Gefäßwandeigenschaften großer Arterien - Was ist wichtig für das klassische Hypertoniemanagement?

Zusammenfassung

Die Klassifikation der arteriellen Hypertonie in Abhängigkeit von Endorganschäden ist in der medizinischen Praxis von wesentlicher Bedeutung, da die Prognose und die Therapiebedürftigkeit der Hochdruckkrankheit nicht nur von der Blutdruckhöhe, sondern wesentlich vom Ausmaß der Endorganschäden abhängt. Neben den klassischen Endorganschäden an Herz und Niere gewinnt heute in der Praxis die Erfassung von strukturellen und funktionellen Schäden der großen Arterien eine zunehmende Bedeutung. Mit modernen nicht-invasiven Verfahren können arterielle Gefäßwandeigenschaften in der klinischen Routine untersucht werden. Zu den strukturellen hypertonieassoziierten Gefäßwandveränderungen zählen zunächst eine Verdickung des Intima-Media-Komplexes, die Plaquebildung, die Stenosierung der Gefäße und die Aneurysmenbildung. Zu den funktionellen Veränderungen gehören zum einen die endotheliale Dysfunktion, zum anderen eine Veränderung der elastischen Wandeigenschaften mit zunehmender arterieller Gefäßsteifigkeit und Verlust der Windkesselfunktion. Die Gefäßsteifigkeit führt zu einer verfrühten Pulswellenreflektion mit Anstieg des zentralen systolischen und Abfall des zentralen diastolischen Blutdrucks und daraus resultierender Nachlaststeigerung und Reduktion des myokardialen Perfusionsdrucks. Im letzten Jahrzehnt konnte die Bedeutung der strukturellen als auch der funktionellen Wandeigenschaften großer Arterien als unabhängige Prädiktoren der kardiovaskulären Morbidität und Mortalität eindeutig belegt werden. Deshalb ist die Bestimmung der Intima-Media-Dicke bereits Teil der Standardevaluation hypertensiver Patienten. Wegen der ebenfalls großen prognostischen Bedeutung der funktionellen Gefäßwandeigenschaften verbessert deren Erfassung die Risikostratifizierung. Durch moderne Antihypertensiva können die Wandeigenschaften großer Arterien günstig beeinflusst werden. Die Evaluation der arteriellen Gefäßwandveränderungen sollte daher ein wesentlicher Bestandteil des Managements von Patienten mit arterieller Hypertonie sein.

Summary

Decisions about the management of patients with hypertension should not be based on the level of blood pressure alone but also on the presence of target organ damage. Apart of classical sites of target organ damage - kidney and heart - the assessment of functional and structural alterations of large arteries is of increasing clinical importance. Modern non-invasive procedures allow the assessment of large artery wall properties within the clinical routine. Hypertension associated large artery damage may present as structural and functional alterations. Structural alterations comprise intima-media thickening, plaque formation, stenosis of the artery and formation of aneurysms. Functional alterations comprise endothelial dysfunction and alterations of the mechanical properties of the arterial wall with increasing stiffness and loss of the Windkessel function. Loss of central artery elastic properties will ensue an early reflection of the pulse wave with a resulting increase in central systolic and central diastolic pressure. This causes an increase in left ventricular afterload and a reduction in diastolic perfusion of the myocardium. In the last decade the relevance of large artery structural alterations, endothelial dysfunction and arterial stiffness for the risk of cardiovascular morbidity and mortality in hypertensive patients could be demonstrated convincingly. Measurement of intima-media-thickness therefore is part of the standard evaluation of hypertensive patients. Because of the equal prognostic relevance of functional properties of the arterial wall, assessment of large artery functional alterations is helpful for the risk stratification of hypertensive patients. Modern antihypertensive drugs have favourable effects on arterial wall properties. Therefore, the quantification of large artery wall properties should be part of the management of hypertensive patients.

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