drug should be prescribed with consideration of the patient’s individual situation, including age, comorbidities, and possible adverse effects. Simplifying the medication schedule, careful monitoring of the adverse effects, and checking the BP at home are useful for improving patient compliance and making the patient an active participant in the treatment.
Strategies for prescription of antihypertensive drugs
Principles of drug selection
Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers
Congestive heart failure
Left ventricular hypertrophy
Coronary artery disease
Elderly, isolated systolic hypertension
Prevention of atrial fibrillation
Selection of drugs
Indications and contraindications of antihypertensive drugs
Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers
CHF, diabetic nephropathy
Renal artery stenosis, hyperkalemia
Ischemic heart disease, myocardial infarction
High blood glucose, peripheral artery disease
Asthma, severe and symptomatic bradyarrhythmia
Elderly hypertension, isolate systolic hypertension, ischemic heart disease (non-dihydropyridine calcium antagonists)
Severe and symptomatic bradyarrhythmia
CHF, isolated systolic hypertension
High blood glucose
Classes of antihypertensive drugs
Diuretics decrease BP initially by reducing reabsorption of sodium in the renal distal convoluted tubules and later by decreasing peripheral vascular resistance. High-dose thiazide-derivative diuretics can induce hypokalemia, glucose intolerance, hyperuricemia, arrhythmia, and adverse lipid metabolism, but low doses rarely have these effects. For decreasing BP, the dose can be increased to 25 mg a day. Combination of diuretics with beta-blockers is not recommended in patients with obesity or high risk for diabetes because of adverse effects such as new-onset diabetes and adverse lipid metabolism. No specific thiazide diuretic is recommended over the others because there has been no study comparing them directly, although chlorthalidone and indapamide are reported to be most effective for lowering BP . As thiazide diuretics must frequently be administered at high doses to achieve optimal BP control, and because such high doses increase the adverse effects, thiazide-like diuretics may be preferred to avoid high dosage and/or reduce metabolic derangement. Spironolactone is proven effective in patients with heart failure and can also be considered at low doses (range, 20 to 50 mg) for treatment of resistant HTN.
Selective beta-1 blockers are recommended for patients with HTN in combination with angina pectoris, myocardial infarction, or tachycardia. Beta-blockers are also effective in younger patients who have higher heart rates . However, they should be used with caution in patients with asthma, chronic obstructive pulmonary disease, second- or third-degree atrioventricular block, or peripheral vascular disease .
Beta-blockers can have adverse effects on blood glucose and lipid metabolism and should therefore be used cautiously in elderly patients or patients with elevated blood sugar, diabetes, or metabolic syndrome . They should also be used carefully in patients with variant angina because they can worsen symptoms.  Because atenolol is inferior for stroke prevention, first-line therapy is not recommended for elderly patients with HTN . Concomitant use of beta-blockers and diuretics will increase the incidence of diabetes and should therefore be avoided in patients at high risk for developing diabetes . Vasodilatory beta-blockers might have different effects than atenolol, but no comparative study has yet been performed [71,72].
Long-acting calcium antagonists are preferable to short-acting calcium antagonists, which can cause tachycardia and increase cardiac workload. Because calcium antagonists have a vasodilatory effect on the coronary artery, they are highly effective in patients with stable angina or variant angina, which is caused by coronary artery spasm. They are also effective for slowing the progression of carotid atherosclerosis and reducing cardiac hypertrophy . The non-dihydropyridine calcium antagonists, verapamil and diltiazem, are effective after myocardial infarction because they do not produce reflex tachycardia. They are also effective in patients with hypertrophic cardiomyopathy because they improve diastolic filling. The common side effects of dihydropyridine calcium antagonists are tachycardia, ankle edema, headache, and facial flushing. Non-dihydropyridine calcium antagonists may cause constipation, conduction delay, and decreased myocardial contractility and should therefore be prescribed cautiously to patients with systolic heart failure or heart block. In addition, special caution is needed when administering them in combination with beta-blockers in elderly patients.
Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers
ACE inhibitors/angiotensin receptor blockers reduce mortality in patients with heart failure and help to inhibit the progression of renal disease. They also help to prevent LVH and atherosclerosis but have little effect on blood glucose or lipid metabolism . In addition, they can improve vascular endothelial cell function and promote revascularization. However, they can cause a hypotensive response in dehydrated or elderly patients . When administered to a patient with bilateral renal artery stenosis, they can have adverse effects such as severe hypotension and deterioration of renal function . The serum creatinine level may increase within the first 2 months after the start of treatment. However, there is no need to discontinue the drug unless the serum creatinine increases to less than 30% rise than the baseline creatinine level or unless serum potassium is 5.5 mEq/L or higher . Care should be taken in patients with a serum creatinine level higher than 3.0 mg/dL . The blood potassium level and renal function should be checked before and within 1 to 2 weeks after administration of the drug and then again 3 or 6 months later. ACE inhibitors inhibit bradykinin degradation and can thus cause a dry cough, but this resolves within a few days to a few weeks after stopping the medication. Dry cough is more common in women and nonsmokers. Angiotensin receptor blockers have no effect on bradykinin and therefore rarely cause cough. ACE inhibitors/angiotensin receptor blockers are contraindicated in pregnant women because of their teratogenic effects on the fetus.
Alpha-blockers can alleviate urinary symptoms in patients with prostate enlargement and also improve the metabolism of sugars and lipids. However, they can cause orthostatic hypotension and are associated with worsening of heart failure. Agents that act on the central nervous system, such as clonidine, methyldopa, and reserpine, have many side effects and are therefore not recommended as first-line drugs. Renin inhibitors have been developed and used in other countries but have not yet been introduced in Korea. Renin inhibitors significantly reduced BP and proteinuria when used alone or in combination with diuretics. However, aliskiren has not been proven to improve the prognosis of patients with CVD. Methyldopa is still preferred for the treatment of HTN in pregnant women but is not the first choice because of its side effects. Hydralazine is a vasodilator that is relatively safe for pregnant women with HTN.
Resistant HTN is defined as BP that cannot be controlled (BP ≥ 140/90 mm Hg) despite treatment with more than three different classes of antihypertensive drugs, including diuretics. The prevalence of resistant HTN is reported to be 5% to 30% in other countries. However, considering the frequency of pseudo-resistant HTN, the prevalence of true resistant HTN is assumed to be less than 10% . Patients with resistant HTN are at much higher risk for complications such as CVD and kidney disease .
Differential diagnosis of uncontrolled hypertension
Wrong cuff use
Using too small cuff
White coat hypertension
Calcified vessel in the elderly (pseudohypertension)
Lifestyle factors: severe weight gain, heavy or binge drinking, excess salt intake
Medication: cold remedies, nonsteroidal anti-inflammatory drugs, corticosteroid, cyclosporine/tacrolimus, erythropoietin, cocaine, herbal licorice
Sleep apnea syndrome
Volume expansion by renal diseases
Vascular damage or stiffness
Prescription of antihypertensive drugs: insufficient dose, wrong use of diuretics, ineffective combination, drug interaction
Bilateral destruction of the renal sympathetic nerves that course along the renal artery by the use of radiofrequency ablation catheters is an increasingly popular nondrug therapeutic approach to HTN. Reduction of BP lasts for more than a year after the procedure, and the BP-reducing effect was reported to be maintained for another 3 years of follow-up .
The treatment itself has no significant complications and can therefore be used in patients with resistant HTN. However, there is insufficient short-term and long-term evidence for the efficacy of renal denervation . Carotid stimulation is also reported to be effective for lowering BP in patients with resistant HTN; however, there is very little randomized blind study data supporting its efficacy .
Reduction or discontinuation of antihypertensive medications
In patients whose BP has been well controlled for years, the dose of antihypertensive drug can be reduced. Afterwards, the BP should be checked regularly, and the continued practice of lifestyle modifications monitored .
Other drug treatments
The goal of antihypertensive therapy is to reduce the overall CV risk in patients who have other risk factors such as diabetes, dyslipidemia, coronary artery disease, stroke, and CKD. Accordingly, these other risk factors should be treated at the same time.
Aspirin administration was shown to produce an absolute benefit for the secondary prevention of CVD in patients with HTN . However, the role of aspirin for secondary prevention remains a matter of debate.
Low-dose aspirin (100 mg) can be prescribed to patients in high-risk groups in order to reduce the risk of CVD [92,93]. Antiplatelet agents should be administered after the BP is controlled, and patients should be checked periodically for gastrointestinal bleeding.
Lipid-lowering agents have a protective effect on high-risk patients with HTN. Although there is very little Korean data, a 50% reduction in low-density lipoprotein (LDL) cholesterol in patients who had an LDL cholesterol level ≥130 mg/dL significantly lowered the risk for CVD . Lowering the LDL cholesterol level to <100 mg/dL is recommended in hypertension patients with coronary artery disease or diabetes mellitus . For hypertension patients with acute coronary syndrome, LDL should be lowered below 70 mg/dL. There is evidence for reducing the LDL cholesterol level to <135 mg/dL in patients with stroke ; however, there is little data regarding the effect of lowering the LDL cholesterol to <70 mg/dL in such patients.
Recent clinical studies have shown that aggressive blood glucose control (a hemoglobin A1C level less than 6.0% or 6.5%) reduces the incidence of ischemic heart disease in patients with type 2 diabetes; however, there was no significant change or even increase in stroke or total mortality. Therefore, in patients with diabetes, the blood glucose level should be controlled so that the hemoglobin A1C is less than 7.0% in most patients and less aggressively (target hemoglobin A1C of 7.5% to 8.0%) in older patients or patients with diabetes of long duration, who have increased risk for hypoglycemia .
Monitoring and follow-up
Patients should generally be followed up once monthly, at least until the target BP is achieved. Patients with severe HTN (stage two or more) need more frequent follow-up. The serum potassium and creatinine levels should be measured at least one to two times yearly. If the BP is controlled and stable, then the patient should be followed up every 3 to 6 months. A longer follow-up interval may be associated with low compliance. Therefore, patient compliance also must be monitored, and the need for blood tests should be emphasized to encourage attendance at follow-up visits. A longer follow-up interval to monitor the status of BP control can be achieved by encouraging home BP measurement.
Trust between doctor and patient is the most important issue in the treatment of HTN, and the patient should therefore be encouraged to participate in the development of the treatment plan. Many patients may have obtained information about various antihypertensive agents through various routes, so discussion may be necessary. First, identify the patient’s point of view to determine the relative importance of efficacy, cost-effectiveness, and side effects. It is necessary to reduce overall CV risk as much as possible while maintaining the patient’s compliance. Self-measurement of BP by using home BP monitoring can improve compliance.
Angiotensin receptor blocker
Body mass index
Chronic kidney disease
Diastolic blood pressure
Korean National Health and Nutrition Examination Survey
Left ventricular hypertrophy
Systolic blood pressure
On behalf of the committee of the clinical practice guidelines at the Korean Society of Hypertension, we thank professors Cheol-Ho Kim and Hyeon Chang Kim for their kind consultations. Additionally, we thank the officials of the The Korean Society of Internal Medicine, The Korean Geriatrics Society, The Korean Stroke Society, The Korean Diabetes Association, The Korean Society of Nephrology, and The Korean Society of Cardiology for their endorsement of this guideline.
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