Medicinal

Medicinal therapy with antihypertensives

The antihypertensive therapy pursues the aim of reducing the increased cardiovascular risk with side effects as low as possible effectively. Since there are frequently cardiovascular accompanying illnesses or end organ damages and the objective blood pressure values are defined more lowly than early in these cases a combination therapy is for the majority of the hypertension for patients required. The individually different accompanying illnesses, end organ damages and side action profiles have the optimal differential therapy seem with the antihypertensives as a strategic objective of the medicinal medical treatment available. A duration therapy is the medicinal medical treatment about years, it lifelongly, therefore often requires a good information of the patient, too. At the beginning the organism frequently reacts with tiredness, exhaustion, dizziness, because the body has got used to the increased blood pressure and must adapt itself only to the lower, normal values. These symptoms last for commonly few weeks and then disappear again if the body has itself adaptedly to the values brought back to normal. These symptoms therefore represent, if indication for the therapy abortion no dramatic blood pressure drop walks along and no-one the symptoms don't endanger the patient (e.g. fall tendency at dizziness with fracture danger). Furthermore every medicine needs a certain time until it has reached its working mirror and can develop its full effect. It doesn't make sense to change the medication all couple of days because some do himself first time therefore. As a rule, medicine is reached the full effectiveness one after 2-6 weeks. You should therefore always start with a low dosage. In the morning, due to the physiologic zirkadianen rhythmic with peak values in the morning and lowest values in the sleep antihypertensives still should be taken before getting up, day further doses then should distributed over the day into dependence of course taken be the blood pressure. Nightly hypotensions must be avoided, however, (particularly with older people with the danger of the cerebralen inferior blood flow and the orthostatic collapse when getting up with in turn fall danger).

A widespread fault under the patients is to remove the tablets after normalization of the blood pressure high-handedly even to a dangerous rebound phenomenon whereupon which one the blood pressure rises by return of post again and after removing certain medicines blood pressure can lead, then life-threatening trigger increase can one must therefore certainly because one takes the tablets point out explicitly to patients that the normalization of the blood pressure values doesn't mean that one has "healed" and can remove the medicines but that the values are normal. Hypertension doesn't represent any short-term disturbance disease which also continues to exist if the blood pressure values are adjusted well under medicines, but one -- mostly lifelong. If values increased again after a while of the good attitude appear, then it is presumable to an adaptation to the previous come and it medicine requires a therapy rearrangement or - supplement. To himself characteristic of the follow-up primarily self measurements and regular measurements in the doctor's practice. In the single case cannot be predicted about which blood pressure lowering medicine a patient asks with hypertonus best. Therefore the therapy suggestions represented here only can be regarded as a guide.

Different antihypertensives:

Diuretika:
They become measured out only lowly since usually started hypertonsion a dose increase doesn't obtain any essential further hypotension and because of its relatively weak antihypertensive effect only as a combination partner with others, frequently used at older patients in the doctor's office primarily. Against this they are potent medicines at the acute and chronic cardiac insufficiency. You work about an increase of the salt and water excretion about the kidneys. For Diuretika a prognostic advantage is proved to patients by reduction in the mortality at hypertension.

Contraindications: Heavy kidneys and liver functional disorders, heavy electrolyte disturbances, digitalis poisonings, pregnancy and silent time
  • Thiazide (e.g. Esidrix, HCT, Aquaphor): Blocking of the sodiumchloride-cotransportes at the early distal tubule. Loss of 15% of the sodium+potassium filtered glomerularly. Working duration depending on preparation 12-48 hour. Thiazide work 30 ml/min also at a glomerular filtration rate of <. Side effects: Serum electrolyte disturbances: Potassium, hyponatremia, body fluid deficit (exsiccosis)
  • Loop diuretics (z.B. Furosemide, Torasemid, Piretanid): Blocking of the Na/K2Cl carrier in the ascendent part of the Henle's loop through which you eliminate to 40% of the filtered sodium. You are employed primarily in the therapy of the acute and chronic cardiac insufficiency. Go in this can a resistance develop. In this case the loop diuretic should be not permanently measured out more highly but be combined with a thiazid which a sequential nephronblockade causes through which the diuresis increases again. Cave .: Potassium and magnesium loss! Furosemide is effective also at a Glomerulumfiltrat of < 5 ml/min.. The diuresis after 10-20 starts min. after intravenous gift. Working duration < 6 hour. Side effects: Serum electrolyte disturbances: Potassium, hyponatremia, body fluid deficit (exsiccosis), kidney function restriction
  • Potassium economizing Diuretika (Aldosterone antagonists: e.g. Spironolacton, other: e.g. Amilorid, Triamteren into combination with Thiaziden): Effect admission only after 3-4 days . indication: primary hyperaldosteronism (Conn syndrome), secondary hyperaldosteronism at a decompensated cirrhosis or cardiac insufficiency (with ascites or edemas).
Side effects: Hyperkalemia, hyponatremia

ACE inhibitor (Prilate) (e.g. Captopril, Enalapril, Ramipril, Lisinopril, Benazepril): Blocking of an enzyme (angiotensin-Converting-enzymes) and therefore operation the renin angiotensin aldosterone mechanism of the kidney. A very potent hypotension arises from the interplay of several working approaches:
  • Reduction in the peripheral vascular resistance
  • Reduction of the sympathikoadrenergen system or the catecholamine release
  • Reduction of the sodium and water retention with a following volume decrease
  • Hindering of the dissimilation of endogenous substances seeming vasodilatory
Furthermore a kardio and nephroprotekltive effect is, so that ACE inhibitors still should be used up to a creatinine value of-1.8 mg/dl also at a restricted kidney function and in proved the therapy or an essential role for the prognosis play the cardiac insufficiency for ACE inhibitors after myocardial infarctions. Newer studies unite more prognostically advantage proved patients by reduction in the mortality at hypertension also for the ACE inhibitors have. ACE inhibitors are good for the antihypertensive therapy with Diuretika for which already various active substance combinations, most are with hydrchlorthiazid on the market to combine.

Side effects: Stimulus cough, reinforcement of the effect of insulin or oral antidiabetics, headaches, dizziness, angioneurotic edema, hyperkalemia . Cave: no combination with potassium economizing Diuretika!

Contraindications. Mutual renal artery stenosis, graft kidney, intake of potassium economizing Diuretika, hyperkalemia, immunosuppressive therapy, liver insufficiency, heavy renal insufficiency (creatininclearance < 30 ml/min.), Aortenstenose.

AT-I-Blocker(Sartane) (e.g. Irbesartan, Losartan, Valsartan):
The antagonists angiotensin II OT I receptor. Use effect on lower side effects largely is but more expensive most at incompatibility of ACE inhibitors, since. Newer studies unite more prognostically advantage proved by reduction in the mortality at Hypertonike patients also for OT I blockers have Side effects: Headaches, tiredness, hyperkalemia, creatinine increase, liver functional disorders. Contraindications: Mutual renal artery stenosis, aortae and mitra valvular stenosis, hyperkalemia, taking of potassium economizing Diuretika, pregnancy and silent time.

Calcium antagonists of the Nifedipin type (e.g. Amlodipin, Felodipin, Nitrendipin, Nifedipin): Blockade of the calcium canals of the musculature > relaxation-primarily the peripheral vessel musculature, through this hypotension. Newer studies unite more prognostically advantage produced by reduction in the mortality at hypertension patients also for calcium antagonists have. Side effects: Headaches, Flush, dizziness, tiredness, ankle edemas. Contraindications: Cardiac insufficiency (NYHA III and IV), unstable angina pectoris and acute myocardial infarction, pregnancy and silent time.

Beta blocker: (z.B. Atenolol, Bisprolol, metoprolol) For beta blockers a prognostic advantage is proved to patients by reduction in the mortality at hypertension just like for Diuretika. You work negatively inotropic ( Reduction of the contractility of the heart), negatively bathmotropic (Reduction of the excitability), negatively chronotropic ( Deceleration of the heart rate) and negatively dromotropic (Deceleration of the over-line speed) The oxygen consumption of the heart it works more economically, the blood pressure sinks primarily by the negatively inotropic and chronotropic effect sink. Side effects: Bradycardia (heart rate deceleration), development of an A-V block, bronchospasm, giddiness, nausea, tiredness, reinforcement of the hypoglycemia at diabetes, aggravation of a peripheral circulatory disorder, erection disturbances. Contraindications: extreme A-V block, COPD/asthma bronchial, intake of central sympathicolytica, bradycardia.

Alpha blocker: (e.g. Doxazosin, Urapidil) effect by sympathicolysis with dilation of the peripheral blood vessels and therefore by reduction of the resistance waste of the blood pressure. Side effects: Orthostatism reaction (Blood pressure drop when getting up in the legs, dizzinesses, headaches, edemas, tiredness) Contraindications: Pregnancy and silent time.

Sympathicolytica seeming central:
  • Stimulatoren of the imidazole receptors (e.g. clonidine, Moxonidin), through this inhibition of renin and norepinephrine removing suddenly can > hypotension trigger hypertensive crises. Side effects: Sedation, dry mouth, orthostatism reaction, obstipation, bradycardia, sleeplessnesses, impotences. Contraindications: Intake of beta blockers, Sick sinus syndrome, bradycardia, A-V block °ILiver or renal insufficiency, pregnancy.
  • "False neurotransmitter " with stimulation of the alpha 2 receptors and by the reflectory one sympathicolysis (e.g. Methyldopa). At the pre-eclampsia in the pregnancy we use as ultima reason or else not in use.
Side effects : Allergies, lupus, sedation, dry mouth, sodium and water retention. Orthostatserektion, liver damages, impotences, gynecomastia, psychic disturbances. Falsely positive values of the catecholamine dissimilation products in the urine.

Arterioläre vasodilators (z.B. Dihydralazine, Minoxidil): Vessel dilatation at the arterioles by a direct effect at the smooth vessel musculature. Only index at the heaviest hypertension! Cave: heavy blood pressure drops are possible, therefore measure out slowly. Side effects: reflectory tachycardia, orthostatism, headaches, lupus, sodium and water retention. Contraindications: KHK, since triggering of angina pectoris possible.


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