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Diagnostik und Therapie bei therapieresistenter Hypertonie

Diagnostic procedures and therapy in patients with resistant hypertension

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Zusammenfassung

Rund 10% aller Patienten mit arterieller Hypertonie, die medikamentös antihypertensiv behandelt werden, können als „schwer einstellbar“ bzw. „therapieresistent“ eingestuft werden. Eine Therapieresistenz liegt definitionsgemäß vor, wenn trotz einer dreifachen antihypertensiven Medikation inkl. eines Diuretikums Zielblutdruckwerte unter 140/90 mm Hg nicht erreicht werden. Patienten mit therapieresistenter Hypertonie tragen ein hohes Risiko für Hypertoniefolgeerkrankungen, besonders bei Vorliegen zusätzlicher kardiovaskulärer Risikofaktoren wie Diabetes mellitus, Hyperlipidämie und Nikotinkonsum. Die Genese einer schwer einstellbaren Hypertonie ist oft multifaktoriell. Häufig trägt eine nicht sachgemäß durchgeführte Blutdruckmessung zu falsch hohen Blutdruckwerten bei. Non-Compliance in Bezug auf die Einnahme der verordneten Antihypertensiva scheint bei etwa jedem fünften Betroffenen die Hauptursache der Therapieresistenz zu sein. Bei rund 10% der Patienten mit therapieresistenter Hypertonie liegt eine bisher unbehandelte, unvermutete bzw. neu hinzugetretene sekundäre Hypertonieform vor. Das Ziel der Therapie ist die Normalisierung des Blutdrucks, die oft einen multifaktoriellen Ansatz erforderlich macht. Einer optimalen Dosierung der verordneten Antihypertensiva kommt dabei besondere Bedeutung zu. Neuere invasive Verfahren (z. B. renale Denervation) ergänzen das therapeutische Arsenal bei therapieresistenter Hypertonie, wobei aus heutiger Sicht wegen der fehlenden Langzeitergebnisse eine abschließende Bewertung dieser Ansätze noch nicht erfolgen kann.

Abstract

Criteria for hard-to-control or resistant hypertension are met by about 10 % of the antihypertensive drug treated population. Resistant hypertension is defined as failure to lower blood pressure below 140/90 mmHg with triple antihypertensive medication including a diuretic. Patients with resistant hypertension are at high risk for the development of hypertensive end-organ damage, particularly in patients with diabetes, lipid disorders and smokers. Causes include cuff-related artefacts, non-adherence to treatment (about 20 % of cases) and secondary forms of hypertension (about 10 % of cases). The aim of treatment is normalization of blood pressure often by a multifactorial approach. An optimized dosing regimen of antihypertensive drugs is crucial. Newer device-based forms of therapy (e.g. renal sympathetic denervation) are promising but are awaiting further clinical and risk profile substantiation.

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Literatur

  1. Chobanian AV, Bakris GL, Black HR et al (2003) National High Blood Pressure Education Program Coordinating Committee: the JNC 7 report. JAMA 289:2560–2572

    Article  PubMed  CAS  Google Scholar 

  2. Fagard RH (2012) Resistant hypertension. Heart 98:254–261

    Article  PubMed  CAS  Google Scholar 

  3. Falaschetti E, Chaudhury M, Mindell J, Poulter N (2009) Continued improvement in hypertension management in England. Results from the Health Survey for England 2006. Hypertension 53:480–486

    Article  PubMed  CAS  Google Scholar 

  4. Hajjar I, Kotchen TA (2003) Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1998–2000. JAMA 290:199–206

    Article  PubMed  Google Scholar 

  5. Lloyd-Jones DM, Evans JC, Larson MG et al (2000) Differential control of systolic and diastolic blood pressure: factors associated with lack of blood pressure control in the community. Hypertension 36:594–599

    Article  PubMed  CAS  Google Scholar 

  6. Calhoun DA, Jones D, Textor S et al (2008) Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 117:e510–526

    Article  PubMed  Google Scholar 

  7. Sierra A de la, Segura J, Banegas JR et al (2011) Clinical features of 8,295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension 57:898–902

    Article  PubMed  Google Scholar 

  8. Oparil S, Cahoun DA (1998) Managing the patient with hard-to-control hypertension. Am Fam Physician 57:1007–1014

    PubMed  CAS  Google Scholar 

  9. Berlowitz DR, Ash AS, Hickey EC et al (1998) Inadequate management of blood pressure in a hypertensive population. N Engl J Med 339:1957–1963

    Article  PubMed  CAS  Google Scholar 

  10. Hyman DJ, Pavlik VN (2001) Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 345:479–486

    Article  PubMed  CAS  Google Scholar 

  11. Moser M, Setaro JF (2006) Resistant or difficult-to-control hypertension. N Engl J Med 355:385–392

    Article  PubMed  CAS  Google Scholar 

  12. Persell SD (2011) Prevalence of resistant hypertension in the United States, 2003–2008. Hypertension 57:1076–1080

    Article  PubMed  CAS  Google Scholar 

  13. Brown MA, Buddle ML, Martin A (2001) Is resistant hypertension really resistant? Am J Hypertens 14:1263–1269

    Article  PubMed  CAS  Google Scholar 

  14. Staessen J, Gasowski J, Wang JG et al (2000) Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 355:865–872

    Article  PubMed  CAS  Google Scholar 

  15. Cuspidi C, Macca G, Sampieri L et al (2001) High prevalence of cardiac and extracardiac organ damage in refractory hypertension. J Hypertens 19:2063–2070

    Article  PubMed  CAS  Google Scholar 

  16. Sarafidis PA, Bakris GL (2008) Resistant hypertension: an overview of evaluation and treatment. J Am Coll Cardiol 52:1749–1757

    Article  PubMed  Google Scholar 

  17. Vinker S, Alkalay A, Hoffman RD et al (2008) Long-term adherence to antihypertensive therapy: a survey in four primary care clinics. Expert Opin Pharmacother 9:1271–1277

    Article  PubMed  Google Scholar 

  18. Zeller A, Schroeder K, Peters TJ (2007) Electronic pillboxes (MEMS) to assess the relationship between medication adherence and blood pressure control in primary care. Scand J Prim Health Care 25:2002–2007

    Article  Google Scholar 

  19. Jackson KC, Sheng X, Nelson RE et al (2008) Adherence with multiple-combination antihypertensive pharmacotherapies in a US managed care database. Clin Ther 30:1558–1563

    Article  PubMed  Google Scholar 

  20. Nuesch R, Schroeder K, Dieterle T et al (2001) Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study. BMJ 323:142–146

    Article  PubMed  CAS  Google Scholar 

  21. Hausberg M, Mann J, Kühn K (2008) Nieren und Hochdruck. Dtsch Med Wochenschrift 133:1853–1856

    Article  CAS  Google Scholar 

  22. Anderson GH Jr, Blakeman N, Streeten DH (1994) The effect of age on prevalence of secondary forms of hypertension in 4,429 consecutively referred patients. J Hypertens 12:609–615

    Article  PubMed  Google Scholar 

  23. Gonzaga CC, Calhoun DA (2008) Resistant hypertension and hyperaldosteronism. Curr Hypertens Rep 10:496–503

    Article  PubMed  CAS  Google Scholar 

  24. Lehnert H, Scholz T, Schäfer M, Klose S (2007) Endokrine Hochdruckformen. Dtsch Med Wochenschrift 132:207–217

    Article  CAS  Google Scholar 

  25. Middeke M (2009) Telemetrische Blutdruck- und Therapiekontrolle. Ein Instrument zur Förderung der Therapieadhärenz. Klinikarzt 38:146–150

    Article  Google Scholar 

  26. Mann JF, Schmieder RE, McQueen M et al (2008) Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet 372:547–553

    Article  PubMed  CAS  Google Scholar 

  27. Parving HH, Brenner BM, McMurray JJ et al (2012) Baseline characteristics in the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE). J Renin Angiotensin Aldosterone Syst 13:387–393

    Article  PubMed  Google Scholar 

  28. Laurent S, Schlaich M, Esler M (2012) New drugs, procedures, and devices for hypertension. Lancet 380:591–600

    Article  PubMed  CAS  Google Scholar 

  29. Dickerson JEC, Hingorani AD, Ashby MJ et al (1999) Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 353:2008–2013

    Article  PubMed  CAS  Google Scholar 

  30. Logan AG, Perlikowski SM, Mente A et al (2001) High prevalence of unrecognized sleep apnea in drug-resistant hypertension. J Hypertension 19:2271–2277

    Article  CAS  Google Scholar 

  31. Esler MD, Krum H, Sobotka PA et al (2010) Renal sympathetic denervation in patients with treatment resistant hypertension (the Simplicity HTN-2 Trial): a randomized controlled trial. Lancet 376:1903–1909

    Article  PubMed  Google Scholar 

  32. Krum H, Schlaich M, Whitbourn R et al (2009) Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of principle cohort study. Lancet 373:1275–1281

    Article  PubMed  Google Scholar 

  33. Mahfoud F, Vonend O, Bruck H et al (2011) Expert consensus statement on interventional renal sympathetic denervation for hypertension treatment. Dtsch Med Wochenschr 136:2418–2422

    Article  PubMed  CAS  Google Scholar 

  34. Bisognano JD, Bakris G, Nadim MK et al (2011) Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension; results from the double-blind, randomized placebo-controlled rheos pivotal trial. J Am Coll Cardiol 58:765–773

    Article  PubMed  Google Scholar 

  35. Chapman N, Dobson J, Wilson S et al (2007) Effect of spironolactone on blood pressure in subjects with resistant hypertension. Hypertension 49:839–851

    Article  PubMed  CAS  Google Scholar 

  36. Mann SJ (1999) Severe paroxysmal hypertension (pseudopheochromocytoma). Arch Intern Med 159:670–674

    Article  PubMed  CAS  Google Scholar 

  37. Werlemann BC, Offers E, Kolloch R (2004) Complianceprobleme bei therapierefraktärer Hypertonie. Herz 29:271–275

    Article  PubMed  Google Scholar 

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Lenz, T., Hoyer, J. Diagnostik und Therapie bei therapieresistenter Hypertonie. Nephrologe 8, 79–92 (2013). https://doi.org/10.1007/s11560-011-0615-6

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