Therapie des adipösen Hypertonikers

Zusammenfassung

Adipositas geht mit einer ca. 50 %igen Prävalenz hypertoner Blutdruckwerte einher, die in Abhängigkeit vom Body Mass Index bis auf 80 % ansteigt. Ätiopathogenetisch stellt das viszerale Fett mit Aktivierung des Neuroendokrineums (Sympathicus, RAAS), der Induktion einer Insulinresistenz mit Hyperinsulinämie und der direkten medullären Kompression durch Fetteinlagerungen in den Nieren die entscheidende Grundlage für die veränderte Hämodynamik und den Blutdruckanstieg dar. Primäres Ziel ist eine durch Ernährungs- und Lifestyle-Modifikation erzielte, lang anhaltende Gewichtsreduktion, welche ggf. mit gewichtsreduzierenden Medikamenten zu ergänzen sind. Dabei senkt Orlistat zugleich den Blutdruck, was vom Sibutramin nur unter bestimmten Voraussetzungen in speziellen Situationen ausgeht. Interessanterweise steigt der Blutdruck nach gewichtsreduzierenden chirurgischen (bariatrischen) Maßnahmen im Verlaufe von zehn Jahren wieder deutlich trotz anhaltender Gewichtsreduktion an. Die antihypertensive medikamentöse Differentialtherapie sollte sich am pathophysiologischen Realisierungsmuster und den Begleit- und Folgeerkrankungen orientieren. Dabei dürften ACE-Hemmer (alternativ Angiotensin-Rezeptor-Blocker) in Kombination mit niedrig dosierten Diuretika die Priorität geniessen, gefolgt in der Kombination mit Kalziumantagonisten. Beta-Rezeptoren-Blocker sollten immer dann zum Einsatz kommen, wenn eindeutige kardiale Indikationen dafür bestehen.

Summary

There is a 50 % prevalence of obesity with arterial hypertension. This ratio can increase up to 80 %, depending on body mass index. Important pathogenetic origins are quantity of visceral body fat along with the activation of neuroendocrineum (sympathicus, renin-angiotensin system), an induction of insulin resistance with hyperinsulinemia, and a direct compression of the medulla by fat deposits in the kidneys, which results in hemodynamic changes and an increase in blood pressure. The primary aim is a reduction in weight by means of a balanced diet and life style modification, which can be augmented by weight reducing medication. Orlistat lowers blood pressure and body weight simultaneously, whereas sibutramine accomplishes this only under certain circumstances. Interestingly, blood pressure increases again over the course of 10 years following weight reducing surgical procedures, despite ongoing weight loss. Antihypertensive differential therapy should be focused on pathophysiology and concomitant and target organ disease. Thus ACE inhibitors (alternatively angiotensin receptor blockers), in combination with low dose diuretics, should be preferentially administered, followed by calcium antagonists. Beta blockers should be used if definite cardiac indications are present.

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