The goal of the treatment of elderly hypertension is to minimize the overall risk of cardiovascular disease, but there are differences in the recommendations of the previous domestic and foreign guidelines for blood pressure reduction goals for elderly hypertension. How should elderly hypertension be managed? At the 27th International Society of Hypertension Scientific Conference (ISH 2018), Professor Dang Aimin from Fuwai Hospital of Chinese Academy of Medical Sciences answered this.
Clinical characteristics of elderly hypertension
➤Mainly increased systolic blood pressure: Isolated systolic hypertension (ISH) accounts for 60% of hypertension
➤Big blood pressure fluctuations, "morning peak" phenomenon (early morning high blood pressure) increased, high blood pressure combined with orthostatic hypotension and postprandial hypotension increased
➤Abnormal circadian rhythm: non-dipper type or super-dipper type increased
➤White coat hypertension increased: pseudo-hypertension increased
➤High blood pressure in the elderly often coexists with multiple diseases, such as cerebrovascular disease (cerebral hemorrhage, ischemic stroke, transient ischemic attack), heart disease (history of myocardial infarction, angina pectoris, history of coronary artery revascularization, Chronic heart failure) and kidney disease (diabetic nephropathy, impaired renal function), etc.
Diagnosis and treatment process of elderly hypertension
1. Diagnosis and treatment process of elderly ISH
Figure 1 Diagnosis and treatment process of elderly ISH
2. Diagnosis and treatment process of early morning hypertension
Figure 2 The diagnosis and treatment process of early morning hypertension
3. Diagnosis and treatment process of elderly orthostatic blood pressure variation
Figure 3 Diagnosis and treatment process of elderly orthostatic blood pressure variation
4. The diagnosis and treatment process of postprandial hypotension in the elderly
Figure 4 Diagnosis and treatment process of postprandial hypotension in the elderly
5. Diagnosis and treatment process of elderly refractory hypertension
Figure 5 Diagnosis and treatment process of refractory hypertension in the elderly
6. Principles of coexistence of hypertension and multiple diseases in the elderly
Combined with heart failure: If there is no contraindication, ACEI/ARB, β-blockers and diuretics can be used . Try to avoid the use of CCB. For those who are difficult to control blood pressure, choose the dihydropyridine CCB (felodipine or amlodipine) with higher vascular selectivity.
With coronary heart disease: β-blockers and ACEI should be the first choice , if there are no contraindications, should be used early; for elderly coronary heart disease with difficult blood pressure control, or complicated with vasospasm angina, CCB plus nitrate can be used;
Combined with atrial fibrillation: Meta-analysis shows that ACEI/ARB can significantly reduce the recurrence of atrial fibrillation in patients with atrial fibrillation and heart failure, which is the first choice; for persistent rapid atrial fibrillation, β-blockers or non-dihydropyridine CCB can be used to control ventricular rate .
Complicated with stroke: the blood pressure of acute stroke should be steady. For elderly hypertensive patients with chronic cerebrovascular disease, the key is to maintain cerebral blood flow; blood pressure target is 140/90 mmHg; long-acting CCB, ACEI/ARB, and diuresis can be preferred agents and so on.
Concomitant diabetes: The use of ACEI/ARB to lower blood pressure can improve glucose metabolism, endothelial function, reduce urine microalbumin, and delay the occurrence of diabetic nephropathy. Especially ARB has better kidney protection, so it should be preferred.
With renal insufficiency: ACEI/ARB can reduce urine protein and reduce the occurrence of end-stage renal disease. It can be the first choice, but blood creatinine and electrolyte levels should be monitored; when the antihypertensive effect is not up to standard, long-acting dihydropyridine CCB can be added , There is a tendency for fluid retention, can be combined with a small dose of loop diuretics .
7. Antihypertensive treatment for frail elderly
There is no evidence for the benefit of antihypertensive therapy in elderly patients with grade 1 hypertension (systolic blood pressure 140-150 mmHg). Therefore, it is recommended that systolic blood pressure ≥160 mmHg is the threshold for starting antihypertensive therapy.
The goal of systolic blood pressure control for elderly, frail, elderly patients is less than 150 mmHg, but not less than 130 mmHg; when the blood pressure is lower than this value, the dose of antihypertensive drugs should be reduced or even stopped.
Pay attention to the application of family self-tested blood pressure and ambulatory blood pressure monitoring in elderly patients.
Calcium channel blockers, thiazide diuretics and angiotensin converting enzyme inhibitors should be the preferred antihypertensive drugs for elderly patients.
summary
Professor Dang Aimin finally concluded that achieving blood pressure reduction is the key to reducing cardiovascular events in elderly hypertensive patients. In general, the blood pressure of the elderly reaches the standard <140/90 mmHg; "young" elderly patients and those in good physical condition can be reduced to <130/80 mmHg. To strengthen blood pressure management, attention should be paid to monitoring adverse reactions such as kidney damage.
The blood pressure pattern and clinical conditions of elderly hypertensive patients are complex and changeable. Individualized and comprehensive management should be carried out on the premise of following the guidelines.
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