Studienlage in praxistaugliche Strategien umsetzen - Blutdruckmanagement zur Primär- und Sekundärprophylaxe des Schlaganfalls

Zusammenfassung

Die arterielle Hypertonie ist der wichtigste Risikofaktor für den Schlaganfall: Bereits eine geringfügige Reduktion des Blutdrucks reduziert das Schlaganfallrisiko erheblich - bei bisher nicht an einem Schlaganfall Erkrankten um 30-40 %, übrigens auch in üblicherweise als normoton definierten Bereichen. Daraus lässt sich eine Indikation zur regelmäßigen Messung des Blutdrucks und zu nichtmedikamentöser und medikamentöser antihypertensiver Therapie zur Primärprävention des Schlaganfalls ableiten. Patienten, die bereits einen Schlaganfall erlitten haben, profitieren unabhängig vom Ausgangsblutdruck ebenfalls von einer blutdrucksenkenden Therapie. Zur Sekundärprophylaxe ist die Kombination von Diuretika und ACE-Hemmern zugelassen. Bei Wirkungslosigkeit oder Nebenwirkungen dieser Therapieoptionen ist der Wechsel zu anderen Präparaten sinnvoll. Noch ist die Wirksamkeit dieser Intervention nicht getrennt nach Schlaganfallsubtypen überprüft worden. Da aber sowohl Makro- als auch Mikroangiopathie und Vorhofflimmern als wesentliche Ursachen des Schlaganfalls durch die arterielle Hypertonie bedingt sind oder diese als Kofaktor haben, ist für alle Subtypen ein Nutzen anzunehmen. Für Patienten mit höhergradigen bilateralen Karotisstenosen muss die antihypertensive Therapie an die hämodynamischen Verhältnisse angepasst sein, wobei eine gewisse Zurückhaltung in der Blutdrucksenkung angezeigt ist. Dies gilt auch für multimorbide Patienten. Bei allen Patienten wird das Ausmaß der erreichten Blutdrucksenkung durch Nebenwirkungen und Compliance bestimmt sein.

Summary

Arterial hypertension is the most important risk factor for stroke. Relatively small reduction of blood pressure reduces the risk of a first stroke by more than one third. This is also true in ranges of blood pressure that are usually defined as normal. These data implicate, that for primary prevention of stroke, blood pressure should be regularly taken in healthy individuals and, if elevated, an antihypertensive treatment should be started, consisting of changes in lifestyle and antihypertensive drugs. Patients who have already suffered a stroke benefit from antihypertensive treatment regardless of their baseline blood pressure. The combination of diuretics and ACE inhibitors is available for secondary prevention of stroke. If the lowering of blood pressure is not sufficiently reached or there are side effects, the drug regime can of course be changed. The effect of antihypertensive treatment on the different stroke subtypes has not been investigated separately yet. As all of the subtypes have hypertension as a risk factor, it is reasonable to assume a positive effect of antihypertensive treatment on all of them. In patients with bilateral significant carotid stenosis, there is probably an increase in stroke risk with lower blood pressure. In these patients, it seems to be wise to only moderately lower the blood pressure. In many stroke patients, multimorbidity renders pharmacotherapy more challenging. The amount of blood pressure reduction in the individual patient will depend on the side effects of treatment and on the compliance of the patient.

Key Words

stroke - primary prevention - secondary prevention - blood pressure - antihypertensive agents

Literatur

• 1 Collins R, Peto R, MacMahon S. et al. . Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context.  Lancet. 1990;  335 827-838
• 2 Dahlof B, Devereux RB, Kjeldsen SE. et al. . Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.  Lancet. 2002;  359 995-1003
• 3 Grau AJ, Weimar C, Buggle F. et al. . Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank.  Stroke. 2001;  32 2559-2566
• 4 Hansson L, Lindholm LH, Ekbom T. et al. . Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study.  Lancet. 1999;  354 1751-1756
• 5 Hansson L, Zanchetti A, Carruthers SG. et al. . Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group.  Lancet. 1998;  351 1755-1762
• 6 Lindholm LH, Ibsen H, Dahlof B. et al. . Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.  Lancet. 2002;  359 1004-1010
• 7 MacMahon S, Peto R, Cutler J. et al. . Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias.  Lancet. 1990;  335 765-774
• 8 Mellion MB. Exercise: how much is enough, and how much is too much?.  Heart Dis Stroke. 1994;  3 2-4
• 9 Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack.  Lancet. 2001;  358 1033-1041
• 10 Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review.  Stroke. 2003;  34 2741-2748
• 11 Rodgers A, MacMahon S, Gamble G. et al. . Blood pressure and risk of stroke in patients with cerebrovascular disease. The United Kingdom Transient Ischaemic Attack Collaborative Group.  BMJ. 1996;  313 147
• 12 Rothwell PM, Howard SC, Spence JD. Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease.  Stroke. 2003;  34 2583-2590
• 13 Sacks FM, Svetkey LP, Vollmer WM. et al. . Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group.  N Engl J Med. 2001;  344 3-10
• 14 Staessen JA, Gasowski J, Wang JG. et al. . Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials.  Lancet. 2000;  355 865-872
• 15 The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. . Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).  JAMA. 2002;  288 2981-2997

1 losartan intervention for endpoint reduction in hypertension

2 dietary approaches to stop hypertension

3 perindopril protection against recurrent stroke study

4 prevention regimen for effectively avoiding second strokes

5 ongoing telmisartan alone and in combination with ramipril global endpoint trial

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