High Blood Pressure (Hypertension) — Diagnosis and Treatment

Arterial hypertension is the most common chronic condition in Germany — an estimated 30 million people are affected, the majority without any noticeable symptoms.^[1] That is what makes it so dangerous. High blood pressure causes no pain. For years, it silently damages the heart, kidneys, brain and blood vessels — until a heart attack, stroke or kidney failure becomes the first perceptible sign.

Early, precise diagnosis and consistent treatment are therefore not precautionary measures but prevention in the truest sense of the word.

What is high blood pressure — and when does it need treatment?

The current guidelines of the European Society of Cardiology (ESC/ESH 2023)^[1] define arterial hypertension as a blood pressure of ≥ 140/90 mmHg measured in a clinical setting. The threshold is lower for home blood pressure monitoring (≥ 135/85 mmHg) and lower still for 24-hour ambulatory monitoring (ABPM): ≥ 130/80 mmHg.

Whether and when medication is appropriate depends not on the reading alone — but on your individual risk profile. Is there also a diabetes diagnosis? Excess weight? Elevated blood lipids? Smoking? A family history of cardiovascular disease? The more risk factors are present, the lower the threshold for active intervention.

Blood pressure that does not respond to medication

Around 10–15% of all patients with hypertension have secondary hypertension — blood pressure that is not a primary condition, but a consequence of another underlying disease.^[2] These cases often go undetected for years because blood pressure fails to normalise despite multiple medications.

The most common cause of secondary hypertension is obstructive sleep apnoea (OSA). Every apnoea episode during sleep activates the stress hormone system — with a measurable surge of cortisol and catecholamines that keeps blood pressure elevated throughout the day. Studies show that up to 50% of patients with severe, treatment-resistant hypertension have undiagnosed sleep apnoea.^[3]

Treating sleep apnoea often lowers blood pressure significantly — sometimes enough to reduce or discontinue antihypertensive medications. For this reason, sleep diagnostics are part of the standard work-up for difficult-to-control hypertension.

Hypertension as part of the metabolic syndrome

High blood pressure rarely appears in isolation. Elevated blood pressure, excess weight, insulin resistance (a precursor to type 2 diabetes) and unfavourable blood lipid levels together form what is known as the metabolic syndrome — a cluster of risk factors that amplify each other and multiply cardiovascular risk.

This is not a coincidence. Visceral fat tissue (abdominal fat) is metabolically active: it releases messenger substances that promote inflammation, impair insulin sensitivity and directly stress blood vessel walls. A weight reduction of 5–10% lowers systolic blood pressure by an average of 5–8 mmHg — often more than a single antihypertensive drug.^[4]

This is why we treat hypertension in context, not in isolation. Patients who also have excess weight, elevated blood sugar or sleep apnoea benefit from an integrated approach — one appointment, not four referrals.

How we diagnose blood pressure precisely

A single reading in the practice is rarely sufficient. Blood pressure fluctuates substantially throughout the day, and many patients experience a so-called white-coat effect — blood pressure rises situationally due to the stress of a medical appointment, without any true hypertension being present. Conversely, some patients show normal readings in the clinic while their pressure remains elevated overnight — a phenomenon known as masked hypertension.

The gold standard for diagnosis is ambulatory 24-hour blood pressure monitoring (ABPM). The device records automatically through the day and night and produces a complete profile: daytime average, night-time dip, morning surge. This so-called "dipping status" carries independent prognostic significance — patients whose blood pressure fails to dip sufficiently at night (non-dippers) face elevated cardiovascular risk regardless of their daytime values.^[1]

Treatment — lifestyle first, medication when needed

The ESC/ESH 2023 guidelines emphasise that in mild hypertension without end-organ damage and with low overall risk, a lifestyle intervention period of 3–6 months is justified before starting drug therapy.^[1] What makes a measurable difference in that window:

• Salt reduction: Target below 5 g of table salt per day — every gram saved lowers systolic pressure measurably
• Weight loss: Approximately 1 mmHg systolic per kilogram of body weight lost^[4]
• Regular physical activity: Aerobic exercise — walking, swimming, cycling — for 30 minutes daily lowers blood pressure comparably to a low-dose antihypertensive drug
• Alcohol reduction: Even moderate regular consumption raises blood pressure in a clinically relevant way
• Sleep: Poor sleep quality — especially with sleep apnoea — keeps blood pressure chronically elevated

When lifestyle measures are insufficient, or when cardiovascular risk is already elevated, guidelines recommend combination drug therapy — typically two agents from the outset of treatment. We select individually, based on comorbidities, kidney function and tolerability.

dr. Albrecht Wenzel is a certified hypertension specialist (DHL — Deutsche Hochdruckliga, 2023) and an active member of the German Hypertension League. Treatment follows the current ESC/ESH 2023 Guidelines for the Management of Arterial Hypertension.

GLP-1 therapy and blood pressure — a dual benefit

Patients with both obesity and hypertension can benefit from modern GLP-1 therapy on multiple levels. GLP-1 receptor agonists (semaglutide, tirzepatide) not only reduce body weight — they also lower systolic blood pressure by an average of 3–6 mmHg in clinical trials, independently of weight loss.^[5,6] This effect is attributed to direct vasoprotective mechanisms.

For some patients, this means a single treatment that simultaneously improves weight, blood sugar and blood pressure. Whether this could be right for you is something we can discuss in a consultation.