In the industrialized nations, high blood pressure (arterial hypertension) is a widespread disease and the biggest risk factor for the development of cardiovascular diseases, such as heart attacks or strokes.
In Germany, every second person over the age of 50 is affected by hypertension - but in many cases goes unnoticed. Often there are additional risk factors for cardiovascular diseases such as obesity, nicotine consumption, diabetes mellitus and physical inactivity.
The danger of arterial hypertension is that it is asymptomatic over a long period of time. This not only makes it difficult to recognize them, but also often causes incomprehension as to how important a consistent therapy is.
In general, a hypertonic blood pressure situation is spoken with values of more than 140/90 as of a quiescent blood pressure measured several times. However, when to start therapy and which target pressures to achieve depends not only on the level of baseline blood pressure, but also on the overall risk constellation.
First change of lifestyle, then medication
In any case, the first measure of treatment is a change in lifestyle, consisting of a reduction in body weight, abstinence from alcohol and nicotine, a Mediterranean, low-salt diet and sufficient exercise.
If there are already very high blood pressure values at the time of diagnosis or if it is not possible to lower the blood pressure by changing the lifestyle, a drug therapy is indicated. This is initially started with only one preparation, in case of failure, a combination therapy may be necessary.
A good attitude of blood pressure is very important in many ways. On the one hand, acute complications such as a blood pressure derailment can be prevented. On the other hand, a consistent adjustment of blood pressure prevents long-term consequences of arterial hypertension. This mainly includes damage to various organs such as the heart, brain, kidneys and eyes.
Hypertension (arterial hypertension) is defined exclusively by the level of blood pressure. In German-speaking countries, the following blood pressure limits measured at rest apply:
||130/85 - 139/89 mmHg|
|Hypertension grade I
||140/90 - 159/99 mmHg|
|Hypertension grade II
||160/100 - 179/109 mmHg|
|Hypertension grade III
||> 180/110 mmHg|
A hypertensive crisis is said to be in excess of 180/120; a hypertensive emergency is defined by increases in value to over 230/120 in addition to life-threatening organ damage such as heart failure or cerebral hemorrhage due to hypertension.
As part of the blood pressure measurement, the mean daily value should remain below 130/85 mmHg, the 24-hour mean below 130/80 mmHg.
Hypertension is common
Arterial hypertension has become a common disease in Western countries and the most common risk factor for diseases of the cardiovascular system. On average, every second person has an elevated blood pressure in adults, and in the case of additionally existing obesity, the prevalence of hypertension is as high as 75%.
In arterial hypertension basically two forms are distinguished: the primary, frequently occurring arterial hypertension as well as the secondary, rather rare and as a result of other diseases appearing arterial hypertension. Both go back to different causes.
1. Primary hypertension
With a total proportion of 90%, primary arterial hypertension is the most common form of hypertension. The exact causes of the development of primary hypertension have not yet been fully elucidated. However, it seems to be a multifactorial genesis in which several factors in the interaction lead to the disease.
Genes, environment and lifestyle
An important risk factor is genetics. Thus, if you have a first-degree relative (sibling or parent) who also suffers from arterial hypertension, the likelihood of disease is higher. In addition, the interaction between genes, lifestyle and environmental factors seems to play a role in disease development, as not everyone with a positive family history will eventually develop arterial hypertension.
Some of the most important lifestyle factors that can increase the risk of high blood pressure, but that can be influenced by you, are:
- Smoking: Many pollutants of the cigarette settle directly on the vessel walls and promote the development of arteriosclerosis. Arteriosclerotic calcified vessels lose their potential to expand and become gradually rigid and tight. As a result, the same amount of blood must flow through narrower vessels in the same time, which increases the pressure significantly and in the longer term is crucially involved in the development of arterial hypertension.
- High consumption of alcohol and caffeine: Coffee and alcohol increase the content of their heartbeat and lead to a mostly short-lasting persistent increase in blood pressure. However, overconsumption may increase blood pressure in the longer term.
- high intake of common salt: common salt, also known as sodium chloride, can contribute to an increase in blood volume and thus blood pressure by binding fluid. For this reason, in the presence of arterial hypertension, the intake of saline should be limited to about 5 g per day, which is equivalent to a level teaspoon of table salt.
- Overweight: In the context of arterial hypertension not only the absolute weight plays a role, but also, or in particular, the waist circumference. For example, in men over 102 cm and in women over 88 cm waist circumference, there is a significantly higher risk of developing hypertension.
- Physical inactivity: Many studies have shown that regular moderate physical activity of 30 minutes three to four times a week has a preventive effect on the development of high blood pressure. With pre-existing hypertension, physical exercise can be instrumental in lowering blood pressure levels.
- psychological stress and stress: Mental stress drives the blood pressure through an activation of the sympathetic, the portion of the autonomic nervous system, which is responsible for flight and fight and for the mobilization of physical reserves, in the height.
The two factors age and gender, which also have an influence on the development of the disease, can not be influenced. For example, men of advanced age are more likely to develop arterial hypertension than women of the same age.
2. Secondary hypertension
Secondary hypertension, which accounts for approximately 10% of all hypertension, causes hypertension as a result of other underlying conditions. The most important underlying diseases are sleep apnea syndrome, kidney hypertension (renal hypertension) and arterial hypertension caused by endocrinological (hormonal) diseases.
- Sleep apnea syndrome: Obstructive sleep apnea syndrome, also known as OSAS, is one of the most common causes of secondary hypertension. As part of the sleep apnea syndrome there are nocturnal breathing pauses of at least ten seconds duration, between each of which loud snore episodes lie. The brief stop of breathing leads to a lack of oxygen, which in turn causes a stress reaction in the body and in the long term causes an increase in blood pressure. Of the sleep apnea syndrome are usually affected men between 40 and 60 years, often suffering from obesity, smoke and evening alcohol consumption. Due to the bad night sleep it comes next to an increase in blood pressure to daytime tiredness, fatigue and a reduced ability to concentrate.
- Renal hypertension: Renal hypertension is caused by various kidney diseases. The kidney plays a key role in the regulation of blood pressure, as it filters all the blood several times a day, cleans it of contaminants and regulates its composition and flow. For example, if blood pressure drops, the kidney may release certain hormones that act as regulators to increase blood pressure in succession. However, various diseases of the kidney lead to a disorder of this mechanism and about a pathological increase in blood pressure. This most commonly occurs in the context of renal insufficiency, renal artery stenosis, glomerulonephritis, and kidney tumors.
- Endocrine hypertension: Diseases of the endocrine system lead in different ways to a change in the physiological hormone balance. Many of these diseases are associated with an increase in blood pressure, which is often difficult to adjust medication. Among the most important endocrine diseases are: hyperaldosteronism (Conn's disease), hypercortisolism (Cushing's syndrome), hyperthyroidism (hyperthyroidism) and pheochromocytoma.
Questions and Answers on Causes & Prevention
The insidious thing about arterial hypertension is that it runs asymptomatically for a very long time and yet it can lead to serious damage to the vascular system.
Often misjudged and misinterpreted
Since hypertension develops in most cases in the second half of life, symptoms such as sleep disorders, mood swings, nervousness, headaches, and concentration problems are attributed to menopause, especially in women, rather than increased blood pressure.
Similarly, newly-occurring cardiac arrhythmias or stress air distress are more likely due to stress and age than to a change in blood pressure. This is not surprising since arterial hypertension very rarely causes symptoms, usually only when the blood pressure values have already risen far above the norm.
Who thinks about hypertension?
Possible complaints that should definitely be clarified with regard to arterial hypertension, if no other cause for them are possible, are:
- Ear noises, such as ringing in the ears
- Headache, which is mainly located at the back of the head and shows up in the early morning hours
- Pressure pain or tightness around the chest
- frequent nosebleeds
- Sleep disorders and evening restlessness
More on this topic can be found here:
Important questions about symptoms and complaints
The diagnosis of arterial hypertension can be made quickly and safely by your attending GP. The aim of every hypertension diagnosis is, in addition to the diagnosis, the determination of the severity of arterial hypertension and the classification into primary or secondary manifestations.
As part of the clarification, your attending physician will first conduct a detailed initial consultation, the so-called anamnesis. Followed by a physical examination and measuring the blood pressure and writing an ECG. In many cases, a long-term blood pressure measurement is carried out over 24 hours in order to be able to better assess the course of the blood pressure throughout the day.
During the initial medical consultation (medical history), your doctor will primarily want to know if high blood pressure is important in your family and if you have any other medical conditions that increase the risk of cardiovascular disease. These include obesity, diabetes mellitus, lipid metabolism disorders and smoking.
Furthermore, the doctor will have an advisory talk with you about the consequences of hypertension and will explain to you how important the consequent drug treatment of your condition is.
The physical examination serves to record your pulse quality and to hear the heart. In arterial hypertension the pulse is very hard and difficult to squeeze off, in technical language this is also referred to as pulsus durus.
Listening to the heart is used to assess cardiac rhythm and heart valve function. Conspicuous changes in valve function or cardiac arrhythmias may be the result of many years of arterial hypertension and should be further clarified.
Blood pressure measurement
Blood pressure measurement is the most important tool for the diagnosis of arterial hypertension. Only when repeated blood pressure measurements on both arms at different times repeatedly showed elevated levels, can be spoken of hypertension.
But beware, in many people, blood pressure rises as soon as they are examined by a doctor, although there is usually no arterial hypertension. This so-called Weißkittelhypertonie or nervous hypertension can be counteracted by measuring your blood pressure at home regularly.
Furthermore, you should rest for 3-5 minutes before the medical blood pressure measurement and repeatedly on both arms with a time interval of 1-2 minutes each. With some time and rest - goods that are rarely found in doctor's offices - the blood pressure usually settles at a medium level.
Self-measurements are useful in many ways. On the one hand, you can control yourself so that your blood pressure only goes up when a doctor is present. On the other hand, regular self-surveys will make you the greatest blood pressure expert and help you better understand which medication will help you the fastest and best and which blood pressure area you feel comfortable with.
For self-measurement electronic measuring devices are usually used. It is important that you put them on correctly and bring the arm to be measured to about heart height. Incorrect body posture or faulty installation of the measuring device can significantly affect the blood pressure values. Before you take the first measurement, it is best to consult a specialist shop and try out the fitting and measuring once under the guidance.
24-hour blood pressure measurement
A blood pressure measurement over 24 hours offers several advantages. It can measure your blood pressure on a portable device on a normal day-to-day, periodic night-time basis, capturing your blood pressure during "real" life.
This is especially beneficial if there is a suspicion of white-coat hypertension, but also to evaluate drug-induced blood pressure therapy during the day.Furthermore, nocturnal blood pressure peaks can be detected, which are not recorded under normal measuring conditions.
In the evaluation of the 24-hour blood pressure, especially the average values of day and night, but also the course over 24 hours are considered and Next assessed whether a nocturnal lowering of blood pressure takes place, which is usually 10% below the daily average.
When it could be secondary
Indications of secondary hypertension can be found during blood pressure testing for the following criteria:
- young age of less than 30 years or sudden onset of arterial hypertension over the age of 60 years
- sudden severe worsening of well-adjusted high blood pressure despite regular use of the medication
- Absence of nocturnal drop in blood pressure by more than 10% of the daily average
- Reduced drop in nocturnal blood pressure by less than 10%
- recurrent hypertensive crises
- lack of therapeutic success despite a drug therapy with three blood pressure agents
If one or more of these indications is present, your doctor should clarify possible causes of secondary hypertension. These include, among other things, the examination of the kidneys and the endocrine system, as well as the clarification of a possibly existing sleep apnea syndrome.
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All about diagnostics and examinations
The therapy of arterial hypertension is based on different pillars, all of which aim to achieve certain blood pressure targets. Because only by a well-adjusted blood pressure, the risk of secondary diseases of the cardiovascular system can be reduced.
In addition to a drug therapy, which consists of one or more blood pressure-regulating drugs, there is the important pillar of non-drug therapy, which provides primarily for a change in the lifestyle.
Blood pressure targets
The optimal blood pressure for you is not measured by a generally valid scheme, but is based on your personal cardiovascular risk. This means that in addition to the level of your blood pressure and other diseases that lead to an increase in risk for heart attacks or strokes, be included in the decision on how high the target blood pressure may be. Furthermore, other diseases such as kidney disease, diabetes mellitus and your age berüchsichtigt.
This results in the following situations:
- Your target blood pressure is less than 140/90 mmHg if you are less than 75 years old and you have no other pre-existing conditions.
- Your target blood pressure is below 135/85 - 120/70 mmHg if you are at an increased risk of stroke, heart attack, or chronic kidney disease or if you are over 75 years old.
- Your target blood pressure is 150/85 mmHg if you have diabetes mellitus.
1. non-drug therapy measures
There are a number of non-drug-related measures that can help reduce blood pressure. Who consistently changes his life, has the chance to get a slightly elevated blood pressure even without taking medication to get a grip. The most important measures include:
- the reduction or cessation of alcohol consumption
- the consequent restriction of salt consumption to about 5g a day. In this case, especially foods such as frozen goods (eg frozen pizza), salted meat, cheese and bread should be avoided.
- keeping a Mediterranean diet consisting of lots of fresh vegetables and fish or white instead of red meat and carbohydrates
- the consistent renouncement of nicotine
- sufficient exercise (at least three times a week for 30-40 minutes)
- the continuous weight reduction
- the regular self-measurement of the blood pressure as well as the documentation of the values
Especially the last point helps to control yourself and to be able to identify small or bigger successes at an early stage. This often leads to increased motivation and the desire to lower blood pressure without the use of medication.
2. Medicamentous therapy measures
For the treatment of arterial hypertension, various preparations are available, which are used as monotherapy or combination therapy.
The five main groups are:
ACE inhibitors dilate the vessels
ACE inhibitors are drugs that prevent the formation of angiotensin II. This hormone is responsible for raising blood pressure in the physiological state. Through the stimulation of certain receptors, angiotensin II is able to narrow the vessels and reduce the excretion of water through the kidneys. As a result, there is a rise in blood pressure.
ACE inhibitors are often used in arterial hypertension because they protect the heart and have a protective effect on the kidneys if diabetes mellitus is present. A disadvantage of this class of drugs is that they lead in up to 20% of cases as a side effect to a tormenting cough. Then a switch to AT1 receptor antagonists is required.
The most important ACE inhibitors are:
- Ramipril (Delix®, Vasotope®)
- Enalapril (Xabef®)
- Captopril (Cor tensobon®, Lopirin Cor®, Tensobon®)
Alternatively: AT1 receptor anatagonist
AT1 blockers have the same effects and advantages as ACE inhibitors but do not cause the side effect of irritating cough. They do not reduce blood pressure via a reduced formation of angiotensin II, but directly block the receptor to which angiotensin II normally binds.
The most important AT1 receptor blockers are:
- Candesartan (Atacand®, Blopressid®)
- Lorsartan (Lozaar®)
- Valsartan (Cordinate®, Diovan®, Provas®)
Diuretics wash out
Diuretics, commonly referred to as water tablets, can lower blood pressure by promoting the excretion of fluid through the kidneys, thereby reducing blood volume. As a result, the vessel pressure decreases and the blood pressure drops.
The most important diuretics include:
- Loop diuretics such as furosemide (Diurapid®, Furobeta®, Furosal®, Fusid®) and Torasemind (Anat®, Toracard®, Torem®)
- Thiazide diuretics such as hydrochlorothiazide (Disalunil®, Esidrix®) or clopamide (Briserin®)
- Aldosterone antagonists such as spironolactone (Aldactone®, Jenaspir®, Verospriron®) or Eplerenon (Inspra®, Eplerenon STADA®)
Diuretics can already be used as a monotherapy in the case of slightly elevated blood pressure values and as combination therapy in the case of difficult-to-control blood pressure. They are particularly important when in addition to arterial hypertension comorbidities such as heart failure or renal insufficiency exist, as many diuretics have protective effects on the heart and kidneys.
Beta blocker: not for everyone
In addition to a blood pressure-lowering effect, beta-blockers also have a frequency-regulating effect on the heartbeat, thereby protecting the heart from too fast a rhythm and thus from overexertion. In particular, the vasodilator effect of some beta-blockers can be exploited in additional comorbidities such as peripheral arterial disease.
A disadvantage of beta-blockers is that they should not be used in many diseases. These include, inter alia, bronchial asthma, COPD and acute heart failure. In addition, they must be dosed very carefully, if in addition there is diabetes mellitus, since beta-blockers can promote hypoglycaemia. Depression, psoriasis, and erectile dysfunction can be exacerbated by the use of beta-blockers.
The most commonly used preparations are:
- Metoprolol (Beloc®, Beloc ZOK®, Lopresor®)
- Nebivolol (Nebilet®)
- Bisoprolol (bisoprolol®, Concor®)
Calcium antagonists: not only against hypertension
Calcium antagonists are also used in the context of arterial hypertension. By inhibiting the Calcium influx into the cells of the vascular musculature they lead to a relaxation of the vessels and thus improve the blood flow. As a result, there is a drop in the blood flowing through the vessels per time and thus a reduction in blood pressure.
The advantage of calcium antagonists is that they also reduce the risk of complications of arterial hypertension such as heart attack or stroke. Side effects occasionally associated with the use of calcium antagonists include headache, foot swelling and, less commonly, hands, flushing and sleep disorders.
In the context of arterial hypertension, especially long-acting dihydropyridine-type calcium antagonists are used, such as:
- Amlodipine (Norvasc®)
- Lercandipine (Carmen®, Corifeo®)
From 160 mmHg it is no longer possible without
When the right time for starting a drug therapy of arterial hypertension has come, depends on the level of blood pressure, but also on the overall risk of cardiovascular sequelae. From systolic blood pressure values of more than 160 mmHg, drug therapy is always indicated.
With only a slight rise in blood pressure and a moderate overall risk of cardiovascular disease, monotherapy with ACE inhibitors, beta-blockers, thiazides or calcium antagonists is usually started first. Since all antihypertensive drugs are about equivalent, there is not the drug of choice. Rather, the decision for or against an antihypertensive is based on the risk constellation and comorbidities.
Combination therapy for severe cases
If no lowering of the blood pressure can be achieved by monotherapy or if there is a very high overall cardiovascular risk, a double combination is used. The most common dual therapies are:
- Diuretic plus ACE inhibitor, AT1 blocker, calcium antagonist or beta blocker
- Calcium antagonist plus beta blocker, ACE inhibitor or AT1 blocker
No matter which preparation is used, it is always started with a low dose, which is slowly increased. The effects can only be assessed after an average of one to two weeks, often even after 2-4 weeks in the case of beta-blockers and thiazides.
Due to the constantly increased blood pressure, especially small vessels are damaged. Each organ can be affected. In particular, however, there is a slow but revered injury to the following organs:
So make sure to treat an elevated blood pressure early and consistently - even if you do not notice the symptoms of arterial hypertension. Only then can dangerous consequences be prevented.
More about this topic can be found here:
Accompanying and secondary diseases of hypertension
Author: Lisa Wunsch
G. Herold: Internal Medicine, Self-Publishing, 2012.
H. Lüllmann et al .: Pharmacology and Toxicology, Thieme, 2016.
German Society of Cardiology - Cardiovascular Research: ESC Pocket Guidelindes: Guideline for the management of arterial hypertension, https://www.hochdruckliga.de/tl_files/content/dhl/downloads/2014_Pocket-Leitlinien_Arterielle_Hypertonie.pdf, last accessed on 05/28/2018.