1、老 年 高 血 压,田 旻,高血压(hypertension)： 是指体循环动脉压增高，可使收缩压或舒张压高于正常或两者均高。,原发性高血压（essential hypertension）或高血压病（hypertensive disease）：是一种以血压升高为主要表现而病因尚未明确的独立疾病。 继发性高血压（secondary hypertension）或症状性高血压（symptomatic hypertension），病因明确，是某种疾病的临床表现之一。 单纯性收缩期高血压（isolated systolic hypertension）多见于老年人。,流行病学：,1.地域差别：欧美较亚非高
2、，工 业化国家较发展中国家高。国内，北方地区较南方高。 2.患病率逐年增高：国外：1978 50% 1997 60% 国内：1959 739204人 5.11%1979 4012128 7.73%1991 全国平均 11.88%2001 上海老年人 城市 33.6% 农村 20.09%,3.知晓率、治疗率、控制率低 25%、 12.5%、3%。 4.老年收缩期高血压临床试验总结报告 欧洲老年人高血压专题研究委员会瑞士老年人高血压试验（stop）老年收缩期高血压研究等指出：抗老年高血压治疗，特别是对老年收缩期高血压的治疗均可降低脑中风及心脏事件的发生率。,病因,老年期前高血压延续而来 遗传因素
3、社会因素：环境、膳食、精神、吸烟、肥胖、过量饮酒。 动脉结构改变,发病机制,精神神经作用（psychogenic theory，neurogenic theory） 肾素血管紧张素醛固酮系统平衡失调（renal theory）,3.胰岛素抵抗（insulin resistance）： 高胰岛素血症可能 改变细胞膜NaKATP酶活性 刺激交感神经的活性 增加肾脏对水钠的重吸收 提高血压对盐的敏感性 刺激生长因子及内皮素分泌,4.其他 摄钠过多 前列腺素A、E合成不足 ACE促进激肽降解 加压素、内皮素等肽类物质也引起注意,临床表现 一、高血压的一般表现,脑部表现：头痛、头晕、头胀、注意力不集中等
4、，可并发中风。 心脏表现：心功代偿期 ， 心悸，心功失代偿期，左心衰。 肾脏表现：肾功代偿期，蛋白尿，肾功失代偿期，肾衰。,临床表现 二、特殊表现,单纯收缩期高血压多见 高血压的波动性大 体位性低血压倾向多见 假性高血压表现 老年高血压的靶器官损害表现,心脏改变：心肌肥厚 ，舒缩功能受损，左心衰 肾功能的改变：蛋白尿，BUN、肌酐生高，肾衰 体液成分的改变：周围血浆肾素活性降低，受体反应性减弱,SBP 和 DBP对年龄校正后的CAD死亡率的作用：MRFIT,90-99,80-89,75-79,70-74,70,120,120-139,140-159,160+,收缩压 (mm Hg),20.6,
5、10.3,11.8,8.8,8.5,9.2,11.8,12.6,12.8,13.9,24.6,25.3,25.2,24.9,16.9,23.8,31.0,25.8,34.7,43.8,38.1,80.6,37.4,48.3,每10,000病人年CAD死亡率,100,舒张压（mmHg）,实验室检查,目的：帮助原发行高血压的诊断、分级，了解靶器官的功能状态及心血管危险因素，指导正确选择药物。 项目： 常规检查项目包括血常规、尿常规、肾功、胸部x线、心电图、超声心动图、动态心电图、眼底检查。 其他： 血脂分析、血糖。,诊断,确定血压高与血压分级 除外症状性高血压 重要器官功能状态评估,鉴别诊断,老年
6、人血压升高有特定的原因 假性高血压 (Pseudo-hypertension) 白大衣高血压（white coat hypertension） 体位性低血压,治疗,目的：减少心、脑、肾等靶器官损害及其所致死亡的危险。 目标：使血压保持在正常或理想水平 140/90 对策 ：非药物治疗和/或药物治疗,非药物治疗,限制钠盐 适量运动 调整饮食结构 戒烟 节制饮酒 适量饮茶,药物治疗,用药原则： 从小剂量开始 如某种药物疗效差或耐受性差，更换另一种药物 联合用药 使用长效制剂 对高危、很高危的患者，尽快给药 中危、低危患者控制其他危险因素，改变生活方式,抗高血压药物：利尿剂 收缩期高血压、心衰、肥胖
7、、早期肾衰。低钾、IGT、室早。受体阻滞剂伴冠心病（CAD）。呼吸道阻塞性疾病、周围血管病慎用。转换酶抑制剂（ACEI）伴糖尿病、高尿血症、或心衰。干咳，肾衰慎用。,钙离子拮抗剂伴冠心病、糖尿病、痛风或有代谢紊乱，特别适于老年人ISH。血管紧张素II受体拮抗剂（angiotension II receptor antagonist）对心衰有特殊价值，无干咳。受体阻滞剂：易产生体位性低血压在老年高血压治疗中已不常用。,老年难治性高血压的治疗：原因：有继发因素同时服用升高血压的药物有假性高血压有进行性肾功不全不坚持治疗,合并其他危险因素和疾病时降压药物的选择：,对合并疾病可能友益,对合并疾病可能有
8、害,预防,改变生活方式 加强对健康保健价值的认识 随访与教育,Hypertention,Hypertention is one of the most ubiquitous diseases.The pressure at which blood is pumped through the arteries is kept level by built-in regulators, such as the carotid sinus in the neck. Body hormones also play a role in regulating blood pressure, speedin
9、g it up in emergencies when the body needs added energy and nourishment, slowing it down at night during sleep.,When regulating mechanisms go awry for some reason, the blood pressure becomes much greater then normal, putting stress and strain on the arteries. This is the condition called hypertentio
10、n or high blood pressure(HBP). Unfortunately, since you can not feel a change in your blood pressure the way you can in your heartbeat, it is possible to have high blood pressure for years without knowing it. Despite its silence, HBP is not harmless. Untreated HBP can lead to both heart disease and
11、stroke.,The high prevalence of hypertention in our elderly population makes it a disease of major importance. Through our vast facities for delivery of quality medicine care, we can make an important contribution to the prevention of the major complication of hypertention in our country.,In 5 to 10
12、percent of cases, hypertention is the result of some organic malfunction, usually in the kidneys or the adrenal glands. This is called secondary hypertention, and can often be cured by surgery. The remainder are idiopathic, called essential hypertention. Though the mechanism is not understood, many
13、risk factors have been associated with this type of HBP:,Inherited susceptibility.Overweight.Stress.High salt intake.Smoking.Insulin resistance.,The characteristic lesions of hypertention are found in the arterioles, and type of lesion varies with the severity of the hypertention. When the diastolic
14、 blood pressure is persistently elevated at levels of 130 to 150 mm-hg, or higher, fibrinoid necrosis of the media of arterioles is seen in the kidney, spleen, pancreas, and brain, including the retinal vessel. Fibrinoid necrosis may be caused by prolonged vasospasm.,While fibrinoid necrosis of the
15、arterioles represents a reaction to severely elevated blood pressure, the response to a moderate but long sustained increase in blood pressure, the response to a moderate but long sustained increase in blood pressure (diastolic 95 to 130) is hyalinosis and hyperplasia of the media of small arteries
16、and arterioles, and even of some medium sized arteries, such as the arcuate of the kidney. The media of the vessels become,greatly thickened (hypertrophy) by hyperplasia of the smooth muscle. An increase in hyaline also can be detected by special stains.The thickening of the wall leads to progressiv
17、e narrowing of the lumina of these small vessels.,A number of surveys have indicated that only about 45 percent of the people with hypertention know that they have hypertention. Of this percentage, only one third of them were being adequately treated, that is, their blood pressure is being well cont
18、rolled.,What are the reasons for this sad state of affairs? The major reason is that the bulk of patients have remained unconvinced that the treatment of hypertention justified the associated side effects, expense, and inconvenience. There,also is a highly prevalent notion that hypertention does not
19、 require continuous serveillance or control. Patients with hypertention feel well until major complications develop. It is difficult to convince them that they need to take daily medications which may , for a time at least, make them feel less well than they were before.,Key words Hypertention 高血压病 Artery 动脉 Arteriole 小动脉 Hormone 激素 Malfunction 功能失调 Insulin resistance 胰岛素抵抗 Fibrinoid necrosis 纤维素样坏死 Vasospasm 血管痉挛 Hyaline 透明的 Hyperplasia 肥厚,
