老年高血压病(双语).ppt

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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，工 业化国家较

2、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社会因素：环境、膳食、精神、吸烟、肥

3、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，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

4、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 和和 DBP对年龄校正后的对年龄校正后的CAD死亡死亡率的作用：率的作用：MRFIT90-9990-9980-8980-8975-7975-7970-7470-747070120120120-120-139139140-140-159159160+160+收缩压收缩压收缩压收缩压(mm (mm

5、Hg)Hg)20.610.311.88.88.59.211.812.612.813.924.625.325.224.916.923.831.025.834.743.838.180.637.448.3每每每每10,00010,000病人年病人年病人年病人年CADCAD死亡率死亡率死亡率死亡率100100舒张压（舒张压（舒张压（舒张压（mmHgmmHg）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

6、症状性高血压重要器官功能状态评估 鉴别诊断老年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

8、疾病可能有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,speeding i

9、t 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 hypertention or hig

10、h 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 stroke.The hig

11、h 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 percent of cases,h

12、ypertention 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 risk factors have been ass

13、ociated 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 blood pressure is persistentl

14、y 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 arterioles represents a reaction to se

15、verely 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 and arterioles,and even of some medium siz

16、ed arteries,such as the arcuate of the kidney.The media of the vessels becomegreatly 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 progressive narrowing of the lumina of these small vessels.

17、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 controlled.What are the reasons for this sad state of affa

18、irs?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.Therealso is a highly prevalent notion that hypertention does not require continuous serveillance or control.Patients with hy

19、pertention 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 wordsHypertention 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