Arterial hypertensionI10.90

Arterial hypertension is present when systolic blood pressure values exceed 140 mmHg and/or diastolic blood pressure values exceed 90 mmHg. Above these values, a therapy-induced reduction in blood pressure is beneficial to the patient.

The list of blood pressure values of the World Health Organization WHO corresponds to the definition of the German Hypertension League (www. Hochdruckliga.de)

Category Systole mmHG Diastole mmHG

Optimal blood pressure < 120 < 80

Normal blood pressure 120 - 129 80 - 84

High normal blood pressure 130 - 139 85 - 89

Grade 1 - mild hypertension 140 - 159 90 - 99

Grade 2 - moderate hypertension 160 - 179 100 - 109

Grade 3 - severe hypertension ≥ 180 ≥ 110

Isolated systolic hypertension (ISH) > 140 < 90

In case the so-called upper and lower values (systolic and diastolic) of a patient are in different categories, the higher one is to be assumed.

A special form of hypertension is the so-called isolated systolic hypertension, in which the systolic pressure is elevated at >140 mmHg and the lower - diastolic - in the normal range is < 90 mmHg.

The level of systolic blood pressure is the best predictor of stroke and coronary heart disease. The pulse pressure (=RRsyst - RRdiast) is the best predictor for heart failure and total mortality. A high pulse pressure is associated with an increased risk of dementia development in older hypertensive patients.

I. Primary hypertension (exclusion diagnosis): Primary or essential hypertension: cause unknown; majority of all hypertension cases in adults (proportion is about 90%).The potential causes of arterial hypertension are diverse. Clarification of a possible organic cause (secondary hypertension) is of great importance. Furthermore, nutritional factors such as increased salt intake play a role, as do obesity, insulin resistance, increased alcohol consumption, increasing age, stress factors, smoking and immobility. Environmental factors seem to affect only genetically susceptible individuals.

II. secondary hypertension (known underlying disease or demonstrable factors are ascertainable - about 10% of adults; inverse ratio in children):

1. Sleep apnoea syndrome (G47.39)
2. Renal hypertension
   • Renoparenchymatous diseases: glomerulonephritis, diabetic glomerulosclerosis, polycystic nephropathy
   • Renovascular hypertension: Renal artery stenosis
3. Endocrine hypertension:
   • Acromegaly, AGS, Cushing's syndrome, hyperaldosteronism (Conn's syndrome), hyperparathyroidism, hyperthyroidism, pheochromocytoma
4. Pregnancy-induced hypertension (HES; O13 - about 15% of all pregnancies).
   • Gestational hypertension with or without proteinuria
   • Eclampsia
   • HELLP syndrome

5. Drug-induced hypertension: ovulation inhibitors, glucocorticoids, erythropoietin, NSAIDs, ciclosporin A, bevacizumab, sunitinib, sorafenib

6. Passenger blood pressure increases from drugs, such as alcohol, amphetamines, ecstasy, and cocaine; furthermore, licorice abuse(glycyrrhetinic acid) can also cause blood pressure increases.

7. White coat hypertension (exclusion by 24h blood pressure measurement).

8. Monogenetic forms of hypertension (rare): Mineralocorticoid hypertension with increased renal sodium and water retention resulting in suppression of plasma renin activity (PRA) and increased renal potassium excretion and consecutive hypokalemia:
   • Liddle syndrome (autosomal dominant mutation of the regulatory subunits of the amiloride-sensitive sodium channel - ENaC-).
   • Apparent mineral corticoid excess -AME - (autosomal recessive mutation of 11beta-hydroxysteroid dehydrogenase, with loss of mineralocorticoid receptor selectivity. This leads to a lack of conversion of cortisol u cortisone - cortisol has a similar effect to aldosterone - ).
   • Geller syndrome (receptor disorder with constitutive activation of the mineralocorticoid receptor).
   • Gordon syndrome (hyperkalemia, hyperchloremic metabolic acidosis, normal or elevated aldosterone, low renin, and normal renal function).

Other causes of secondary hypertension:

Chronic pain, vascular diseases such as aortic valve insufficiency, aortic isthmic stenosis, autoimmune diseases such as systemic lupus erythematosus, vasculitides, psychiatric disorders: generalized anxiety disorder, panic disorders (with/without agoraphobia), social phobias, renin-producing tumors (renin is a proteolytic enzyme produced in the cells of the juxtaglomerular apparatus - renin-angiotensin-aldosterone system).

In western industrial nations, the spread of arterial hypertension represents a major medical challenge. Hypertension is more common in the adult black population (32%) than in white (23%) or Mexican (23%) adults.

The following age-related prevalences are given:

45 - 54 years: 20 - 30

55 - 64 years of age: 30 - 40

65 - 74 years of age: 40 - 50

Vitamin D deficiency is also frequently associated with hypertension.

Increased cardiac output (volume hypertension) and/or increased peripheral resistance (resistance hypertension).

Increased cardiac output and increased peripheral resistance (triggered by functional vasoconstriction with increased sympathetic activity or by structural vascular wall changes = vascular remodeling) are mutually additive. In accelerated phases, occluding fibrinoid arteriolonecrosis can occur, which can lead to ischemia of downstream supply areas. It is not uncommon for the skin to show livedo-like(livedo reticularis) images (skin vessels and vessels of the ocular fundus as a reflection of the peripheral vascular situation).

Primary hypertension (diagnosis of exclusion): The potential causes of arterial hypertension are manifold. A clarification of a possible organic cause (secondary hypertension) is of great importance. Furthermore, nutritional factors such as increased salt intake play a role, as do overweight, insulin resistance, increased alcohol consumption, increasing age, stress factors, smoking and immobility. Environmental factors seem to affect only genetically susceptible individuals.

Secondary hypertension:

Sleep apnea syndrome

Renal hypertension

Renoparenchymatous diseases: glomerulonephritis, diabetic glomerulosclerosis, polycystic nephropathy.

Renovascular hypertension: renal artery stenosis

Primary hypertension > 30 years

Asymptomatic for a long time, dyspnoea on exertion (acute left heart failure), pectanginal symptoms, dizziness, palpitations, ringing in the ears, nosebleeds, sweating, early morning headaches (especially in the back of the head), nausea and vomiting, erectile dysfunction, facial erythema, nervousness, restlessness, irritability, difficulty concentrating.

Vessels: Early arteriosclerosis can be detected in the majority of hypertensive patients.

Ocular fundus: Hypertension-related vascular changes in the ocular fundus (fundus hypertonicus, hypertensive retinopathy = vascular changes in the retina from stage 3 of hypertension-related changes).

Heart: Hypertensive heart disease. Left heart failure and coronary artery disease are cause of death in 2/3 of all patients with arterial hypertension.

CNS (cause of death in 15% of patients with arterial hypertension): Cerebral ischemia and cerebral infarction; hypertensive mass hemorrhage, acute hypertensive encephalopathy.

Kidney: Hypertensive nephropathy

Large vessels: Abdominal wall aneurysm in 10% of male hypertensives >65 years; aortic dissection.

Circulatory: Malignant hypertension with secondary malignant nephrosclerosis.

Compl: Hypertensive crisis

US examination equipment: ECG, chest X-ray, abdominal sonography, echocardiography, fundoscopy

Urine status, serum creatinine, serum potassium, cholesterol (HDL(LDL), triglycerides, glucose

Determination of the degree of severity of hypertension; blood pressure measurements on both arms, possibly logged blood pressure self-measurements, in special cases long-term outpatient blood pressure measurements (ABDM).

General information

A permanently elevated blood pressure causes lasting damage to the heart muscle and the vascular system, with the result that the demands on the heart become ever greater. As a result, cardiac dysrhythmia, cardiac insufficiency and atrial fibrillation can occur.

If the blood pressure is too high, all possible risk factors must therefore be ruled out first, such as stress, overweight, smoking, disorders in fat metabolism and diabetes.

An unwavering rapid lowering of blood pressure with emergency medicine is necessary if the blood pressure suddenly rises sharply. This is known as a hypertensive crisis, which can cause organ and brain damage, heart failure and even heart attack, pulmonary oedema and aortic rupture.

In all cases, normal blood pressure values (=/<140mmHg) should be aimed for. In emergencies, medication should be used, but preferably a healthy and balanced lifestyle.

Therapies in the presence of arterial hypertension

The possible consequential damages should be determined and cardiovascular risks (WHO criteria)

The World Health Organization assesses the 3 degrees of mild to severe hypertension as follows:

• Mild hypertension - Grade 1: Without organ damage
• moderate hypertension - grade 2: slight organ damage and possibly arteriosclerosis
• Severe hypertension - Grade 3: Severe organ damage with secondary diseases such as heart failure, heart attack, stroke, angina pectoris, kidney failure and others.

Depending on the risk factors and diagnosed severity of hypertension, the therapy is cascade-like. The non-drug interventions form the basis of all further therapies:

• Regular endurance sports (walking, jogging, swimming, hiking). Weekly units of 3x 30 min are required.
• Salt restriction here a value of maximum 4-6g/day is recommended.
• Lower cholesterol levels by changing your diet. Main foodstuff is fruit and vegetables, the aim is to reduce fat and animal protein. After all, a high cholesterol level is partly responsible for the dreaded arteriosclerosis.
• Stop smoking. The narrowing of the arteries resulting from tobacco consumption represents a further risk factor for cardiovascular disease.
• Reduction of stress factors. Rethinking one's life situation as well as adaptation is therefore just as essential in order to steer blood pressure back into normal channels.
• Minimization or complete abstention from alcohol; weight reduction in case of overweight.
• In terms of weight reduction, a BMI of 25kg/m2 and an abdominal girth of <102cm (m) /88cm(w) is recommended.

High normal blood pressure (130 - 139 / 85 - 89 mmHg) The recommendations for the therapy of high normal blood pressure values (prehypertension) are controversial. The current European guidelines (2013) do not recommend drug therapy. In the US-American JNC7-Report of the U.S. Department of Health and Human Services (2004), pharmacological therapy is at least considered in the presence of prehypertension (120-139/80-89 mmHg) together with other indications if lifestyle changes are not effective (e.g. in cases of concomitant heart failure, e.g. after myocardial infarction, high risk of CHD, diabetes, chronic kidney disease).

Grade 1 hypertension (140 - 159/ 90-99 mmHg): without other risk factors, grade 1 and 2 hypertension should be treated with lifestyle changes and, if these do not reduce blood pressure below 140/90 mmHg after a few months, with antihypertensives.

Grade 2 hypertension (160 - 179 / 100 - 109 mmHg): if there are three or more risk factors or if there is damage to the end organs, it is important to start medication therapy immediately.

Hypertension grade 3 (≥ 180 / ≥ 110 mmHg): depending on the risk factors and the diagnosed severity of hypertension, additional medication may be required.

Drug treatment approaches

In any case, the therapy must be carried out consistently over a long period of time, possibly throughout the patient's life. The patient must be prepared for this perspective. The target blood pressure is =/<140/90mmHg. An adequate therapy improves the prognosis considerably. First choice drugs are: diuretics, beta-blockers, ACE inhibitors, calcium antagonists and AT-II receptor antagonists. In many cases they are combined with each other to achieve the optimal effect. For these drugs, prognostic benefit has been proven.

Diuretics: are low-dose antihypertensive drugs (e.g. chlorotalidone or HCT 12.5-25mg/day). Diuretics are often used in combination with other antihypertensives.

Beta-blockers (e.g. bisoprolol, metoprolol): Their aim is to inhibit the action of adrenaline (also noradrenaline, the stress hormone) by blocking the beta-adrenoceptors. Preference is given to beta1-selective beta blockers without sympathomimetic effect.

ACE inhibitors (prilates: e.g. captopril, enalapril, ramipril): inhibit the angiotensin-converting enzyme (ACE) and prevent the conversion of angiotensin I into angiotensin II which increases blood pressure. Thus the peripheral vascular resistance is reduced due to the decreased angiotensin II production.

Calcium antagonists (e.g. amlodipine, nifedipine): block the L (long lasting) calcium channels in the vessels. Vessels remain dilated (afterload reduction).

Angiotensin-2 receptor blockers (ARB): AT2 receptor blockers (e.g. candesartan, valsartan) inhibit the action of angiotensin II at the AT1 receptor. This leads to blood pressure reduction and inhibition of vascular remodelling. Their advantage are the reduced side effects.

High blood pressure associated with cardiovascular disease causes up to 50% of all deaths.

Only borderline hypertension can be treated with phytopharmaceuticals. Standardized garlic preparations(daily doses of 900-1200mg/day p.o. e.g. Kwai® forte 300 mg Drgs.), hawthorn preparations(Crataegi folium cum flore) and sedative aznei plants(valerian root, lavender and lemon balm flowers) are suitable for this purpose. Otherwise, the blood pressure should be adjusted with the medically proven therapy strategies with the individually adapted target blood pressure values (age <80 years: <140/90 mmHg; age >80 years: <150/90 mmHg)

see also wild garlic

If an initial stage drug is ineffective or intolerable in terms of side effects, it can be replaced by another (sequential monotherapy). If a drug is only partially effective but well tolerated, the dose can be increased or a second drug can be added to another group (stepwise therapy). In general, treatment should be started with only one drug, unless the hypertension is severe.

Diuretic + beta-blocker (propanolol + hydrochlorothiazide; metoprolol + hydrrochlorothiazide; atenolol + chlorothalidone; timolol + hydrochlorothiazide)

Diuretic + ACE inhibitor (captopril + hydrochlorothiazide; benazepril+ hydrochlorothiazide; lisinopril+ hydrochlorothiazide; enalapril+ hydrochlorothiazide)

ACE inhibitor + Ca-blocker (Amlodipine + Benazepril)

Angiotensin II receptor blocker + diuretic (losartan + hydrochlorothiazide)