1、HYPERTENSIONKKI IL LL LER RI IS SE ENNT TL LOO WW200140160120180204060801000A softer blowing soundA sharp thump A softer thump A blowing or whooshing soundK1K2K3K4K5135/85 Ambulatory Pressure 140/90 Clinic PressureSustained HypertensionWhite Coat HypertensionTrue NormotensionMasked Hypertension 160%
2、of MenSystolic pressure mmHg CHARACTERISTICS OF HYPERTENSION IN THE ELDERLYIncreased Systolic blood pressure and pulse pressure Left ventricular mass and wall thickness Arterial stiffness Calculated total peripheral resistanceDecreased Cardiac output and heart rate Renal blood flow,plasma renin acti
3、vity,and angiotensin II levels Arterial compliance and blood volume Diastolic blood pressureBlack H.JCH 2003;5:12Bentley Dw,Izzo JL.J Am Geriatr Soc.1982;30:352-359.Stroke VolumeAortaResistance ArteriolesPressure(Flow)Young ArterySystoleDiastoleElastic VesselArteriosclerotic ArteryStiff VesselSystol
4、eDiastoleArterial Wall Compliance and Pulse Pressure WaveLifestyle ModificationsBar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age in normotensive open bars and hypertensive color bars subjects.420-2-4-6-8-10-12-14-16-18-2020-3031-4041-50AGE
5、yrsWeinberger M.Hypertens 1991;18:6951-6060Change in Mean Arterial Blood PressureWeinberger M.Hypertens 1991;18:69Effect of 30 minute walk 3 days a weekAge 70-79SystolicDiastolicExercise Group Baseline 156 10 mm Hg 86 8 mm Hg 3 months151 15 mm Hg 80 6 mm HgControl Group Baseline153 7 mm Hg 85 8 mm H
6、g 3 months156 10 mm Hg 85 6 mm HgConone et al.Med Scl in Sports and Exercise.1991 Algorithm for Management of the Elderly-Primarily Systolic Hypertension1)Lifestyle changesLow dose diuretic(12.5 mg HCTZ)CCB B-Blocker ACE or ARB3)Stop,Look&Listen before dosages Let the Baroreceptors reset4)Rx until g
7、oal achieved+Trials Examining Treatment of Hypertension in the ElderlyEWPHEMRC-ElderlySHEPSTOP-HSyst-ChinaSyst-Eur(N=840)(N=4396)(N=4736)(N=1627)(N=2394)(N=4695)Stroke reduction,%-36-25-33-47-38-42CAD change,%-20-19-27-13+6-26CHF reduction,%-22Not stated-55-51-58-27%of Patients receiving3552(b-block
8、er)446711-2626-36 combination drug therapy 38(diuretic)Prisant,Moser M.Arch Int Med 2000;160:284Major Clinical Trials Showing Benefit of Treating Isolated Systolic HypertensionSHEPSyst-EurSyst-China(n=4736)(n=4695)(n=2394)Baseline160-219/160-219/160-219/SBP/DBP(mm Hg)909595BP reduction:27/923/720/5S
9、BP/DBP(mm Hg)Drug therapyChlorthalidoneNitrendipineNitrendipineAtenololEnalaprilCaptoprilHCTZHCTZOutcomes(%)Stroke334238CAD273027CHF5529All CVR disease323125Journal of Clinical Hypertension Vol II,No.5,page 336,September/October 2000.Independent Predictors of Using Antihypertensives Medications in 2
10、000VariableAdjusted OR(95%CI)of Using AntihypertensivesComorbid conditions Asthma/COPD0.43(0.40-0.47)Depression0.50(0.45-0.55)GI disorders0.59(0.54-0.64)Osteoarthritis0.63(0.59-0.67)Cardiovascular conditions Coronary artery disease1.31(1.23-1.40)Cerebrovascular disease1.03(.97-1.10)Congestive heart
11、failure1.05(0.99-1.11)Diabetes1.16(1.10-1.22)Wang PS et al.Hypertension 2005;46:273-279Barriers to Optimal Control of HypertensionInaccurate measurement of blood pressure(BP)Focusing on diastolic BP rather than systolic BP goalFailure to consider absolute global riskFailure to advocate lifestyle mod
12、ificationsFailure to use polypharmacyFailure to use effective drug combinationsFailure to titrate doses upwardFear of reaching excessively low diastolic BPThe patient with truly resistant hypertensionBehavioral barriersFranklin S.JCH 2006;8:524 Blood Pressure in SHEP and Syst-Eur(mm Hg)SHEPSyst-EurE
13、ntry160-219/90160-219/95Goal(SBP)160+20 150+20 Baseline170/77174/86Achieved:Rx143/68151/79Achieved:Placebo155/72161/84Difference:Rx-Placebo12/410/5Journal of Clinical Hypertension,Vol II,No.5,page 336.March/April 2000.REDUCTION OF STROKES WITH BP LOWERING-SHEP TRIALNo.of Patients:4736Follow-up:4.5 y
14、ears 37%in ischemic strokes 47%in lacunar infarcts 54%in hemorrhagic strokesLower BPs -fewer strokesAm J Hypertension 2000;13:724-733 For persons over age 50,SBP is a more important than DBP as CVD risk factor.Starting at 115/75 mmHg,CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.Persons who are normotensive at age 55 have a 90%lifetime risk for developing HTN.Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.JNC 7:New Features and Key Messages
