Neue Bluthochdruck-Leitlinien - Handlungsbedarf für Hausärzte?

Zusammenfassung

Neue US-amerikanische und europäische Leitlinien zur Hypertonie weisen neben einem erwartungsgemäß hohen Grad an Übereinstimmung etliche Differenzen auf, die sich im Wesentlichen beziehen auf:
- Blutdruckdefinitionen
- unterschiedliche Therapieempfehlungen zur „First-Line”-Therapie und
- Therapie mit Kombinationspräparaten.
Bei einer Hypertonie-Prävalenz von wenigstens knapp 30 % bei deutschen Erwachsenen sind verschiedene Therapiemaßnahmen zu bündeln, um so einen der Hauptrisikofaktoren für die erhöhte kardio- und zerebrovaskuläre Mortalität positiv zu beeinflussen. Von allen Leitlinien wird die Bedeutung von Lebensstiländerungen (Nikotinkarenz, Gewichtsreduktion, etc.) betont; neu ist die Empfehlung von Kombinationspräparaten zur Verbesserung der Compliance bereits zu Beginn einer medikamentösen Bluthochdruck-Therapie.

Abstract

Apart from an expected high degree of agreement, recently published European and American hypertension guidelines show some relevant differences in:
- blood pressure definitions
- different therapeutic recommendations regarding the first- line therapy and
- combination therapy.
With a prevalence of hypertension of at least 30 % among German adults, public health and medical initiatives need to be focused on this major risk factor for cardio- and cerebrovascular mortality. Apart from evidence-based pharmacotherapy and combination preparations for better compliance, strategies should concentrate on life-style changes with proven effectiveness (smoking cessation, weight reduction, etc).

Schlüsselwörter

Leitlinien - Hypertonie - Schwellenwerte - „First-line”-Therapie - Kombinationstherapie

Key words

Guidelines - hypertension - thresholds - first-line therapy - combination therapy

Literatur

• 1 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
• 2 AWMF, Deutsche Hypertonie Gesellschaft (Hochdruckliga) .Leitlinien für die Prävention, Erkennung, Diagnostik und Therapie der arteriellen Hypertonie. 2001/2003
• 3 Blech J. Die Krankmacher - wie Ärzte und Pharma-Industrie neue Krankheiten erfinden.  Der Spiegel. 2003;  33
• 4 Boersma E, Keil U, De Bacquer D. et al . Blood pressure is insufficiently controlled in European patients with established coronary heart disease.  J Hypertens. 2003;  21 1831-1840
• 5 Chobanian A V, Bakris G L, Black H R. et al . The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report.  Jama. 2003;  289 2560-2571
• 6 De Backer G, Ambrosioni E, Borch-Johnsen K. et al . European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.  Eur Heart J. 2003;  24 1601-1610
• 7 European Society of Hypertension (ESH), European Society of Cardiology (ESC) . Guidelines for the management of arterial hypertension.  J Hypertens. 2003;  21 1011-1053
• 8 Geleijnse J M, Witteman J C, Bak A A, den Breeijen J H, Grobbee D E. Reduction in blood pressure with a low sodium, high potassium, high magnesium salt in older subjects with mild to moderate hypertension.  Bmj. 1994;  309 436-440
• 9 Hansson L, Zanchetti A, Carruthers S G. 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
• 10 Iskedjian M, Einarson T R, MacKeigan L D. et al . Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis.  Clin Ther. 2002;  24 302-316
• 11 National Institute of Health (NIH) . The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure.  Arch Intern Med. 1997;  157 2413-2446
• 12 Kaiser T, Florack C, Stephan U, Sawicki P T. Should BP targets be lower in diabetic patients with microalbuminuria or nephropathy.  Br J Diabetes Vasc Dis. 2003;  3 278-281
• 13 Law M R, Wald N J. Risk factor thresholds: their existence under scrutiny.  BMJ. 2002;  324 1570-1576
• 14 Vollmar H C, Koneczny N, Butzlaff M, Isfort J. Leitlinie Hypertonie 2003. 
• 15 Mulrow C D, Chiquette E, Angel L. et al .Dieting to reduce body weight for controlling hypertension in adults (Cochrane Review). The Cochrane Library, Vol 2, John Wiley, Chichester, 2004
• 16 Pastor-Barriuso R, Banegas J R, Damian J, Appel L J, Guallar E. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality.  Ann Intern Med. 2003;  139 731-739
• 17 Port S, Demer L, Jennrich R, Walter D, Garfinkel A. Systolic blood pressure and mortality.  Lancet. 2000;  355 175-180
• 18 Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration . Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.  Lancet. 2002;  360 1903-1913
• 19 Psaty B M, Lumley T, Furberg C D. et al . Health Outcomes Associated With Various Antihypertensive Therapies Used as First-Line Agents: A Network Meta-analysis.  Jama. 2003;  289 2534-2544
• 20 Thamm M. Blutdruck in Deutschland - Zustandsbeschreibungen und Trends.  Gesundheitswesen. 1999;  61 (Sonderheft 2) S 90-S 93
• 21 Vasan R S, Larson M G, Leip E P, Kannel W B, Levy D. Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study: a cohort study.  Lancet. 2001;  358 1682-1686
• 22 World Health Organization - International Society of Hypertension . Guidelines for the Management of Hypertension.  J Hypertens. 1999;  17 151-185
• 23 Wing L M, Reid C M, Ryan P. et al . A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly.  N Engl J Med. 2003;  348 583-592
• 24 Wolf-Maier K, Cooper R S, Banegas J R. et al . Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States.  Jama. 2003;  289 2363-2369
• 25 Zidek W, Dusing R, Haller H, Middeke M, Paul M, Schmieder R, Schrader J. [New recommendations of the German Society of Hypertension for the drug treatment of hypertension].  Dtsch Med Wochenschr. 2003;  128 2468-2469
• 26 Lawes C M, Bennett D A, Feigin V L. Blood pressure and stroke: an overview of published reviews.  Stroke. 2004;  35 776-785
• 27 Vasan R S, Larson M G, Leip E P. et al . Impact of high-normal blood pressure on the risk of cardiovascular disease.  N Engl J Med. 2001;  345 1291-1297
• 28 Williams B, Poulter N R, Brown M J. et al . British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary.  Bmj. 2004;  328 634-640
• 29 Schrier R W, Estacio R O, Esler A. et al . Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes.  Kidney Int. 2002;  61 1086-1097
• 30 Ogden L G, He J, Lydick E. et al . Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification.  Hypertension. 2000;  35 539-543
• 31 N N. arznei-telegramm. 2003;  34 97-98