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Aktuelle Aspekte der Kombinationstherapie bei Hypertonie

Current aspects of combination therapy in hypertension

  • CME Weiterbildung · Zertifizierte Fortbildung
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Der Kardiologe Aims and scope

Zusammenfassung

Die überwiegende Mehrzahl aller Hypertoniepatienten bedarf zur Blutdrucknormalisierung einer Therapie mit ≥2 Medikamenten. Insbesondere aus Gründen der langfristigen Therapietreue empfehlen Fachgesellschaften übereinstimmend die Verwendung sog. „fixer“ Kombinationen zur Vereinfachung des Therapieschemas. Entsprechend den aktualisierten Leitlinien der ESC/ESH sind in Bezug auf 2er-Kombinationen RAS-Blocker (ACE-Hemmer und AT1-Antagonisten) oder Kalziumantagonisten plus Diuretika oder RAS-Blocker plus Kalziumantagonisten zu präferieren. Die ACCOMPLISH-Studie konnte zeigen, dass eine RAS-Blocker/Kalziumantagonist-Kombination zumindest bei Patienten mit hohem kardiovaskulärem Gesamtrisiko günstigere prognostische Wirkungen entfaltet als eine RAS-Blocker/Diuretikum-Kombination. Für den Fall der Notwendigkeit einer 3er-Kombinationsbehandlung empfehlen die aktualisierten Europäischen Leitlinien die Kombination eines ACE/Hemmers oder AT1-Antagonisten gemeinsam mit einem Kalziumantagonisten und einem Diuretikum. Ausbleibende Blutdrucknormalisierung unter einer ausreichend dosierten 3er-Kombination rechtfertigt die Diagnose einer „therapierefraktären“ Hypertonie. Vor weiterer Therapieeskalation sollte die Therapietreue des betreffenden Patienten thematisiert und ggf. eine Suche nach sekundären Hypertonieformen initiiert werden.

Abstract

The overwhelming majority of hypertensive patients need two or more antihypertensive agents to normalize blood pressure. According to US and European guidelines, so-called single-pill drug combinations should be employed whenever possible in order to simplify the regimen and increase long-term medication adherence. With respect to dual-drug combinations, the recently revised European (ESC/ESH) guidelines recommend the following options: RAS blocker (ACE inhibitor and angiotensin receptor blocker) or calcium channel blocker (CCB) plus diuretic or RAS blocker plus CCB. In a head-to-head comparison in patients at high cardiovascular risk, the ACCOMPLISH trial has recently shown a prognostic advantage for a RAS blocker plus CCB combination as compared to RAS blocker plus diuretic. Regarding triple-drug combinations, the revised European guidelines give preference to the combination of an ACE inhibitor or angiotensin receptor blocker plus a CCB and diuretic. Refractory hypertension is defined as the failure to achieve normal blood pressure values despite an effectively dosed triple-drug regimen containing a diuretic. In such patients, poor patient compliance and secondary hypertension should be considered before escalating therapy.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Der Autor hat für wissenschaftliche Vorträge (AWD, Berlin Chemie, Boehringer Ingelheim, Novartis, Sanofi Aventis, UCB-Schwarz, 7×4 Pharma) und Beratungstätigkeit (AWD, Novartis, UCB-Schwarz, 7×4 Pharma) Honorare erhalten.

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  1. Medizinische Klinik und Poliklinik 1, Wilhelmstr. 35–37, 53111, Bonn, Deutschland

    R. Düsing

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Düsing, R. Aktuelle Aspekte der Kombinationstherapie bei Hypertonie. Kardiologe 4, 27–36 (2010). https://doi.org/10.1007/s12181-009-0243-9

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  • DOI: https://doi.org/10.1007/s12181-009-0243-9

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