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HomeProductsClinically provenMÖWE Symposium: Modern Hypertension Management and SPC‑Based Therapy Strategies

Oliver Vonend, Reinhold Kreutz, Roland Schmieder, Borchard Pundt, Petra Sandow, Joachim Weil, Jan Galle


Key words
hypertension, blood pressure control, valid guidelines, single‑pill combinations (SPCs), indapamide, angiotensin II receptor blockers (ARBs), antihypertensive treatment, adherence, primary care, real‑world evidence, German health system

Introduction

This report summarises the key scientific and clinical findings presented by the leading experts at the 2025 MÖWE Symposium in Berlin. It focused on current challenges and evolving strategies in the management of arterial hypertension. Germany faces a high prevalence of hypertension, with treatment rates and guideline‑recommended BP control remaining suboptimal – an issue repeatedly highlighted across the symposium. The experts emphasised that despite clear recommendations from the European and national guidelines, combination therapy, particularly in the form of single‑pill combinations (SPCs), continues to be underutilised in daily clinical practice in Germany.

The speakers at the symposium addressed several causes of this care gap, including inconsistent standards of blood pressure measurement in primary care, therapeutic inertia, the high proportion of monotherapy prescriptions, and structural factors arising from Germany’s regulatory and reimbursement system. Real‑world data from German cohorts were repeatedly cited, demonstrating improved adherence, persistence, and clinical effectiveness when SPCs are used instead of multi‑pill regimens.

In addition to discussing the latest ESC (2024) and ESH (2023) guidelines and the German National Disease Management Guideline on Hypertension (NVL), the symposium provided practical guidance for German physicians regarding evidence‑based prescribing, documentation requirements, and economic considerations within the statutory health insurance system. The sessions also explored the renewed clinical relevance of thiazide‑like diuretics such as indapamide, new therapeutic developments, and case‑based decision‑making from everyday clinical practice.

Together, the seven expert articles offer an integrated perspective on how modern, guideline‑aligned
hypertension management can be implemented more systematically in Germany to improve
treatment outcomes and reduce cardiovascular risk at the population level.

1. The burden of hypertension in Germany – a still underestimated disease burden

Arterial hypertension is the most important modifiable risk factor for the development of cardiovascular diseases [1]. The key risk factors for the development of arterial hypertension include obesity, diabetes mellitus, tobacco use, male sex, older age, elevated LDL cholesterol levels, and genetic predisposition [1]. According to the 2023 WHO report The race against a silent killer, the prevalence rates of arterial hypertension continue to rise, particularly in industrialised countries [2]. Moreover, cardiovascular diseases are already the leading cause of death worldwide [3].

In Germany, the prevalence of arterial hypertension among adults over the age of 30 is approximately one third of the population (30%), with slightly higher rates in men than in women (34% vs. 25%) [2]. No other chronic disease occurs with comparable frequency [1–3]. A critical concern is that less than half 45% – of all diagnosed hypertensive patients receive adequate antihypertensive therapy [2]. This under treatment substantially contributes to persistently high incidences of myocardial infarction, stroke, atrial fibrillation, and other cardiovascular and renal events.

Several evidence based guidelines are available to optimise diagnosis and treatment. Three relevant
guidelines are briefly presented below:

  1. German National Disease Management Guideline (NVL): Primarily aimed at general practice and includes patient friendly information [4].
  2. European Society of Hypertension (ESH, 2023) Guideline: Provides a detailed classification and practical therapy recommendations [5].
  3. European Society of Cardiology (ESC, 2024) Guideline: Offers updated, internationally aligned treatment recommendations from a cardiological perspective [6].

Although the guidelines do not propose a uniform nomenclature or staging system for hypertension, the definition of hypertension is consistent across all of them and unchanged from previous definitions: hypertension is diagnosed when systolic office blood pressure is at least 140 mmHg and/or diastolic blood pressure is at least 90 mmHg.

Blood pressure measurement in clinical practice is central to diagnosis. However, practical challenges exist, such as the limited availability of validated fully automated oscillometric devices and the lack of sufficient rest periods before measurement owing to hustle and bustle and time pressure in everyday practice. A standardised measurement should be performed after 3–5 minutes of rest in a seated position, with three measurements taken at one minute intervals [5].

As an alternative to automated in-office blood pressure measurement [8], the guidelines recommend home blood pressure monitoring (HBPM) as an important method in hypertension management, while 24 hour ambulatory blood pressure monitoring (ABPM) is particularly recommended in specific clinical situations and is considered the diagnostic gold standard [4,5]. For documenting HBPM values, the German Hypertension League provides a blood pressure diary [9].

For differentiated risk stratification, it is important to consider accompanying risk factors such as metabolic parameters, lifestyle habits, and family history. Additionally, biological markers such as the urine albumin to-creatinine ratio provide important information about hypertensive organ damage and are used for staging chronic kidney disease (CKD) [5,10]. This is particularly important because patients with hypertension have an increased risk of developing CKD [10]. In clinical practice, however, this diagnostics is often insufficiently performed.

Antihypertensive therapy includes both pharmacological interventions (typically using first line antihypertensive agents such as ACE inhibitors, AT1 blockers, diuretics, calcium channel blockers, or beta blockers) and non pharmacological interventions [4–7]. The latter comprise regular physical activity, aerobic endurance training combined with dynamic or isometric strength training, and weight reduction [6].

The goal of therapy is initially to control hypertension (blood pressure below 140/90 mmHg) and ideally to further lower systolic pressure into the target range of 120–130 mmHg in most – especially younger – patients, provided this is well tolerated [5].

2. Single-pill combination (SPC) as the basis of hypertension management

Four main classes of substances are used in clinical practice for the treatment and control of arterial hypertension [5]. These include ACE inhibitors and angiotensin receptor inhibitors (ARB), calcium channel blockers (CCB), beta-blockers, and thiazide or thiazide-like diuretics (T/TL diuretics). Most patients should receive dual combination therapy immediately after diagnosis, taken once daily in the morning [5]. Preference should be given to combination products consisting of an ACE inhibitor or an angiotensin receptor inhibitor combined with a calcium channel blocker or a diuretic. In selected cases – in patients with low cardiovascular risk and blood pressure below 150/95 mmHg, patients with high-normal blood pressure but very high cardiovascular risk, or frail elderly patients – starting with monotherapy may be appropriate [5].

A 4% decline in the proportion of prescriptions for single-pill combination (SPC) antihypertensives in Germany was observed between 2016 and 2020 [11]. In 2020, the share of SPC antihypertensives was only 11%, while monotherapy accounted for 89%, even though the use of SPC at treatment initiation has been clearly recommended in the 2018 ESC/ESH hypertension guidelines and even earlier guidelines [11]. Dual SPC therapy offers significant advantages in the treatment of arterial hypertension. When treatment is initiated directly with the SPC of ACE inhibitor or ARB + CCB or T/TL diuretic, up to 60% of hypertensive patients can achieve blood pressure control [5].

The pathogenesis of hypertension, a multifactorial disease, is complex and involves several physiological signalling pathways influenced by both exogenous (environmental) and endogenous factors. This complexity means that treatment with two complementary agents increases the likelihood of effective therapy and attainment of treatment goals [5]. The pathophysiology supports the use of SPCs, as they are intrinsically safe, improve patient adherence and persistence, and facilitate telemedical monitoring [12]. Moreover, therapeutic inertia – i.e. physicians’ reluctance to intensify treatment despite inadequate blood pressure control – is reduced. Ultimately, SPCs help treat a larger proportion of patients and enable earlier achievement of blood pressure targets [12]. Recent studies have shown that the systolic blood pressure should ideally fall within a target range of 120–130 mmHg.

The findings from a large real-world study demonstrate that patients who take only one tablet (‘single pill’) rather than multiple tablets (‘multi pill’) show higher persistence in medication adherence [13]. Additionally, these patients show a lower incidence of cardiovascular events, reduced mortality rates, and fewer hospitalisations. In a recent study, three dual SPCs were compared [14]. The triple-component SPC containing telmisartan, amlodipine, and indapamide served as the initial therapy and reference. The findings of the study indicate that, after twelve weeks of treatment, the combination of an angiotensin receptor blocker and a diuretic showed significant superiority in blood pressure control compared with other dual combinations. In summary, it can be concluded that the dual SPC therapy represents the foundational therapy for arterial hypertension.

3. Indapamide – rediscovered role of thiazide-like diuretics

The first antihypertensive agents – diuretics – were discovered in the 1950s. Over the following decades, additional classes of medications were introduced (1960s: α-/β-blockers; 1970s: calcium channel blockers (CCBs); 1980s: angiotensin-converting enzyme (ACE) inhibitors; 1990s: angiotensin receptor blockers (ARBs); 2000s: direct renin inhibitors). More recently, new groups of medications have been developed, including RNA-interference medications, GLP-1 receptor antagonists, and aldosterone synthase inhibitors. These therapies offer various advantages, including the possibility of treating patients with therapy-resistant hypertension. One such new agent is zilebesiran, an RNA-interference therapeutic targeting angiotensinogen. Following a single subcutaneous injection, it can lead to a long-lasting reduction in blood pressure of up to –22.5 mmHg systolic and –10.8 mmHg diastolic for twenty-four weeks and is expected to become available in the future [15]. In addition, renal denervation is considered a therapeutic option for the treatment of uncontrolled (resistant) hypertension.

Indapamide, a thiazide-like diuretic that has been available on the market for several decades (first approved in Germany in 1985), has recently been rediscovered in Germany as a valuable combination partner (it has been used successfully, including in combinations, in other European countries such as France, Spain, and Portugal). Chemically a benzamide derivative, indapamide inhibits sodium reabsorption in the distal tubule and reduces peripheral resistance. It is metabolically neutral and effectively lowers arterial blood pressure through its saluretic effect and a direct vascular action [16,17]. Indapamide can also contribute to the regression of hypertension-associated target organ damage. In combination with other antihypertensive agents, it further reduces cardiovascular and renal complications as well as mortality.

Compared to thiazide diuretics such as hydrochlorothiazide (HCT), indapamide has a significantly longer half-life, resulting in a prolonged duration of action [18–21]. Evidence also suggests that, at equivalent doses, indapamide achieves greater blood pressure reduction than HCT (this evidence is indirect, as there are no direct head-to-head comparisons) [22,23]. Furthermore, indapamide therapy demonstrates a more favourable metabolic profile than HCT. Studies have shown that under indapamide, total cholesterol and triglyceride levels remain stable after one year, whereas they worsen significantly under HCT; HbA1c even decreases slightly after three months of indapamide therapy [24–26]. These changes in the lipid profile are relevant in addition to the antihypertensive effect. It has also been shown that renal function is not impaired by indapamide therapy.

Moreover, indapamide effectively reduces left ventricular hypertrophy – significantly more so than HCT – and, when used in combination therapy, leads to reductions in cardiovascular and stroke risk as well as overall mortality [27–29]. In conclusion, international guidelines have for years recommended thiazide-like diuretics as preferred agents for the treatment of arterial hypertension [30].

4. Prescribing without regress from the perspective of the German Association of Statutory Health Insurance Physicians (KV)

According to the legal framework governing medical care, the treatment relationship between a patient and a physician is governed by a treatment contract as soon as the patient presents at the practice with a referral form (curative or for co-/continuing treatment) or with their health insurance card. The subsequent treatment must be provided in accordance with legal requirements, the Pharmaceutical Directive, and the clinical care guidelines [31]. During inpatient care, the responsibility for medication decisions lies with senior physicians, whereas in the outpatient setting, medication prescribing is bound by the Pharmaceutical Directive [32]. Furthermore, the German Social Code (Sozialgesetzbuch, SGB) stipulates that patients are entitled to guideline-based medical care that corresponds to the current state of scientific knowledge (excerpt from the Social Code Book V (SGB V), §2 Services: The quality and efficacy of services must correspond to the generally accepted state of medical knowledge and take medical progress into account.) [33].

The Pharmaceutical Directive defines which medications and treatments are necessary, sufficient, appropriate, and economical. The guidelines provide the framework for decision-making processes (e.g. the hypertension guideline recommends: Start with dual combination therapy for most patients [34]).

The German Social Code provides for various review procedures, including budget/average value audits and plausibility checks (EBM) [33]. These are conducted for a maximum of 5% of all contracted physicians. In addition, individual case audits are carried out in instances of violations against the Pharmaceutical Directive or against regulatory approval requirements. In Germany, different review systems are used depending on the federal state. These include the reference-value audit, the average-value audit, and the target-value audit. The Pharmaceutical Directive is another relevant element in this context [32]. It defines which medications are prescription-only and which are not; pharmacy-only requirements take precedence over prescription requirements. Off-label prescribing of medications is strictly prohibited. Exceptions require approval from the statutory health insurance, for which an application must be submitted [32]. The indication applies only in cases of life-threatening or regularly fatal diseases for which no treatment method exists that corresponds to recognised medical standards, and in which the use of a non-approved active substance can be expected to have a noticeable positive effect on therapeutic outcomes. All three criteria must be fulfilled [32].

Ensuring supply security in pharmacotherapy is also of significant importance. This requires that the treating physician has access to specific professional information, such as the Summary of Product Characteristics (SmPC).

Only 5% of physicians are subjected to economic efficiency audits. Prior expenditure notifications issued by the Associations of Statutory Health Insurance Physicians (KVen) to physicians should be considered. Accurate ICD diagnoses must be billed in accordance with the approved indication of the prescribed active substance; therefore, correct and complete ICD coding is essential.

Single-pill combination therapies are economically very sensible overall, as the price difference compared to the costs of mono substances is often minimal. Their use in patient treatment is highly valuable as they promote prophylaxis as well as patient compliance and adherence.

5. Economical prescribing from the perspective of a practice owner

In medical practice, according to Book V of the German Social Code (SGB V) § 2, ‘services must be provided in compliance with the principle of economic efficiency’ (SGB § 12). The principle of economic efficiency specifies that services must be adequate, appropriate, and cost-effective, and must not exceed the necessary scope [33]. Services that are unnecessary or uneconomical may not be claimed by insured persons, may not be provided by healthcare professionals, and may not be reimbursed by health insurance funds. However, financial considerations have no significant relevance when assessing the medical necessity of treatment [35]. The well-being of the patient is the highest priority. In cases where medications are absolutely identical, price is considered the decisive criterion for choosing a medicine. However, as soon as a clinical advantage exists (e.g. improved adherence), the medication is deemed economical, and its price becomes of secondary importance.

A common issue contributing to poor adherence is polypharmacy in elderly patients [36–39]. Nevertheless, adherence is crucial for treatment success and event-free survival [40]. Additional causes of non-adherence include the absence of symptoms, lack of disease insight, lack of confidence in the treatment, and complex therapeutic regimens [41]. Single-pill combination therapies are preferred with regard to low adherence associated with the intake of multiple single agents in long-term therapy for chronic diseases [42,43]. Patient adherence to prescribed medications also influences numerous clinical outcomes, including reductions in LDL cholesterol, systolic blood pressure, cardiovascular events, and re-hospitalisation [42,44,45]. These factors have a substantial impact on clinical prognosis.

In clinical practice, two legal provisions are of particular importance with respect to civil-law obligations: § 630a(2) of the German Civil Code (BGB) and § 76 IV SGB V [33,46]. These stipulate that treatment must be carried out according to current professional standards. In addition, a patient covered by statutory health insurance is entitled to ‘the duty of care in accordance with the provisions of civil contract law.’ If these legal requirements are not observed and the specialist standard of care is not met, a medical error is present.

In summary, adherence in the treatment of chronic diseases is of utmost importance. Measures that improve adherence include reducing the number of tablets, initiating low-dose combination therapy from the outset, avoiding changes in the shape and colour of tablets, and implementing single-pill strategies. Furthermore, single-pill strategies are superior to identical loose combinations in terms of adherence, achievement of target values, and reduction of cardiovascular events. They are also cost-effective and reduce the risk of drug interactions.

6. Hypertension – treatment in general practice – case studies and modern strategies with indapamide combinations

Hypertension represents a major global health challenge. Worldwide, approximately 1.28 billion adults have high blood pressure [47]. It is the deadliest disease and the leading cause of premature death, as it is associated with an increased risk of chronic kidney disease, heart failure, and coronary artery disease. From an economic perspective, around 10% of global healthcare spending is directly linked to hypertension [48,49]. However, only about a half of affected adults receive adequate treatment and achieve controlled blood pressure levels [47]. This is due in part to numerous challenges in blood pressure management, such as reduced treatment efficacy resulting from poor adherence, insufficient treatment intensity, therapy discontinuation caused by adverse effects, the need for individualised approaches in the presence of complex comorbidities, and resistant hypertension. Optimal communication between a physician and patient is essential for overcoming these challenges.

A meta-analysis involving 27 million patients demonstrated that treatment adherence in hypertension remains relatively low worldwide. Non-adherence to antihypertensive therapy was common globally (27–40%), particularly in low- and middle-income countries, with no improvement between 2010 and 2020 [50]. The new 2024 guidelines of the European Society of Cardiology define systolic blood pressure in the range of 130–139 mmHg as ‘elevated blood pressure.’ This classification serves as a tool for risk stratification and aims to identify individuals with high cardiovascular risk who may benefit from initiating a blood pressure-lowering medication [51]. The recommended treatment target is 120–129/70–79 mmHg. The exceptions include patients with symptomatic orthostatic hypotension, aged > 85 years, individuals with moderate to severe frailty, or those with a limited life expectancy (< 3 years) [51].

The first clinical case concerns a 52-year-old man, a non-smoker with obesity (BMI 34 kg/m²), recently diagnosed with hypertension (office BP 158/94 mmHg), who showed inverse dipping on 24-hour blood pressure monitoring, indicating increased cardiovascular risk. No evidence of organ damage or diabetes mellitus was present. Laboratory values were as follows: sodium (135 mmol/L), potassium (4.1 mmol/L), creatinine (1.0 mg/dL), renin/aldosterone ratio (22; normal 20–30). To confirm the diagnosis, a 24-hour ABPM was performed, showing an average BP of 149/91 mmHg, with higher nocturnal values (163/90 mmHg) compared to daytime values (143/91 mmHg). According to guideline-based therapy, a low-dose combination treatment was initiated [51]. The patient was started on valsartan/indapamide (160/1.5 mg per day). Initiating combination therapy at the outset of treatment is of prognostic importance and reduces the likelihood of cardiovascular events and premature death [52,53]. Four weeks after therapy initiation, 24-hour ABPM showed a favourable response with an average BP of 124/85 mmHg (nocturnal 126/85 mmHg; daytime 123/83 mmHg).

The second clinical case concerns a 74-year-old woman with mild overweight (BMI 26 kg/m²) and elevated cardiovascular risk due to tobacco use and hyperlipidemia. She already had target organ damage in the form of left ventricular hypertrophy and mild renal impairment with elevated creatinine levels. The patient had been treated with low-dose metoprolol succinate (23.75 mg), but experienced adverse effects such as fatigue, reduced performance, and diffuse hair loss. Blood pressure control under this regimen was insufficient (141/90 mmHg), which is critical considering her elevated cardiovascular risk. A 24-hour ABPM revealed an elevated mean BP (137/86 mmHg) with expected lower nocturnal values (127/78 mmHg) compared to daytime values (146/93 mmHg). Cardiovascular risk assessment showed a SCORE2-OP of 21% for a 10-year risk of a cardiovascular event [54]. The patient was switched to low-dose perindopril/indapamide (5/1.25 mg). Four weeks later, 24-hour ABPM showed values (122/76 mmHg) within the target range.

Early initiation of combination therapy increases the likelihood of achieving target blood pressure levels. The combination of indapamide with ACE inhibitors or angiotensin receptor blockers is particularly effective and well tolerated. Twenty-four-hour blood pressure monitoring is essential for therapy evaluation, and a single-pill combination demonstrably improves adherence and clinical outcomes.

7. Antihypertensive therapy – patient profiles

The first clinical case concerns a 57-year-old man with previously unremarkable medical history, no medication, non-smoker, high coffee consumption during the day, regular wine consumption in the evening, normal weight (BMI 23), good physical fitness, and regular endurance exercise. He is professionally very active and works as the managing director of a medium-sized company. For several months, he had been experiencing episodes of headache and neck pain accompanied by mild facial flushing. Blood pressure measurement at his general practitioner showed a value of 155/95 mmHg. Laboratory parameters were consistently unremarkable, with no electrolyte abnormalities and normal renal retention markers.

Before establishing the diagnosis, repeated office blood pressure measurements, 24-hour ambulatory blood pressure monitoring, and/or home blood pressure monitoring should be performed for the diagnostic work-up of arterial hypertension [5]. Different threshold values apply depending on the measurement method [6]. The patient therefore underwent 24-hour ambulatory blood pressure monitoring in addition to daily home measurements. Home readings fluctuated between 110/85 mmHg (in the evening) and 165/100 mmHg (during work). The 24-hour measurement showed an average blood pressure of 142/78 mmHg, with lower nocturnal values (110/60 mmHg) and higher daytime values (148/88 mmHg). Based on the data, the patient was diagnosed with grade 1 arterial hypertension. Considering the individual patient profile, therapy was initiated with a combination of candesartan and indapamide (16/2.5 mg), resulting in successful blood pressure reduction to 120–130/70–80 mmHg.

The second clinical case is a 49-year-old woman with type 2 diabetes mellitus, obesity (BMI 35), known arterial hypertension for seven years, reduced physical capacity due to bilateral knee osteoarthritis, and tobacco use. Family history revealed arterial hypertension in both parents, death of her father due to cerebral hemorrhage, and type 2 diabetes mellitus in her mother. Social history showed that she is married, has two children, and works as an administrative employee with predominantly sedentary activity.

Laboratory results were abnormal, showing elevated HbA1c (8.7%), elevated serum creatinine (1.3 mg/dL), reduced eGFR (50 mL/min/1.73 m²), and an elevated urine albumin-creatinine ratio (340 mg/g creatinine). These findings are consistent with chronic kidney disease stage 3a A3. The patient was already taking several medications (metformin 1000 mg, 1-0-1; sitagliptin 50 mg, 1-0-0; metoprolol 95 mg, 1-0-1; HCT 25 mg, 1-0-0; aspirin 100 mg, 1-0-0, and ibuprofen 600 mg as needed). Home blood pressure measurements were 150/90 mmHg with peaks up to 190/100 mmHg. The 24-hour blood pressure measurement revealed an average of 163/88 mmHg, with lower nocturnal values (135/85 mmHg) compared to daytime values (165/93 mmHg). Based on diagnostic findings, the patient was diagnosed with grade 2 arterial hypertension.

Her medication regimen was adjusted: metformin was reduced; metoprolol and HCT were discontinued due to metabolic concerns and were replaced; ibuprofen should be avoided due to chronic kidney disease, with metamizole considered as an alternative. Newly prescribed medications included valsartan 160 mg (1-0-0), dapagliflozin 10 mg (1-0-0) for nephroprotection, indapamide 1.5 mg (1-0-0) due to its metabolic neutrality, and amlodipine 5 mg (1-0-0). Sitagliptin/ metformin (50/850 mg) and valsartan/indapamide (160/1.5 mg) were each prescribed as single-pill combinations (SPC). The case remains ongoing, and these are the first steps in the patient’s treatment.

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Scientific reviewers

The experts listed below reviewed and approved the summaries corresponding to their presentations:

  1. Prof. Oliver Vonend (Section 1) – Director, Department of Nephrology and Hypertensiology, HELIOS Dr. Horst Schmidt Klinikum Wiesbaden, Von-Leyden-Str. 23, Wiesbaden, Germany
  2. Prof. Reinhold Kreutz (Section 2) – Director, Institute of Clinical Pharmacology and Toxicology, Chariteplatz 1, Berlin, Germany
  3. Prof. Roland Schmieder (Section 3) – Senior Physician, Department of Internal Medicine 4 – Nephrology and Hypertensiology, University Hospital Erlangen, Ulmenweg 18, Erlangen, Germany
  4. Dr. Borchard Pundt (Section 4) – General Practitioner, Dr. med. Borchard Pundt, Sophienstraße 3, Rastede, Germany
  5. Dr. Petra Sandow (Section 5) – General Practitioner, Praxis Dr. med. Barbara Sandow, Reichsstrasse 81, Berlin, Germany
  6. Prof. Joachim Weil (Section 6) – Department of Cardiology and Angiology (Medical Clinic II), Heart and Vascular Center (HGZ), Sana Kliniken Lübeck, Kronsforder Allee 71-72, Lübeck, Germany
  7. Prof. Jan Galle (Section 7) – Clinic Director, Department of Nephrology and Dialysis, Klinikum Lüdenscheid, Paulmannshöher Str. 14, Lüdenscheid, Germany

Published: April, 2026