Zusammenfassung
Die arterielle Hypertonie ist der wichtigste Risikofaktor für den Schlaganfall. Der Nutzen einer antihypertensiven Therapie ist durch viele Interventionsstudien für die Primär- und auch für die Sekundärprävention für alle Altersgruppen eindeutig belegt. Eine Empfehlung einer hypertensiven Substanz speziell für die Primärprävention des Schlaganfalls gibt es nicht. Um das Therapieziel (Normotonie) zu erreichen, sind meist antihypertensive Mehrfachkombinationen erforderlich. Bei Hochrisikopatienten sowie in der Sekundärprävention sind möglicherweise Hemmstoffe des Renin-Angiotensin-Systems besonders in Kombination mit Kalziumantagonisten und Indapamid vorteilhaft. β-Blocker erscheinen weniger geeignet. Bei Patienten mit linksventrikulärer Hypertrophie oder Vorhofflimmern sind Sartane am besten belegt. Zur Therapiekontrolle sollte auch die ambulante 24-h-Blutdruckmessung eingesetzt werden, da häufig eine gestörte Blutdruckrhythmik mit fehlender nächtlicher Blutdrucksenkung vorliegt, die für die Prognose von erheblicher Bedeutung ist. Der Zusammenhang zwischen vaskulärer Demenz und Hypertonie gilt inzwischen ebenfalls als gesichert. Eine frühzeitige antihypertensive Therapie kann einer Demenzentwicklung und der Einschränkung kognitiver Funktionen vorbeugen.
Abstract
Arterial hypertension is the most important risk factor for stroke. Many interventional trials have unambiguously proven the benefit of antihypertensive therapy in both primary and secondary prevention for all age categories. No recommendation for any single antihypertensive substance for the primary prevention of stroke exists. Achieving the therapeutic goal (normotension) is the crucial factor. In most patients, multiple combinations of antihypertensive drugs are required to do this. For high-risk patients and in secondary prevention, substances inhibiting the renin-angiotensin-system, especially combined with calcium antagonists and indapamid, may be advantageous, while beta-blockers appear to be less well suited. In patients suffering from left-ventricular hypertrophy or atrial fibrillation, sartanes are the best-documented drug class. As TIA or stroke will often disturb the normal circadian rhythm of blood pressure and eliminate the usual night-time drop, monitoring of the therapeutic results must include ambulatory 24h measurements. The interrelation between vascular dementia and hypertension is by now also considered proven. An early start of antihypertensive treatment can prevent the development of dementia and impaired cognitive function.
Literatur
Beckett NS, Peters R, Fletcher AE et al. (2008) Treatment of hypertension in patients 80 years of age or older. N Engl J Med 358: 1887–1898
Collins R, Peto R, MacMahon S et al. (1990) Blood pressure, stroke and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet 335: 827–838
Dahlof B, Devereux RB, Kjeldsen SE et al. (2002) Cardiovascular morbidity and mortality in the losartan intervention for endpoint reduction in the hypertension study (LIFE): a randomised trial against atenolol. Lancet 359: 995–1003
Dahlof B, Sever PS, Poulter NR et al. (2005) Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 366: 895–906
Flather MD, Yusuf S, Koeber L et al. (2000) Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. Lancet 355: 1575–1581
Forette F, Seux ML, Staessen JA et al. (1998) Prevention of dementia in randomised double-blind placebo-controlled systolic hypertension in Europe (Syst-Eur) trial. Lancet 352: 1347–1351
Jamerson K, Weber MA, Bakris GL et al. (2008) Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high- risk patients. N Engl J Med 359: 2417–2428
Knecht S, Wersching H, Lohmann H et al. (2008) High-normal blood pressure is associated with poor cognitive performance. Hyertension 51: 663–668
Lewington S, Clarke R, Qizilbash N et al. (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360: 1903–1913
Lindholm LH, Carlberg B, Samuelsson O (2005) Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 366: 1545–1553
Peila R, White LR, Masaki K et al. (2006) Reducing the risk of dementia: efficacy of long-term treatment of hypertension. Stroke 37: 1165–1170
Peters R, Beckett N, Forette F et al. (2008) Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol 7: 683–689
Progress Collaborative Group (2001) Randomised trial of a perindopril-based blood-pressure lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 358: 1033–1041
Rashid P, Leonardi-Bee J, Bath P (2003) Blood pressure reduction and secondary prevention of stroke and other vascular events. A systematic review. Stroke 34: 2741–2749
Rodgers A, MacMahon S, Gamble G et al. (1996) Blood pressure and risk of stroke in patients with cerebrovascular disease: the United Kingdom transient ischaemic attack collaborative group (letter). BMJ 313: 147
Ruitenberg A, Skoog I, Ott A et al. (2001) Blood pressure and risk of dementia: Results from the Rotterdam study and the Gothenburg H-70 study. Dement Geriatr Cogn Disord 12: 33–39
Schrader J, Lüders S, Kulschewski A et al. (2003) Evaluation of acute candesartan cilexetil therapy in stroke survivors. Stroke 34: 1699–1703
Schrader J, Lüders S, Kulschewski A et al. (2005) Morbidity and mortality after stroke. Eprosartan compared with nitrendipine for secondary prevention (MOSES). Stroke 36: 1218–1226
Schrader J, Lüders S, Diener HC et al. (2008) Effects of long-term antihypertensive therapy with losartan on blood pressure and cognitive function in patients with essential hypertension and other cerebrovascular risk factors (AWARE observational study). Med Klin (Munich) 103: 491–499
SHEP Coperative Research Group (1991) Prevention of stroke by antihypertensive drug treatment in older persons with isolated systlic hypertension. JAMA 265: 3255–3264
Skoog I, Andreasson LA, Landahl S, Lernfelt B (1998) A population-based study on blood pressure and brain atrophy in 85-years-old. Hypertension 32: 404–409
Staessen JA, Gasowski J, Wang JG et al. (2000) Risk of untreated and treated isolated systolic hypertension in the elderly: metaanalysis of outcome trials. Lancet 355: 865–872
Stokes J, Kannel WB, Wolf PA et al. (1989) Blood pressure as a risk factor for cardiovascular disease. The Framingham study – 30 years of follow-up. Hypertension 13 (Suppl I): I12–I18
Sugiyama T, Lee JD, Shimizu H et al. (1999) Influence of treated blood pressure on progression of silent cerebral infarction. J Hypertension 17: 679–684
The ONTARGET Investigators (2008) Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 358: 1547–1559
Turnbull F (2003) Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 362: 1527–1535
Tzourio C, Anderson C, Chapman N et al. (2003) Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med 12;163(9): 1069–1075
Vermeer SE, Prins ND, den Heijer T et al. (2003) Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med 348: 1215–1222
Wing LM, Reid CM, Ryan P et al. (2003) A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 348: 583–592
Yusuf S, Diener HC, Sacco RL et al. (2008) Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 359: 1225–1237
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Schrader, J. Schlaganfall und Hypertonie. Internist 50, 423–432 (2009). https://doi.org/10.1007/s00108-008-2291-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00108-008-2291-9