Therapieresistente und sekundäre Hypertonie

Was ist neu?

Sekundäre Hypertonie 2016 wurden Handlungsempfehlungen zum primären Hyperaldosteronismus in einer internationalen Leitlinie veröffentlicht, die 2018 speziell aus europäischer Sicht erweitert wurden. Ziel ist es, frühzeitig die entsprechenden Patienten zu detektieren, um Endorganschäden und kardiovaskulären Ereignissen vorzubeugen. Bei Verdacht auf eine atherosklerotische Nierenarterienstenose eignet sich als Suchtest leitliniengemäß die farbkodierte Duplexsonografie der Nieren und Nierenarterien. Die Therapie ist in erster Linie medikamentös.

Obstruktives Schlafapnoe-Syndrom Protrusionsschienen führen zu einem vergleichbaren moderaten Effekt auf den Bluthochdruck wie die bisher etablierte Überdruckbeatmung. Sie werden von Patienten besser toleriert.

Therapieresistente Hypertonie – konservative Behandlungsoptionen Bei der therapieresistenten Hypertonie wird als viertes Medikament Spironolacton empfohlen. Durch die zusätzliche Einnahme von Patiromer kommt es insbesondere bei Patienten mit chronischer Nierenerkrankung zu weniger Hyperkaliämien, wodurch eine sichere Spironolacton-Gabe möglich ist.

Therapieresistente Hypertonie – interventionelle Behandlungsoptionen Die renale Denervierung kann in den ersten postinterventionellen Monaten zwar zu einer signifikanten Blutdrucksenkung führen, die aber deutlich moderater ist als initiale Studien suggerierten.

Abstract

Resistant hypertension (RH) is defined in patients who do not meet their blood pressure targets despite the daily intake of three antihypertensive drugs in maximally tolerated dosages. This triple treatment should comprise (1) an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB), (2) a calcium channel blocker and (3) a diuretic. RH should also be diagnosed in patients on four or more antihypertensive drug classes. Of note, the diagnosis of RH requires the exclusion of non-adherence, “white coat effect”, and incorrect BP-measurement.

After diagnosing RH, it is important to recommend lifestyle interventions (e. g. low dietary salt intake, regular physical activity), to pause BP-elevating substances, and to consider the presence of secondary hypertension.

Such secondary forms of hypertension primarily include endocrine disorders and renal disease (both acute kidney injury and chronic kidney disease). The leading endocrine cause is primary hyperaldosteronism, the management of which was highlighted in a recent guideline. Other endocrine causes – such as phaeochromocytoma or hypercortisolism – are much less frequent. In contrast, sleep apnoea disorders are now mostly considered as a comorbidity rather than as a cause of secondary hypertension.

Treatment options for RH include lifestyle optimisation and escalation of antihypertensive medication. In most patients on triple treatment (ACE-I or ARB plus calcium channel blocker plus diuretic), mineralocorticoid receptor antagonists (MRA) should be the next treatment choice. As MRA may be associated with hyperkalemia (particularly in patients with chronic kidney disease), the concurrent use of potassium-lowering agents such as patiromer may allow a safe long-term treatment. In contrast, novel interventional treatment options in RH such as renal denervation are still controversially discussed.

Schlüsselwörter

therapieresistente Hypertonie - resistente Hypertonie - sekundäre Hypertonie - endokrine Hypertonie - renale Hypertonie

Key words

treatment resistant hypertension - resistant hypertension - secondary hypertension - endocrine hypertension - renal hypertension

Publikationsverlauf

Artikel online veröffentlicht:
01. Juni 2021

• Literatur

• 1 Carey RM, Calhoun DA, Bakris GL. et al Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2018; 72: e53-e90 DOI: 10.1161/HYP.0000000000000084.
• 2 Monticone S, Burrello J, Tizzani D. et al Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice. J Am Coll Cardiol 2017; 69: 1811-1820 DOI: 10.1016/j.jacc.2017.01.052.
• 3 Brown JM, Siddiqui M, Calhoun DA. et al The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study. Ann Intern Med 2020; 173: 10-20 DOI: 10.7326/M20-0065.
• 4 Monticone S, D'Ascenzo F, Moretti C. et al Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2018; 6: 41-50 DOI: 10.1016/S2213-8587(17)30319-4.
• 5 Funder JW, Carey RM, Mantero F. et al The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 1889-1916 DOI: 10.1210/jc.2015-4061.
• 6 Williams TA, Reincke M. MANAGEMENT OF ENDOCRINE DISEASE: Diagnosis and management of primary aldosteronism: the Endocrine Society guideline 2016 revisited. Eur J Endocrinol 2018; 179: R19-R29 DOI: 10.1530/EJE-17-0990.
• 7 Wang K, Hu J, Yang J. et al. Development and Validation of Criteria for Sparing Confirmatory Tests in Diagnosing Primary Aldosteronism. J Clin Endocrinol Metab 2020; 105 DOI: 10.1210/clinem/dgaa282.
• 8 Lenders JWM, Kerstens MN, Amar L. et al Genetics, diagnosis, management and future directions of research of phaeochromocytoma and paraganglioma: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2020; 38: 1443-1456 DOI: 10.1097/HJH.0000000000002438.
• 9 Bratton DJ, Gaisl T, Wons AM. et al CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. JAMA 2015; 314: 2280-2293 DOI: 10.1001/jama.2015.16303.
• 10 Schwartz M, Acosta L, Hung YL. et al Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath 2018; 22: 555-568 DOI: 10.1007/s11325-017-1590-6.
• 11 Williams B, MacDonald TM, Morant S. et al Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet 2015; 386: 2059-2068 DOI: 10.1016/S0140-6736(15)00257-3.
• 12 Agarwal R, Rossignol P, Romero A. et al Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet 2019; 394: 1540-1550 DOI: 10.1016/S0140-6736(19)32135-X.
• 13 Bhatt DL, Kandzari DE, O'Neill WW. et al A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014; 370: 1393-1401 DOI: 10.1056/NEJMoa1402670.
• 14 Townsend RR, Mahfoud F, Kandzari DE. et al Catheter-based renal denervation in patients with uncontrolled hypertension in the absence of antihypertensive medications (SPYRAL HTN-OFF MED): a randomised, sham-controlled, proof-of-concept trial. Lancet 2017; 390: 2160-2170 DOI: 10.1016/S0140-6736(17)32281-X.
• 15 Kandzari DE, Bohm M, Mahfoud F. et al Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial. Lancet 2018; 391: 2346-2355 DOI: 10.1016/S0140-6736(18)30951-6.
• 16 Sardar P, Bhatt DL, Kirtane AJ. et al Sham-Controlled Randomized Trials of Catheter-Based Renal Denervation in Patients With Hypertension. J Am Coll Cardiol 2019; 73: 1633-1642 DOI: 10.1016/j.jacc.2018.12.082.