The treatment of hypertension emphasizes individualization and the selection of drug therapy is tailored to the individual, which is especially important for elderly patients with hypertension. In the face of elderly hypertensive patients, it is necessary to “look ahead” according to the length of the disease, the level of blood pressure, the degree of target organ damage, the type of cardiovascular risk factors, the previous response to antihypertensive drugs, the presence of other concomitant diseases and other different situations, but also according to the different clinical types of their comorbidities, purposefully choose the appropriate antihypertensive drug therapy The program, to avoid the blood pressure drop too much and “after”.
1, according to the classification of hypertension selection of drugs
(1) Grade I hypertension
The drug metabolism of the elderly is also different from that of young people, so the selection of drugs for hypertension in the elderly should take drugs that have mild effects, do not cause standing hypotension and have no central side effects. However, it is important to emphasize that the use of reserpine is not recommended to avoid depression.
(2) Class II hypertensive disease
Most patients apply two antihypertensive drugs to achieve good antihypertensive effect. However, it should be noted that the combined application of drugs with different mechanisms of action, when the dose of a single drug can be reduced to prevent excessive antihypertensive magnitude and adverse reactions, and can be changed to maintenance amount when the blood pressure is reduced to the desired level.
(3) Class III hypertension
More than 2 kinds of antihypertensive drugs can be used, and more than 80% of patients can obtain satisfactory results. For those who are not effective, the dose can be increased or changed, or a third antihypertensive drug can be added. In general, dihydropyridine CCB and ACEI or angiotensin receptor antagonist are mostly used, and dihydropyridine CCB and β-blocker can also be used, and diuretics can be added if necessary.
2, according to the combination of risk factors to choose the medication
Clinical research data show that when hypertension is combined with the following risk factors, the selection of antihypertensive drugs should be different according to the risk factors.
(1) Hyperlipidemia.
ACEI, ARB and CCB, which have no effect on lipid metabolism and can even reduce it mildly, can be used. β-blockers can increase triglycerides and LDL and reduce HDL; α-receptor antagonists can lower lipids and can be used.
Thiazides and tab diuretics can be used for a short period of time; methyldopa and reserpine can raise triglycerides and lower HDL, so they should not be used.
(2) Hyperglycemia or diabetes mellitus.
The preferred antihypertensive drug is ARB or ACEI because it not only has no adverse effect on glucose metabolism, but also can reduce insulin resistance, reverse left ventricular hypertrophy and slow down the progression of diabetic nephropathy.
Diuretics and beta-blockers are not suitable for high-dose application because they can reduce insulin sensitivity and aggravate diabetes, and beta-blockers can also mask or prolong the recovery from hypoglycemia.
(3) Hyperinsulinemia.
The first choice is ARB or ACEI. The literature reports that the alpha-blocker prazosin can also increase insulin sensitivity, so it can also be used.
(4) Hyperuricemia.
The ACEI antihypertensive drug coxsartan potassium (Coxua) can increase uric acid excretion, decrease blood uric acid concentration and relieve gout symptoms, so it can be preferred.
All diuretics can increase uric acid and induce acute gout attacks. Therefore, diuretics should be avoided in the treatment of patients with hypertension complicated by gout.
3.Select medication according to the type of comorbidity
When hypertension develops to a certain stage, signs and symptoms of damage to the heart, brain, kidneys and other organs will appear in varying degrees, producing various hypertensive complications in varying degrees. Individualized therapy is to select drugs that do not affect the function of these organs and improve their function to treat hypertension according to the type and severity of the complications in patients with hypertension.
(1) Combined cerebrovascular disease.
Ischemic stroke should not be substantially lowered unless the diastolic blood pressure is ≥105 mmHg, otherwise excessive lowering of blood pressure will significantly reduce cerebral blood flow. Note that the choice of antihypertensive drugs should be smooth in action and free of postural hypotensive adverse effects. Because alpha-blockers can occur first-dose reactions and postural hypotension, they should not be used. CCB is generally used, but ACEI is also available in some patients.
Hemorrhagic stroke has a significant increase in blood pressure and should be treated with urgent hypotension. This type of patient often has increased intracranial pressure, and excessive lowering of blood pressure can affect cerebral perfusion. Therefore, in the acute phase of cerebral hemorrhage, antihypertensive drugs should be considered only if the systolic blood pressure is ≥210 mmHg and the diastolic blood pressure is ≥110 mmHg. The first choice is β-blocker, CCB or ACEI, but avoid excessive drop in blood pressure, generally reduce the blood pressure before the drug 20% is appropriate.
(2) Combined coronary heart disease.
About 30% of hypertensive patients are accompanied by asymptomatic coronary artery disease. For patients with concomitant coronary artery disease, do not lower blood pressure too quickly and excessively to avoid insufficient coronary blood supply and induce acute myocardial infarction and its serious complications, diastolic blood pressure down to about 80 mmHg is appropriate. The use of β-blockers or long-acting CCB or ACEI in patients with angina pectoris can reduce the symptoms of many patients with angina pectoris and myocardial infarction after controlling blood pressure, and for those with large myocardial infarction, the application of ACEI has the effect of preventing progressive heart enlargement, avoiding the use of vasodilators that accelerate the heart rate.
(3) Combined heart failure.
Anti-hypertensive treatment can improve cardiac function and prevent heart failure. ACEI, diuretics and alpha-blockers are generally used for this type. Generally speaking, high doses of beta-blockers with negative inotropic effects are not recommended. In addition, ACEI may reduce death due to progressive heart failure.
(4) Complicated left ventricular hypertrophy.
Left ventricular hypertrophy, which reduces coronary reserve and is an important independent risk factor for myocardial infarction, heart failure, arrhythmias and sudden death, is a strong indication for hypertension treatment in about 50% of elderly people with hypertension. Reversal of left ventricular hypertrophy is also an objective indicator of effective treatment of hypertension.
Lowering blood pressure not only prevents the occurrence of left ventricular hypertrophy, but also reverses it and reduces the incidence of acute cardiovascular events. Currently, the recommended drugs effective in preventing left ventricular hypertrophy are CCB, beta-blockers, angiotensin receptor antagonists and ACEI.
(5) Combined renal impairment.
Elevated blood creatinine is the most important risk indicator of renal impairment, and tachyphylaxis and other collaterals such as diuretics and angiotensin receptor antagonists should be preferred in the treatment of this type of elderly hypertension. Drugs that have no effect on renal blood flow or increase renal blood flow, such as ACEI, angiotensin receptor antagonists, methyldopa and long-pressin, are appropriate.
Thiazides and other diuretics can reduce renal tubular filtration rate, renal blood flow and uric acid excretion, so they can worsen the damaged renal function, so they should not be used; guanethidine and colistin can reduce renal blood flow while causing a drop in blood pressure, so they should not be taken by patients with renal insufficiency.
ACEI and angiotensin receptor antagonists are effective in patients with renal insufficiency, but in patients with bilateral renal artery stenosis hypertension and previous renal disease, ACEI can induce acute renal failure, so it is prohibited.
4, special clinical type of elderly hypertension
In elderly patients with hypertension, a large proportion of them are simple systolic hypertension, which is characterized clinically by a marked increase in systolic blood pressure, while diastolic blood pressure is normal or at a lower level, manifested by an increase in pulse pressure difference. This type of elderly hypertensive patients should use drugs that can mainly reduce systolic blood pressure, but have little effect on diastolic blood pressure.
Evidence-based medical data show that CCB, ACEI, ARB, diuretics and β-blockers are all antihypertensive drugs that improve arterial stiffness and increase arterial elasticity. Among them, CCB is more effective than ACEI, ARB and β-blockers. Nitrates also have the effect of improving arterial elasticity and are effective in reducing the pulse pressure difference.