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Empfehlungen der Projektgruppe Prävention der DGK zur risikoadjustierten Prävention von Herz- und Kreislauferkrankungen

Teil 3: Fettstoffwechselstörungen, arterielle Hypertonie und Glukosestoffwechsel

Recommendations of the project group prevention of the German Cardiac Society (DGK) on risk adjusted prevention of cardiovascular diseases

Part 3: Dyslipidemia, arterial hypertension and glucose metabolism

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Der Kardiologe Aims and scope

Zusammenfassung

Fettstoffwechselstörungen

Der Zusammenhang zwischen kardiovaskulärem Risiko und der Höhe des LDL-Spiegels ist zweifelsfrei nachgewiesen. Der Nutzen einer Absenkung des LDL-Cholesterins, vor allem mit Statinen, zur Minderung des kardiovaskulären Risikos entspricht einer Klasse-I-Empfehlung auf dem Evidenzlevel A. Die LDL-Zielwerte richten sich nach dem individuellen Risiko. Für HDL und Triglyzeride werden keine Therapieziele definiert, sondern lediglich Bereiche angegeben, bei denen von einem erhöhten kardiovaskulären Risiko auszugehen ist. Die leitliniengerechte medikamentöse LDL-Absenkung mit anzustrebenden niedrigen LDL-C-Zielwerten wird durch die preiswerte Verfügbarkeit des generischen Atorvastatins als stark wirksamem Statin deutlich erleichtert.

Arterielle Hypertonie

Die arterielle Hypertonie ist einer der wesentlichen Risikofaktoren für Herzinfarkt, Apoplex und Demenz. Sie liegt vor, wenn in der Arztpraxis der Blutdruck wiederholt größer oder gleich 140 mmHg systolisch oder 90 mmHg diastolisch gemessen wird. Nach Ausschluss einer sekundären Hypertonie und Bestimmung der Endorganschäden kann das kardiovaskuläre Gesamtrisiko definiert werden. Dieses und eventuell bestehende Begleiterkrankungen des Patienten bestimmen die antihypertensive Therapie, deren Basis stets nichtmedikamentöse Maßnahmen darstellen. Zur Pharmakotherapie werden überwiegend fixe Medikamentenkombinationen empfohlen. In regelmäßigen Abständen ist eine Nachüberwachung der Therapie bezüglich Wirksamkeit, Verträglichkeit und Adhärenz erforderlich.

Glukosestoffwechsel

Schon früh in der Entwicklung eines Typ-2-Diabetes mellitus können kardiovaskuläre Komplikationen auftreten. Je frühzeitiger die Diagnose und eine normnahe Blutglukoseeinstellung, desto günstiger die Prognose. Der HbA1c-Zielwert für Diabetespatienten liegt unter 7% (53 mmol/mol), in Einzelfällen, (insbesondere bei neu aufgetretenem Diabetes) noch tiefer. Hypoglykämien sollten jedoch wegen des hohen assoziierten kardialen Risikos unbedingt vermieden werden. Statine sollten in aller Regel gegeben werden, um die LDL-Zielwerte von unter 70 mg/dl (1,8 mmol/l) zu erreichen. Zusätzliche kardiovaskuläre Risikofaktoren oder Endorganschäden erhöhen das Risiko und sind nach den evidenzbasierten Therapieempfehlungen zu behandeln.

Abstract

Dyslipidemia

There is a strong correlation between low-density lipoproteins (LDL) cholesterol level and cardiovascular risk. Risk adjusted treatment, predominantly with statins, improves prognosis (Class I recommendation, evidence level A). The LDL targets depend on the individual risk. For HDL und triglycerides no target levels but only levels below (for HDL-C) or above which an increased cardiovascular risk is documented are defined. The guideline conforming LDL lowering with the defined LDL target levels requires the availability of highly effective statins for all patients.

Arterial hypertension

Arterial hypertension is one of the major cardiovascular risk factors leading to myocardial infarction, stroke or dementia. Repeated blood pressure readings of 140/90 mmHg or more confirm the diagnosis hypertension and should lead to further investigations to exclude secondary forms of hypertension or already established end organ damage. Antihypertensive drugs are prescribed according to the individual cardiovascular risk and additional diseases. Life style modifications markedly reduce blood pressure even in patients receiving blood pressure lowering drugs. A combination of drugs is needed in most cases and fixed combinations are recommended. Follow-up has to be performed regularly to control blood pressure response, possible side effects and patient adherence to therapy.

Glucosemetabolism and diabetes

The stages in the manifestation of type 2 diabetes mellitus develop over several years ranging from impaired fasting glucose to impaired glucose metabolism and manifest diabetes mellitus. Cardiovascular complications can occur early and the earlier the diagnosis is confirmed with subsequent near normal blood glucose adjustment, the more favorable the prognosis. The glycated hemoglobin (HbA1c) target for patients with established type 2 diabetes is less than 7% (53 mmol/mol). In individual cases particularly with new onset diabetes lower values can be attempted. Particular care should be taken to avoid hypoglycemic episodes because of the high associated risk. Statins should be prescribed to reach the LDL-C target of <70 mg/dl (1.8 mmol/l). Additional cardiovascular risk factors increase cardiovascular risk and are to be treated according to the evidence-based therapy recommendations.

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Authors and Affiliations

  1. Neue Kirchstr. 22, 79282, Ballrechten-Dottingen, Deutschland

    H. Gohlke FESC, FACC

  2. Herz-Zentrum Bad Krozingen, Bad Krozingen, Deutschland

    H. Gohlke FESC, FACC & C. Gohlke-Bärwolf

  3. Klinik und Poliklinik für Psychosomatik und Psychotherapie, Universitätsklinikum Köln, Köln, Deutschland

    C. Albus

  4. Park-Klinikum, Bad Krozingen, Deutschland

    G. Bönner

  5. Klinik für Kardiologie, Angiologie und Intensivmedizin, Vivantes Klinikum Neukölln, Berlin, Deutschland

    H. Darius

  6. Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland

    S. Eckert & D. Tschöpe

  7. Kardiologisch-angiologische Gemeinschaftspraxis, Köln-Poll, Deutschland

    D. Gysan

  8. Klinik Schwabenland, Isny-Neutrauchburg, Deutschland

    H. Hahmann

  9. Präventive und Rehabilitative Sportmedizin, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    M. Halle

  10. Klinik für Kardiologie, Klinikum links der Weser, Bremen, Deutschland

    R. Hambrecht

  11. Kardiologische Abteilung, Rehabilitationszentrum München, München, Deutschland

    P. Mathes

  12. Deutsche Sporthochschule Köln, Köln, Deutschland

    H.-G. Predel

  13. Miesbach, Deutschland

    G. Sauer †

  14. Abteilung Präventive Kardiologie, Ludwig-Maximilians-Universität, München, Deutschland

    C. von Schacky

  15. Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig, Leipzig, Deutschland

    G. Schuler

  16. Institut für Medizinsoziologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland

    J. Siegrist

  17. Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik, Universitätsklinikum Leipzig, Leipzig, Deutschland

    J. Thiery

  18. Department für Rehabilitationswissenschaften, Universität Potsdam, Potsdam, Deutschland

    H. Völler

  19. Deutsche Adipositas-Gesellschaft, Bad Rothenfelde, Deutschland

    A. Wirth

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Gohlke, H., Albus, C., Bönner, G. et al. Empfehlungen der Projektgruppe Prävention der DGK zur risikoadjustierten Prävention von Herz- und Kreislauferkrankungen. Kardiologe 7, 141–156 (2013). https://doi.org/10.1007/s12181-012-0468-x

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