High blood pressure (arterial hypertension)

In the case of high blood pressure (arterial hypertension), the values of the measurable blood pressure are elevated over a longer period of time. The medical term arterial hypertension is made up of the Latin words "arterial" (belonging to the artery) and "hypertension" (excess pressure). According to the current guidelines of the European Society of Cardiology (ESC), we speak of high blood pressure if the systolic blood pressure values exceed 140 mmHg (millimeters of mercury) or the diastolic values exceed 90 mmHg. Arterial hypertension is the most common internal disease and is one of the classic widespread diseases, with the prevalence of hypertension in adults in Europe being around 30%. The prevalence of high blood pressure also depends on body weight, socio-economic status and gender - men are more frequently affected by high blood pressure overall.

Systolic and diastolic values

The heart pumps blood into the body with every beat, creating a pressure within the blood vessels that can be measured using a blood pressure cuff, for example. The ideal blood pressure value is 120 / 80 mmHg. The first, usually higher value, is called systolic blood pressure and the second, usually lower value, is called diastolic blood pressure. Systole is the phase in which the heart muscle contracts and ejects blood from the left ventricle. This is contrasted with diastole, in which the heart relaxes and can therefore refill with blood. Blood pressure is usually measured using a blood pressure cuff on the upper arm or invasively using a sensor in the arteries. The blood pressure cuff should always be placed at the level of the heart during a measurement.

The unit for blood pressure is, for historical reasons, mmHg. This stands for millimeters of mercury. High blood pressure is defined as blood pressure above 140 mmHg in systole or above 90 mmHg in diastole.

A one-off moderately high blood pressure often poses no acute danger, but high blood pressure values over a longer period of time have negative effects on the heart, blood vessels, kidneys, eyes and brain. It also increases the risk of cardiovascular diseases such as heart attacks and strokes. This risk can be significantly reduced by treating high blood pressure.

Cardiovascular risk

Whether and how arterial hypertension needs to be treated depends on the blood pressure measured and also on the overall risk of cardiovascular disease. Other diseases such as metabolic syndrome, elevated blood lipids (dyslipidemia) and diabetes mellitus can also increase the cardiovascular risk. A categorical classification of the overall cardiovascular risk is therefore recommended. In Europe, the tool of the European Society of Cardiology (ESC) or the PROCAM health test is recommended for this purpose, which takes into account factors such as systolic blood pressure, gender, smoking habits, age and blood lipid values. These can be used to classify patients into groups according to the calculated risk. According to the ESC recommendations, cardiovascular risk is classified using the SCORE system, for example.

General table of systolic and diastolic blood pressure values:

Blood pressure values of over 180/110 mmHg (grade 3) with evidence of acute organ damage are defined by the ESC as a hypertensive emergency. This requires immediate medical treatment.

A condition with blood pressure values of over 180/110 mmHg without organ damage but with additional symptoms is also known as a hypertensive crisis.

The term hypertensive derailment is also widely used and usually describes high blood pressure values in the sense of a grade 3 without symptoms or organ damage.

However, the terms hypertensive crisis and hypertensive derailment are not uniformly defined and are also used differently.

Essential (primary) hypertension

If no organic causes for high blood pressure are found, the hypertension is referred to as primary or essential hypertension. This affects around 90% of all patients. Essential hypertension has a large number of risk factors and a genetic (polygenic) predisposition is known.

Modifiable risk factors for the development of high blood pressure are

• stress

• insufficient exercise

• eating too much salt

• Eating too much fat

• Food low in potassium

• too much alcohol

• being overweight

• smoking

• insulin resistance

Non-modifiable risk factors for the development of high blood pressure are

• Frequent cases of hypertension in the family

• age

• Gender (men more often than women)

Certain diseases are more frequently associated with high blood pressure:

• Obesity

• Type 2 diabetes

• Increased blood lipid levels

• Kidney disease

If the above diseases occur together with high blood pressure, this is known as metabolic syndrome.

Secondary hypertension

High blood pressure can also be caused by other diseases and is then referred to as secondary hypertension. This affects around 10 % of all patients. The most common causes are kidney, metabolic or vascular diseases.

Possible causes of secondary hypertension include

• Obstructive sleep apnea syndrome: pauses in breathing during sleep due to a narrowing of the throat.

• Kidney diseases: Restriction of kidney function due to damage to the kidney tissue or narrowing of the kidney vessels.

• Aortic isthmus stenosis: narrowing of the aorta.

• Conn's syndrome (primary hyperaldosteronism): Often benign adrenal tumor that causes aldosterone overproduction with subsequent high blood pressure and potassium deficiency.

• Cushing's syndrome: Excessively high blood cortisone levels due to medication or a hormone-producing tumor.

• Pheochromocytoma: Frequently benign adrenal tumor that produces catecholamines. Symptoms are episodic high blood pressure with headaches, dizziness and palpitations.

• Adrenogenital syndrome: Inherited metabolic disorder caused by an enzyme defect in which the production of aldosterone and cortisol in the adrenal gland is impaired.

• Acromegaly: Uncontrolled release of growth hormones by a tumor of the pituitary gland. The extremities are enlarged.

• Thyroid disorders: Overactive thyroid gland(hyperthyroidism).

• Hyperparathyroidism: Increased production of parathyroid hormone.

Other causes and medication are also possible causes of secondary hypertension. These include

• neurogenic hypertension (e.g. brain inflammation)

• psychogenic hypertension (e.g. due to pain)

• oral contraceptives

• non-steroidal anti-inflammatory drugs (NSAIDs)

• immunosuppressive drugs

• tumor medications

• Drugs that promote blood formation (EPO)

• Anabolic steroids

• Stimulants and drugs

• licorice

Special forms of high blood pressure

1. Practice hypertension: So-called "white coat hypertension" refers to repeated blood pressure values of over 140/90 mmHg when measured in a doctor's surgery. However, the values at home are normal.

2. Isolated ambulatory hypertension: So-called masked hypertension refers to normal blood pressure values in the doctor's office with elevated blood pressure values in home measurements or in ambulatory blood pressure monitoring (ABDM). This form of hypertension often occurs in young men, smokers or with a family history of hypertension. The mortality rate is about as high as with untreated high blood pressure.

3. Juvenile isolated systolic hypertension: This special form of high blood pressure mainly affects tall, slim, athletic adolescents or young adults. The systolic blood pressure is elevated when measured conventionally on the upper arm. However, antihypertensive therapy is not usually necessary here.

Moderately high blood pressure normally causes few symptoms and symptoms may be absent for a long time. The disease is therefore usually discovered late as an incidental finding - as part of a preventive examination - or as an emergency in the course of a hypertensive crisis. Sometimes, however, a headache occurs early in the morning or sleep disturbances occur with nocturnal hypertension.

Possible symptoms of high blood pressure can be

• Dizziness

• headache

• fatigue

• nervousness

• nosebleeds

• Shortness of breath

• shortness of breath

• Chest pain

• redness of the face

• impaired vision

• nausea

Elevated blood pressure over a long period of time can damage a number of organs and cause secondary complications.

Hypertension screening should be carried out on all adults from the age of 18. If the results are normal, a blood pressure check is recommended at least every 5 years. Highly normal values should be checked annually. If arterial hypertension is already known, those affected should ideally measure their blood pressure daily and have the recorded values checked regularly by a doctor.

The main aim of blood pressure therapy is to reduce the risk of serious cardiovascular diseases such as strokes or heart attacks. This is achieved by lowering blood pressure and optimizing other risk factors such as high blood lipid or blood sugar levels. With the help of optimal blood pressure therapy, the risk of heart attacks can be reduced by around 25 %, the risk of strokes by 40 % and the risk of left heart failure by around 50 %.

In general, three aspects play a major role in hypertension therapy:

1. Blood pressure level (systolic, diastolic, amplitude)

2. Individual CHD risk (according to PROCAM or ESC score)

3. Existing hypertensive organ damage

As a rule, therapy should be started from a value of 140/90 mmHg. In people who are over 80 years old at the time of initial diagnosis, higher values can also be accepted and therapy is only indicated from values of 160 mmHg systolic.

Target values during blood pressure therapy are values below 130/80 mmHg up to the age of 65. For people older than 65, a systolic blood pressure value of less than 140 mmHg is usually aimed for. The prerequisite is always that the therapy is well tolerated. Excessively low blood pressure values during therapy (hypotension) should be avoided, especially in older people, as they can increase the risk of falling, for example.

Lifestyle

Primary hypertension can be improved by a change in lifestyle and the following measures are the basic therapy for any high blood pressure:

• Weight reduction (BMI approx. 25 kg/m2)

• Regular physical exercise (e.g. walking, running, swimming)

• Mediterranean diet

• Omitting hypertension-promoting medication (e.g. NSAIDs)

• Reduction of salt in the diet (5-6 g NaCl/d)

• less or no alcohol and caffeine

• No nicotine consumption

• Warm baths or mild sauna

If the lifestyle changes are not sufficient, additional medication is prescribed. With the above measures, around 25% of mild hypertension (severity grade 1) can be normalized. In the case of secondary hypertension, the underlying disease must always be treated.

Medication

A whole range of active substances are available for the drug therapy of high blood pressure, which are usually combined to achieve optimum blood pressure values. A dual combination therapy (preferably a fixed combination) increases treatment compliance. Exceptions to this are patients with mild hypertension (severity grade 1) and low cardiovascular risk as well as patients over 80 years of age. In most cases, a low dosage is initially selected and this is increased over time as required. The therapy often lasts a lifetime. Regular medical checks and dose adjustments according to age, lifestyle and possible side effects are necessary.

Once started, blood pressure therapy should never be discontinued without consulting a doctor, as severe fluctuations in blood pressure with hypertensive crises are possible.

The five main groups of active substances for the routine treatment of arterial hypertension are

• ACE inhibitors: e.g. enalapril, lisinopril, ramipril

• AT1 antagonists: e.g. candesartan, losartan, valsartan

• Beta-blockers: e.g. bisoprolol, metoprolol, nebivolol

• Diuretics: e.g. HCT, indapamide, spironolactone

• Calcium antagonists: e.g. amlodipine, lercanidipine, nifedipine

Recommended combinations are an ACE inhibitor or an angiotensin receptor blocker with a calcium antagonist or a thiazide diuretic(hydrochlorothiazide, xipamide). If the above-mentioned active substances are not sufficient or are not tolerated, other reserve drugs (e.g. alpha-1 receptor blockers, centrally acting sympatholytics and arteriolar vasodilators) are available.

The prognosis of arterial hypertension generally depends on early detection and optimal treatment. High blood pressure is generally a disease with few symptoms, but over time it can lead to damage to the blood vessels and organs. This is caused by an increased occurrence of hardening of the arteries(arteriosclerosis) and direct damage and changes due to the increased blood pressure. This can lead to a number of secondary diseases and complications in various organs.

Arterial hypertension is based on partially modifiable risk factors. A correct lifestyle can reduce the risk of developing high blood pressure. These include

Rules for correct blood pressure measurement:

• The measurement should be taken while lying down or sitting. Before the measurement, sit in a chair in a quiet environment for 5 minutes and lean back.

• Use a certified blood pressure monitor.

• A device with an upper arm cuff is ideal. The lower edge of the cuff should be positioned 2.5 cm above the crook of the elbow.

• The cuff should be the right size for your arm.

• Placed at heart level, the cuff provides the most accurate blood pressure readings. The arm should be supported during the measurement.

• You should not move or talk during a measurement.

• The average value of two consecutive measurements is the most accurate.

• At least 1-2 minutes should elapse between individual measurements.