Antihypertensive treatment of elderly hypertensive patients
The antihypertensive treatment for elderly patients should emphasize the attainment of systolic blood pressure, while excessive lowering of blood pressure should be avoided; on the premise of tolerating antihypertensive treatment, the blood pressure should be lowered gradually to reach the standard, and too rapid lowering of blood pressure should be avoided; for patients with good tolerance of blood pressure lowering, antihypertensive treatment should be actively carried out.
The blood pressure of elderly hypertensive patients should be lowered to below 150/90 mmHg, or to below 140/90 mmHg if tolerated. The target value for lowering blood pressure in older adults over 80 years of age is <150/90 mmHg. However, it is unclear whether there is a greater benefit to lowering hypertension in the elderly to less than 140/90 mmHg.
The ideal antihypertensive drug for the treatment of hypertension in the elderly should be
1, smooth and effective.
2. safe with few adverse effects.
3, easy to take and good compliance.
For the elderly with pure systolic hypertension, which is more problematic to deal with, reference is suggested.
When diastolic blood pressure (DBP) <60 mmHg, such as systolic blood pressure (SBP) <150 mmHg, then observe and no drugs can be used; if SBP 150 - 179 mmHg, use small doses of antihypertensive drugs cautiously.
If SBP ≥ 180 mmHg, use small-dose antihypertensive drugs. Small doses of diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor antagonists (ARB) can be used as antihypertensive drugs. In addition, close observation of changes in the condition is required during the administration of medication.
Antihypertensive management of hypertensive disorders in pregnancy
For hypertensive disorders in pregnancy, the first thing to clarify is the concept of gestational hypertension. Only hypertension that first appears after 20 weeks of gestation is called gestational hypertension, while hypertension that occurs before 20 weeks of gestation (including when not pregnant) is called gestational combined chronic hypertension. The pathogenesis of these two diseases is different, but the clinical management principles are similar. Generally, a more lenient blood pressure lowering principle is adopted, and the target level of blood pressure lowering can be kept below 150/90 mmHg.
In general, pregnant women with mildly elevated blood pressure (blood pressure <150/100 mmHg) do not need antihypertensive treatment for the time being and can be closely observed. When SBP ≥ 150 mmHg and/or DBP ≥ 100 mmHg or target organ damage occurs, drug therapy should be considered.
Regarding drug treatment, both domestic and international guidelines recommend methyldopa as the first choice, but this drug is not easy to find in China; the second recommendation is labetalol, which has a definite and stable antihypertensive effect. The second recommendation is labetalol, which has a definite and stable hypotensive effect. It is worth to be cautious in drug selection that ACEI or ARB must not be used, because these two drugs may suffocate the fetus. In addition, propranolol and atenolol may also asphyxiate the fetus and care must be taken in their use. Table 1 below shows the recommended medications for hypertension in pregnancy and when the medications should be started.
Antihypertensive management of hypertension with stroke
For hypertensive patients with stroke, if the stroke is recent, in principle, antihypertensive treatment should not be performed first, unless the patient’s blood pressure is very high, with SBP over 200 mmHg, and should be moderately controlled. after 1 week, aggressive conventional antihypertensive treatment is recommended to control blood pressure to 140/90 mmHg according to our current guidelines. diuretics, calcium channel blockers ( CCB), ACEI, ARB alone or in combination. It should be noted that beta-blockers are not used as a routine drug in principle for patients with hypertension with stroke.
In addition, for patients of advanced age, patients with severe bilateral carotid or intracranial artery stenosis, and patients with severe postural hypotension, cautious antihypertensive treatment is required. Antihypertensive drugs should be started in small doses, blood pressure levels and adverse reactions should be closely observed, and antihypertensive drugs and their doses should be adjusted according to patient tolerance. If obvious adverse reactions such as dizziness occur, the dose should be reduced or the antihypertensive drug should be discontinued, and the blood pressure should be controlled within the safe range (within 160/100 mmHg) as much as possible.
Antihypertensive treatment of hypertension with coronary artery disease
The first choice of medication for hypertension with stable coronary artery disease, unstable angina, non-ST-segment elevation and ST-segment elevation myocardial infarction are all 130/80 mmHg. The first choice of medication for these types of hypertension with coronary artery disease is β-blocker, and if the blood pressure does not reach the target, ACEI or ARB can be considered. This is the general procedure of medication for these diseases. Table 2 below shows the drug selection for hypertension with coronary artery disease for reference.
Antihypertensive management of hypertension with heart failure
Hypertension with heart failure is similar to the treatment of hypertension with coronary artery disease described above, in that the target level for lowering blood pressure is also 130/80 mmHg, and the drug of choice is also a β-blocker plus ACEI or ARB, which should be started at a very small dose and slowly increased until the maximum target dose required for anti-heart failure therapy is reached.
Antihypertensive management of hypertension with diabetes mellitus or chronic kidney disease
The target value for hypertension with diabetes or chronic kidney disease is also <130/80 mmHg. ACEI or ARB is the drug of choice for patients with hypertension with renal disease, especially proteinuria, and hypertension with diabetes, especially microalbuminuria, both of which have a stable antihypertensive effect and a beneficial effect on the kidney and glucose metabolism. If the antihypertensive effect of ACEI or ARB alone does not reach the standard, CCB can be combined with it, and diuretics can be added if the standard is not reached.