According to the national population health survey organized by the Ministry of Health in recent years, the prevalence of hypertension in people aged 60 years and above in China is 49%, while the awareness rate, treatment rate and control rate are low, and there are many complications of hypertension in the elderly, and subclinical and clinical target organ damage is more likely to occur if the blood pressure is not well controlled for a long time. Through the study of recent international hypertension guidelines and Chinese hypertension prevention and treatment guidelines 2010 and a large number of recent clinical meta-analyses, new thoughts and concerns about hypertension in the elderly have been raised: Huangfu Weizhong, Department of Geriatrics, Affiliated Hospital of Inner Mongolia Medical University
I. Clinical thinking of geriatric hypertension
1. Clinical characteristics of geriatric hypertension: (1) increased systolic blood pressure and increased pulse pressure; (2) high blood pressure fluctuation, increased blood pressure “morning peak” phenomenon, prone to postural hypotension; (3) blood pressure rhythm is “non-spoon type” or “super-spoon type”; (4) blood pressure rhythm is “non-spoon type” or “super-spoon type”; (5) blood pressure rhythm is “non-spoon type” or “super-spoon type”. (4) more white coat hypertension; (5) more pseudohypertension; (6) often coexist with multiple diseases and complications [1].
2. Treatment goals for geriatric hypertension: blood pressure in elderly hypertensive patients should be reduced to below 150/90 mmHg, or to below 140/90 mmHg if tolerated [2]. For elderly people over 80 years of age, the goal of lowering blood pressure is below 150/90 to prevent the occurrence of hypotension. Reviewing the 2011 ACCF/AHA guidelines: blood pressure in elderly hypertensive patients under 70 years of age should be lowered to less than 150/90 mmHg; blood pressure in elderly with combined coronary artery disease, diabetes, and chronic kidney disease should be less than 130/80 mmHg; lowered mean systolic blood pressure in elderly aged 70-79 years is less than 135 mmHg; lowered mean systolic blood pressure in elderly aged 80 years and older is less than 140 mmHg [1]. Individualized treatment strategies should be adopted for patients over 80 years of age [3]. , when increasing the drug type and dose, patients should be closely monitored for drug administration. The patients should also be observed for adverse effects [4].
3. non-pharmacological treatment of geriatric hypertension Because of the low metabolic clearance of drugs and the many side effects of medication in elderly patients, non-pharmacological treatment should be given high priority in elderly patients with hypertension. If combined with diabetes mellitus, calorie restriction should be done to keep weight control at the appropriate level, adjust the dietary structure, emphasize low salt and low fat diet, limit sodium to less than 5 g per day, and should control the total calorie intake, while paying attention to potassium and calcium supplementation. The intake of protein should be increased appropriately, especially the intake of milk, beans, sea fish, seaweed food and fiber food, weight reduction appropriately, advocating regular and appropriate exercise, limiting alcohol consumption, advocating smoking cessation, reducing mental stress, and regular health check-ups should be conducted, with special attention to the early detection of subclinical target organ damage related to prevention and treatment.
4. The ideal antihypertensive drug for geriatric hypertension meets the following conditions: (1) smooth and effective; (2) safe and with few adverse side effects; (3) easy to take and good compliance [1].
5. Diagnostic and treatment strategies for geriatric hypertension: (1) start with small doses and gradually lower blood pressure; (2) select drugs carefully and observe closely; (3) combine drugs and gradually reach the target; (4) monitor postural blood pressure and avoid hypotension; (5) individualize treatment according to individual; (6) pay attention to home self-measurement of blood pressure and 24-hour blood pressure monitoring.
6. Commonly used drugs for geriatric hypertension: (1) Long-acting dihydropyridine calcium antagonists as the basic antihypertensive treatment for geriatric hypertension, such as amlodipine (Loxodil), can effectively reduce systolic and diastolic blood pressure. In recent years, a new generation of calcium antagonists has emerged and is used in the treatment of hypertension, such as nifedipine (Baysin) and felodipine (Boeotin). These drugs have long-lasting effects and can maintain the antihypertensive effect for 24 hours. These advantages are in line with the tolerance characteristics of the elderly, so they are suitable for the treatment of hypertension in the elderly. (2) Thiazide diuretics, such as dihydroketuria, have good antihypertensive effect and can be used, but the dose should be small, generally 6.25-12.5mg, which can benefit the patient, and electrolytes and renal function should be monitored. (3) Converting enzyme inhibitors and ARB, converting enzyme inhibitors such as mercaptomethoproline, enalapril and new generation converting enzyme inhibitors, such as Yashida, Lortin, etc., and ARB such as Mecasol, Coxswain, Ambronol, Dextran, etc., which have better efficacy on elderly hypertension and less side effects, can also be used.
II. Concerned about geriatric hypertension
1. Focus on the prevention and treatment of simple systolic hypertension in the elderly
(1) diuretics are preferred for antihypertensive drugs; (2) avoid low diastolic blood pressure in antihypertensive treatment; (3) use 24-hour blood pressure monitoring to evaluate the efficacy and adopt a long-term strategy to achieve the target.
2) Pay attention to the prevention and treatment of elderly hypertension combined with carotid artery stenosis
Unilateral carotid stenosis greater than 70% systolic blood pressure lowering target is 130-149mmHg; bilateral carotid stenosis greater than 70% systolic blood pressure lowering target is 150-169mmHg.
3. Pay attention to the prevention and treatment of morning peak hypertension in the elderly. Increase long-acting hypotensive drugs at night and pay attention to monitoring blood pressure at night and the next morning.
4. Pay attention to the prevention and treatment of postural hypotension Emphasize the measurement of postural hypotension, careful antihypertensive treatment, start with small doses of antihypertensive drugs, and adjust the treatment plan according to blood pressure.
The experts discussed that the general goal of blood pressure lowering for diabetic patients is less than 130/80mmHg; the goal of blood pressure lowering for elderly patients or patients with severe coronary artery disease is 140/90mmHg. It is protective. If the antihypertensive effect is poor, the combination of CCB is the best option [2].
The target blood pressure can be controlled below 130/80 mmHg. If the patient has microproteinuria, blood pressure is at the high limit to start treatment and powerfully reverse renal damage. If renal function is significantly impaired such as blood creatinine greater than 265.2ummol/l, or glomerular rate less than 30ml/(min.1.73m2) or with massive proteinuria, calcium antagonists of the dihydropyridine class are used first. For urine protein less than 1g/l, the blood pressure target is below 130/80mmHg; for urine protein greater than 1g/l, the blood pressure target is below 125/75mmHg [3] to prevent the occurrence of nephropathy and or delay the progression of nephropathy.
7. pay attention to the prevention and treatment of acute stroke combined with hypertension in the elderly. blood pressure should be controlled to less than 180/110 mmHg before thrombolysis in acute ischemic stroke. patients with elevated blood pressure within 24 h of acute ischemic stroke onset should be treated with caution unless systolic blood pressure is greater than or equal to 180 mmHg or diastolic blood pressure is greater than 100 mmHg or accompanied by severe cardiac insufficiency, aortic coarctation, hypertensive encephalopathy. They are generally left untreated. A reasonable goal for lowering blood pressure is a 15% reduction within 24 hours.
In addition, the following points should be taken into account in the treatment of hypertension in the elderly.
1. Elderly hypertension medication must consider whether the combined hypertensive organ damage, generally start with a small dose, generally can be controlled at about 1/2 to 2/3 of the conventional amount, so as not to cause drug accumulation and cause toxic side effects.
2. In elderly hypertensive patients, the degree of subclinical target organ damage is fully assessed before initiating drug therapy [3]. Microurinary protein, glomerular filtration rate, and electrocardiogram are considered as routine tests to screen for subclinical target organ damage in elderly hypertension, and cardiac and vascular ultrasound are widely used in patient risk assessment [4]. Therefore, sudden blood pressure drops and large fluctuations in blood pressure should be avoided, and concern about the adverse effects of blood pressure fluctuations should be tolerated by the patient as a therapeutic goal, and home self-measurement of blood pressure, regular office blood pressure measurement, and ambulatory blood pressure monitoring should be performed. Avoid insufficient blood supply to the heart, brain, kidneys and other important organs due to too low a drop in blood pressure.
3. Treatment of elderly hypertension blood pressure to prevent blood pressure from falling too fast or too low, prevent the occurrence of postural hypotension, and prevent the emergence of cardiovascular events.
4. If diuretics are applied, small doses of thiazide diuretics are preferred, and large doses of diuretics are avoided to avoid acid-base electrolyte disturbances.
5. Elderly patients have poor myocardial contractility and sinus node function, so try to avoid antihypertensive drugs that have the ability to inhibit myocardial contraction and affect the cardiac conduction system [6].
6. Pay attention to the adverse effects of antihypertensive brought by salt diet, because after salt restriction, elderly people’s taste changes instead of affecting their appetite and endangering their health [6].
7. Encourage elderly patients with hypertension to do some appropriate aerobic exercise, which is quite beneficial to improve the quality of life
8. In the treatment of hypertension in the elderly, the elderly are most vulnerable to emotional fluctuations, and it is an important factor affecting the treatment. Older people should actively participate in social activities, and should deal with problems in a calm state of mind, and family members should be asked to strengthen communication with elderly patients to explain the benefits brought by taking medication regularly.
Therefore, in the treatment of elderly hypertension, give the elderly humanistic care, should minimize or eliminate factors that cause blood pressure fluctuations, ensure that patients get enough sleep, prevent mood swings, and create and establish a harmonious family and social environment suitable for the elderly, establish harmonious interpersonal relationships, and appropriately participate in some social activities and aerobic exercises such as tai chi and aerobics within their reach, which is not only beneficial to This is not only beneficial to the treatment of hypertension, but also can make the later years of life more fulfilling and beneficial to physical and mental health.
In conclusion, the treatment of hypertension in the elderly pays more attention to individualized medication [7] and combination therapy in the treatment strategy, long-term attainment is given priority, attention is paid to individualized disease status [8], and the attention of the majority of clinicians to hypertension in the elderly is improved, so that the hypertension in the elderly can be strongly controlled and more elderly hypertensive patients can benefit.
Reference.
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