Therapieziele bei der Hypertoniebehandlung

Abstract

The optimal target blood pressure (BP) in the treatment of hypertensive patients remains controversial. Recently, the systolic blood pressure trial (SPRINT) has proposed that a target systolic blood pressure of < 120 mmHg provides prognostic benefit in elderly hypertensive patients at high cardiovascular risk. The results of SPRINT contrast with several other intervention trials which have investigated the effect of intense BP lowering (Secondary Prevention of Small Subcortical Strokes [SPS3], Action to Control Cardiovascular Risk in Diabetes [ACCORD], Heart Outcomes Prevention Evaluation [HOPE]-3). The differences in outcomes in SPRINT vs. other intervention trials are, to a large extend, due to an "unobserved" BP measurement procedure utilized in the SPRINT trial. Thus, a BP goal of < 120 mmHg, at least by conventional BP measurement, remains unproven. Independent of SPRINT the controversial evidence with respect to BP targets calls for further studies and, possibly, for more individualized treatment goals.

Arterielle Hypertonie gilt als wichtigster kardiovaskulärer Risikofaktor. Im folgenden Beitrag wird die Frage des optimalen Zielblutdrucks näher beleuchtet und aufgezeigt, wie Alter, Ausgangsblutdruck sowie verschiedene Blutdruckmessverfahren Einfluss auf eine wirksame Therapie nehmen können. Außerdem wird erläutert, ob eine zu starke Blutdrucksenkung das Risiko kardiovaskulärer Komplikationen sogar erhöhen kann.

Schlüsselwörter

Hypertonie - Interventionsstudien - J-Kurve - Leitlinien - Systolic Blood Pressure Intervention Trial (SPRINT) - Zielblutdruck

Key words

hypertension - intervention trials - j-curve - guidelines - systolic blood pressure intervention trial (SPRINT) - target blood pressure

• Literatur

• 1 Kearney PM, Whelton M, Reynolds K. et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217-223
• 2 Kannel WB, Dawber TR, Kagan A. et al. Factors of risk in the development of coronary heart disease – six-year follow-up experience: the Framingham Study. Ann Intern Med 1961; 55: 33-50
• 3 Prospective studies collaboration. Age-specific relevance of usual blood pressure to vascular mortality. Lancet 2000; 360: 1903-1913
• 4 Rapsomaniki E, Timmis A, George J. et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations. Lancet 2014; 383: 1899-1911
• 5 Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). 2013 ESH/ESC Guidelines for the management of arterial hypertension. J Hypertens 2013; 31: 1281-1357
• 6 SPS3 study group. Blood-pressure targets in patients with recent lacunar stroke. Lancet 2013; 382: 507-515
• 7 ACCORD study group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 62: 1575-1585
• 8 Zanchetti A, Liu L, Mancia G. et al. Blood pressure and LDL-cholesterol targets for prevention of recurrent strokes and cognitive decline in the hypertensive patient. J Hypertens 2014; 32: 1888-1897
• 9 Lonn EM, Bosch J, López-Jaramillo P. et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med 2016; 374: 2009-2020
• 10 D'Agostino RB, Belanger AJ, Kannel WB. et al. Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham study. Br Med J 1991; 303: 385-389
• 11 Pepine CJ, Handberg EM, Cooper-DeHoff RM. et al. for the INVEST investigators A calcium-antagonist vs. a non-calcium antagonist hypertension treatment strategy strategy for patients with coronary heart disease. The international verapamil-trandolapril IINVEST). JAMA 2003; 290: 2805-2816
• 12 Messerli FH, Panjrath GS. The J-curve between blood pressure and coronary artery disease or essential hypertension. Exactly how essential?. J Am Coll Cardiol 2009; 54: 1827-1834
• 13 Bangalore S, Messerli FH, Wun CC. et al., . J-curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. Eur Heart J 2010; 31: 2897-2908
• 14 LaRosa JC, Grundy SM, Waters DD. et al. for the Treating to New Targets (TNT) Investigators Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005; 352: 1425-1435
• 15 Vidal-Petiot E, Ford I, Greenlaw N. et al. for the CLARIFY Investigators Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease. Lancet 2016; 388: 2142-2152
• 16 Böhm M, Schumacher H, Teo KT. et al. Achieved blood pressure and cardiovascular outcomes in high-risk patients. Lancet 2017; 389: 2226-2237
• 17 Cederholm J, Gudbjornsdottir S, Eliasson B. et al., on behalf of the NDR. Blood pressure and risk of cardiovascular diseases intype 2 diabetes. J Hypertens 2012; 30: 2020-2030
• 18 Adamsson Eryd S, Gudbjörnsdottir S, Manhem K. et al. Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease. BMJ 2016; 354: i4070
• 19 Kannel WB, Wilson PW, Nam BH. et al. A likely explanation for the J-curve of blood pressure cardiovascular risk. Am J Cardiol 2004; 94: 380-384
• 20 Kang YY, Wang JG. The J-curve phenomenon in hypertension. Pulse 2016; 4: 49-60
• 21 Williams B. Hypertension and the “J-Curve”. J Am Coll Cardiol 2009; 54: 1835-1836
• 22 Düsing R. Blood pressure treatment goals in hypertension. Ther Adv Cardiovasc Dis 2016; 10: 332-337
• 23 SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med; 2015 373. 2103-2116
• 24 SPRINT Research Group. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years. JAMA 2016; 315: 2673-2682
• 25 James P, Oparil S, Carter B. et al. 2014 Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014; 311: 507-520
• 26 Wrigh Jr JT, Fine LJ, Lackland DT. et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 or older: the minority view. Ann Intern Med 2014; 160: 499-503
• 27 Bangalore S, Gong Y, Cooper-DeHoff RM. et al. Eighth Joint National Committee panel recommendation for blood pressure targets revisited: results from the INVEST Study. J Am Coll Cardiol 2014; 64: 784-793
• 28 Düsing R, Middeke M. SPRINT Studie zur Blutdrucksenkung – Neuer Zündstoff für die Kontroverse. Deutsches Ärzteblatt 2016; 48: 2210-2211
• 29 Kjeldsen SE, Narkiewicz K, Hedner T. et al. The SPRINT study: Outcome may be driven by difference in diuretic treatment demasking heart failure and study design may support systolic blood pressure target below 140 mmHg rather than below 120 mmHg. Blood Press 2016; 25: 63-66
• 30 Kjeldsen SE, Lund-Johansen P, Nilsson PM. et al. Unattended blood pressure measurements in the Systolic Blood Pressure Intervention Trial. Hypertension 2016; 67: 808-812
• 31 Drawz PE, Pajewski NM, Bates JT. et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure. Hypertension 2017; 69: 42-50
• 32 Filipovský J, Seidlerová J, Kratochvíl Z. et al. Automated compared to manual office blood pressure and to home blood pressure in hypertensive patients. Blood Pressure 2016; 25: 228-234
• 33 Wohlfahrt P, Cıfkova R, Movsisyan N. et al. Threshold for diagnosing hypertension by automated office blood pressure using random sample population data. J Hypertens 2016; 34: 2180-2186
• 34 Dahlöf B, Devereux RB, Kjeldsen SE. et al. for the LIFE study group Cardiovascular morbidity and mortality in the losartan intervention for endpoint reduction in hypertension study (LIFE). Lancet 2002; 359: 995-1003
• 35 Okin PM, Kjeldsen SE, Devereux RB. The relationship of all-cause mortality to average on-treatment systolic blood pressure is significantly related to baseline systolic blood pressure. Circulation 2016; 134: A11287
• 36 Bangalore S, Toklu B, Gianos E. et al. Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials. Am J Med 2017; 130: 707-719
• 37 Bundy JD, Li C, Stuchlik P. et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality. JAMA Cardiol 2017 1421. Online Publikation 31.5.2017
• 38 Weber MA, Poulter NR, Schutte AE. et al. Is it time to reappraise blood pressure thresholds and targets? A Statement from the International Society of Hypertension – A Global Perspective. Hypertension 2016; 68: 266-268
• 39 National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults. Melbourne: National Heart Foundation of Australia; 2016
• 40 Leung AA, Daskalopoulou SS, Dasgupta K. et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol 2017; 33: 557-576
• 41 Chiang CE, Wang TD, Lin TH. et al. The 2017 focused update of the guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS) for the management of hypertension. Acta Cardiol Sin 2017; 33: 213-225
• 42 Task Force of the Latin American Society of Hypertension. Guidelines on the management of arterial hypertension and related comorbidities in Latin America. Journal of Hypertension 2017; 35: 1529-1545
• 43 Krämer K, Hausberg M, Sanner B. et al. Blutdruckmessung und Zielblutdruck. Stellungnahme der Deutschen Hochdruckliga e.V. DHL/Deutsche Gesellschaft für Hypertonie und Prävention. Dtsch Med Wochenschr 2017; 142: 1446-1447
• 44 Weiss J, Freeman M, Low A. et al. Benefits and harms of intensive blood pressure treatment in adults aged 60 years or older. Ann Intern Med 2017; 166: 419-429
• 45 Qaseem A, Wilt TJ, Rich R. et al. for the Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets. Ann Intern Med 2017; 166: 430-437
• 46 Neuhauser HK, Adler C, Rosario AS. et al. Hypertension prevalence, awareness, treatment and control in Germany 1998 and 2008–11. J Hum Hypertens 2015; 29: 247-253