Hypertension in the elderly
Introduction
Introduction to hypertension in the elderly Hypertension is one of the common diseases in the elderly. With the prolongation of life expectancy, the number of elderly people is increasing, and the number of elderly hypertensive patients is increasing. China generally recognizes people over the age of 60 as elderly people, while foreign countries, especially most developed. The country regards 65 years and older as the standard of old age. Hypertension is a major risk factor for coronary heart disease and cerebrovascular disease. These heart and cerebrovascular diseases cause 12 million deaths every year in the world. Therefore, prevention and treatment of hypertension in the elderly And theoretical research has become a topic of great concern to the medical community. The pathogenesis of senile hypertension has not yet been fully elucidated. It is generally believed that the age increases, the intima and medial layers of the aortic wall become thicker, the middle layer of elastic fibers breaks and decreases, the deposition of collagen, lipids and calcium salts, and the undifferentiated vascular smooth muscle cells (VSMC) migrate through the elastic layer. Proliferation, increased connective tissue formation, these structural changes can lead to narrowing of the arterial lumen, increased stiffness, decreased aortic elasticity and reduced self-compliance, decreased elastic expansion, and increased blood vessel pressure without buffering. In elderly patients with elevated systolic blood pressure (ISH), ISH is formed by a decrease in diastolic blood pressure due to a decrease in aortic elastic retraction. In addition to changes in aortic structure (large vessels), endothelial cell dysfunction, changes in neurohumoral factors, hemodynamic changes, environmental and genetic factors play an important role in the development of hypertension in the elderly . basic knowledge The proportion of illness: 0.005% Susceptible people: the elderly Mode of infection: non-infectious Complications: myocardial infarction
Cause
Causes of hypertension in the elderly
Genetic factors (25%)
Essential hypertension has a tendency to cluster in certain families, suggesting that it has a genetic basis or is accompanied by genetic and biochemical abnormalities. The normal blood pressure children with high blood pressure in both parents have an increased proportion of hypertension. However, no special blood pressure regulating gene combinations have been found so far, and no genetic markers for early detection of hypertension crisis have been found.
Sodium retention (25%)
The mechanism of sodium-induced hypertension is still unclear. Sodium retention increases the extracellular fluid volume, so cardiac output increases. Increased sodium levels in vascular smooth muscle cells can lead to increased intracellular calcium concentration and enhanced vasoconstriction. Therefore, peripheral vascular resistance is elevated, which promotes the formation of hypertension.
Mental factors (30%)
Increased sympathetic activity is an important link in the pathogenesis of hypertension. Therefore, when people are suffering from chronic stress, stress, anxiety or long-term environmental noise and visual stimulation, they can cause high blood pressure.
Insulin resistance (5%)
It has been observed that fasting insulin levels are elevated in most hypertensive patients, and glucose tolerance is reduced to varying degrees, suggesting insulin resistance. The following effects of insulin may be associated with elevated blood pressure: 1 Increase renal tubular reabsorption of sodium. 2 enhance sympathetic nerve activity. 3 Increase the concentration of sodium and calcium in the cells. 4 stimulate the proliferation of blood vessel wall hypertrophy.
Other factors (5%)
Epidemiological investigations suggest that the following factors may also be associated with the development of hypertension: obesity, smoking, excessive drinking, low calcium, low magnesium and low potassium.
Prevention
Elderly hypertension prevention
The prevention of hypertension in China is the sooner the more effective measures are taken, the specific strategies for prevention of hypertension can be divided into three levels, namely, primary prevention, secondary prevention and tertiary prevention.
Primary prevention
Primary prevention refers to the existence of risk factors, and the disease has not yet occurred, or preventive measures are taken when the disease is in the subclinical stage to control or reduce the risk factors of the disease, so as to reduce the incidence of individual and the incidence of the population. Called primary prevention. There are two complementary strategies for primary prevention: one is for high-risk groups, so the inspection is wide and the cost is high; the second is for the entire population of the society, not only in large numbers, but also to encourage people to take advantage from childhood-youth. Healthy lifestyle and behavior, primary prevention can not only significantly reduce high blood pressure, coronary heart disease, but also have obvious benefits in preventing diabetes and certain tumors. The specific measures are as follows:
(1) Weight loss: First, control the amount of food, limit the diet to pay attention to a balanced diet, do not advocate the use of drugs to suppress appetite, because the fat provided by the high calories, so the total fat intake should be limited to less than 20% of total calories, the elderly People should eat slowly, eat less and eat more, avoid oversatisfaction; second, increase the amount of exercise, scientific weight loss method emphasizes the combination of low-calorie diet and physical activity, can use fast walking, swimming, health gymnastics, qigong and other medium strength The sports program, step by step, long-term adherence, in order to receive a better weight loss effect.
The possible mechanisms of hypertension caused by excess calories caused by obesity are as follows: 1 increase in blood volume and cardiac output; 2 due to hyperinsulinemia or abnormal relationship between renin and aldosterone, causing sodium retention in the body; 3 neuroendocrine regulation Disorders, such as increased sympathetic adrenergic activity; 4 cell membrane cotransport function defects, abnormal sodium and potassium pump activity, may be the cytopathological basis of hypertension and obesity.
(2) Improving the dietary structure: In 1977, the Chinese Nutrition Society published the Chinese Dietary Guidelines based on the principle of balanced diet, reasonable nutrition, and promotion of health. The main contents include eight articles, namely: food is diverse, cereals are dominant; Eat vegetables, fruits and potatoes; often eat milk, beans or their products; often eat the right amount of fish, eggs, lean meat, eat less fat and oyster sauce; balance the amount of food and physical activity, maintain a suitable weight, eat light Foods that are less salty, such as drinking alcohol, should be eaten in a proper amount to eat clean and unsatisfactory food.
1 Limit sodium salt: The specific recommendations are as follows: A. To reduce the amount of sodium salt and salty seasonings (such as soy sauce, yellow sauce, hot sauce, etc.) when cooking. B. Eat less salted products. C. Promote the consumption of low sodium and high potassium salts (including sodium chloride 70% potassium chloride 25%). D. Use a quantitative salt spoon to help control the amount of salt during cooking. E. Choose low-salt foods in cooked food. F. Parents should prevent children from developing the habit of eating salty foods and try to eat less fast foods containing more sodium. G. The reduction of sodium salt is gradual.
2 increase potassium: According to research, daily urinary potassium excretion increased to 60mmol, which can reduce systolic blood pressure by 0.36kPa (2.7mmHg). The ratio of sodium to potassium in the dietary intake of Chinese population should be 1:1, that is, the daily sodium salt is 5g, the potassium is 4g, and the potassium-rich fresh vegetables and fruits are eaten. The Chinese Nutrition Society recommends that each person eat 12kg of vegetables per month (equivalent 400g per day) 1kg per month (equivalent to 33g per day), and the cooking method should be improved to prevent the loss of potassium in the food due to excessive cooking time.
3 Calcium intake was significantly negatively correlated with blood pressure. Studies have shown that increasing calcium intake can promote sodium excretion, which is conducive to lowering blood pressure. Some surveys have shown that daily calcium intake is lower than 300mg. The blood pressure is 2.6 kPa (20 to 30 mmHg) higher than that of the daily calcium intake of more than 800 mg. In addition, clinical trials have shown that calcium supplementation can reduce systolic blood pressure by 0.4 to 0.8 kPa (3 mmHg to 6 mmHg). The Nutrition Society recommends that the daily calcium intake of adults should be 800mg, while the daily intake of calcium in Chinese adults is 300-500mg, which is far from the supply standard. Therefore, calcium supplementation is more important for the dietary calcium intake in China. The meaning. Should increase the intake of dairy products, 250 ~ 300ml of milk per day can add about 300mg of calcium, green leafy vegetables also contain more calcium, to ensure that fresh vegetables 400 ~ 500g per day (should choose more nutritious dark vegetables and Green leafy vegetables), in addition, shrimp skin, soy products, canned squid with bones, fungus, mushrooms, seaweed and other calcium-containing, children, adolescents, pregnant women and the elderly should have more calcium intake, which is not only good for prevention High blood pressure is also necessary to prevent osteoporosis.
4 reduce dietary fat, supplement high-quality protein: Studies have shown that even if you do not reduce dietary sodium intake and weight loss, such as the ability to control dietary fat below 25% of total calories, polyunsaturated fatty acid to saturated fatty acid ratio (P / S Maintaining at 1, 40 consecutive days can reduce male systolic and diastolic blood pressure by 12%, females by 5%, increase quality protein, generally refers to animal protein and legume protein. Current research shows that protein quality is poor and hypertensive brain The incidence of stroke is high, so it should increase the high-quality protein in the diet. The Chinese Nutrition Society recommends that adults consume 14 kg of cereals per month, 3 kg of potatoes, 1 kg of eggs, 1.5 kg of meat, and 500 g of fish.
5 Eat more vegetables and fruits: Increasing vegetables or fruits can reduce SBP and DBP by 0.4 kPa (3 mmHg) and 0.13 kPa (1 mmHg), respectively. Reducing fat consumption can reduce SBP and DBP by 0.8 kPa (6 mmHg) and 0.4 kPa (3 mmHg, respectively). ), vegetarians have lower blood pressure, and the antihypertensive effect is a combination of fruits, vegetables, cellulose and low fat without depending on the presence or absence of animal protein.
(3) Restricted drinking: Generally speaking, a small amount of drinking does not affect the incidence of hypertension, but a large amount of drinking (referring to drinking more than 2 to 4 servings per day, each serving is equivalent to 15ml of alcohol or 300ml of beer or 100ml of wine or 25ml of white wine), which definitely promotes blood pressure. rise.
Possible mechanisms for alcohol-induced hypertension are:
1 increase the level of catecholamines and corticosteroids.
2 affects the role of renin-angiotensin and vasopressin and aldosterone.
3 The effect of alcohol directly on peripheral vascular tone may increase the flow of calcium into the cells.
4 insulin sensitivity is reduced.
5 magnesium discharge increased, can promote vasospasm.
6 pressure reflection is reduced.
(4) Smoking cessation: Tobacco contains tobacco tar, nicotine, carbon monoxide and other harmful substances. Smoking can damage the function of vascular endothelial cells, causing damage to its regulation ability, causing vasospasm, rapid heartbeat, and rising blood pressure. According to statistics, smokers The prevalence of cardiovascular disease is 2.6 times that of non-smokers, so smoking should be resolutely quit.
(5) Increase physical activity: There is data showing that the risk of high blood pressure is 1.52 times higher than that of physical activity. It has been reported that only one exercise can lower the systolic blood pressure and diastolic blood pressure of normal people by 0.53 to 0.78. kPa (4 ~ 6mmHg), large-scale randomized trials have shown that physical activity combined with weight loss can lower blood pressure. JNCV recommends regular exercise as an effective lifestyle-changing measure for the treatment and prevention of hypertension. The elderly should choose a certain amount of aerobic exercise, such as walking or swimming for 30 minutes, about 5 times a week, you can also play Tai Chi, do aerobics, etc., the elderly should not be too large, and there should be no exercise. Apparent discomfort, heart rate during exercise is not more than 125 times / min is appropriate, the elderly should start from a small amount of exercise, step by step, long-term adherence.
(6) Avoid excessive mental stress: Mental stress plays an important role in the rise of blood pressure. Some studies have shown that mental stress, stressful occupations, high blood pressure levels in the population, practice has proved that competition is strong, stubborn, suspicious, Sentimental, especially angry, people who are hostile to emotions are most susceptible to high blood pressure, so keep your mood calm and peaceful, learn to relax yourself, prevent anger, avoid mental stimulation, rest properly, trust others, sleep well and adjust sleep in time.
Although the occurrence of hypertension is mostly in the elderly, the prevention of hypertension should start from childhood, and the strategic focus of prevention of hypertension should be placed on primary prevention.
2. Secondary prevention
Secondary prevention refers to taking measures to prevent the recurrence or aggravation of the diseased individual or group. These measures often include primary prevention measures, rational drug treatment and post-treatment counseling. In short, secondary prevention is timely. The correct treatment, because China's high blood pressure patients have more than 100 million, 1.5 million people die each year from stroke, so secondary prevention is of great significance.
The criteria for prevention of success: reduce the incidence of cardiovascular and cerebrovascular diseases and mortality, delay the age of complications, improve the quality of life, so that patients do not affect work, study and life expectancy because of high blood pressure. The specific measures are as follows:
(1) Continue to implement the measures for primary prevention.
(2) Perform systematic anti-hypertensive treatment. The plan is as follows:
1 According to different patients, refer to the anti-hypertensive drug evaluation criteria, select the appropriate drug to reduce blood pressure to below 18.6/12kPa (140/90mmHg) within 2 to 4 weeks or longer, and the antihypertensive effect of the drug should be Striving for stability, safety and effectiveness, and at the same time should be low-cost, take 1 time a day, so that patients may continue to adhere to treatment.
2 According to the law of blood pressure change, choose the best time to take the drug. For example, the first dose should be taken at 6 in the morning.
3 In addition to antihypertensive drugs, the addition of small doses (75mg / d) of aspirin, two effects, reduce platelet aggregation to help blood pressure; prevent thrombosis and prevent coronary heart disease and cerebrovascular disease.
4 Use a better monitoring method, that is, measure blood pressure at the peak of blood pressure, so that the blood pressure at the peak also drops to normal.
5 taking into account the treatment of other factors, the treatment of senile hypertension can give priority to diuretics and calcium antagonists, when combined with other risk factors should be treated differently, for example: patients with left ventricular hypertrophy, diabetes, it is appropriate to use angiotensin Enzyme inhibitors; patients with hyperlipidemia, gout, it is not appropriate to use diuretics; male elderly patients with hypertension are prone to prostatic hypertrophy, then blockers, etc., as long as the long-term adherence to the above practices, it must Can receive the expected results.
3. Three levels of prevention
Tertiary prevention is to prevent the occurrence of complications and death of patients, including rehabilitation treatment, that is, patients with hypertension, when serious complications such as acute heart failure, stroke, etc., timely and reasonable treatment, control of disease development, rescue The patient's life, reducing its mortality, and rehabilitation after these complications have stabilized. In clinical work, we observed that the development of serious complications in a large number of hypertensive patients is due to the long-term "asymptomatic" of patients. Causes the patient to have high levels of high blood pressure for a long period of time without being treated or failing to get the correct treatment in time; or because the patient lacks the necessary self-health knowledge.
Prevention of hypertension should emphasize the following points:
(1) For every patient who comes to the hospital for treatment, blood pressure should be routinely measured to find more hypertensive patients.
(2) Hypertension treatment is based on blood pressure levels, not symptoms. For those patients with elevated blood pressure and asymptomatic, they must be advised to receive treatment.
(3) There must be regular medication, regular review, so that the blood pressure really falls below the normal value.
(4) When the condition is stable, the patient is urged to take the medicine and cannot stop thinking that he is okay and automatically stop taking the medicine.
4. Community prevention
The key to community prevention and control is to have a combination of leadership, experts, and grassroots medical personnel. In addition, 11 years of comprehensive prevention and treatment of cardiovascular disease in Chaoyang District of Beijing, the incidence of myocardial infarction and stroke are respectively controlled by prevention. 31/100,000, 117/100,000 fell to 21.1/100,000 and 67/100,000 after prevention, down 29% and 43% respectively.
(1) Establishing organizations and training personnel: To do a good job in community prevention and treatment of high blood pressure, we must first establish a prevention and control network system with leaders, experts, professionals, grassroots health workers and the masses. WHO has suggested that we can follow the following three levels. Training.
First, third-level training, the main researchers in the national and metropolitan cardiovascular research centers for hypertension prevention research, should have a wealth of modern cardiology, internal medicine, epidemiology and related knowledge, and Can be responsible for the organization of the planning and training of relevant scientific research personnel in the province or region.
Second, secondary training, mostly refers to provincial, regional hospitals or centers of internal medicine, epidemiology or occupational diseases and other experts, they are responsible for training regional or county-level cardiovascular disease or chronic disease personnel.
Third, the primary training is for grassroots hospitals, factories and mine health stations, street health clinics and rural health workers. The trainees, pharmacists, midwives, full-time health workers and volunteers who have received secondary training will be trained. .
(2) Community intervention:
1 General principles of community intervention strategies:
A. Community analysis should be tailored to local conditions: the prevalence of hypertension is different in different regions of China, and its distribution trend is low in the south and high in the north. This is closely related to the social environment, geographical environment and living customs of different regions. There are also some differences in the risk factors for hypertension and other environmental factors.
B. Multidisciplinary Participation: Community interventions for hypertension are based on epidemiology and require modern medical knowledge, behavioral knowledge, and sociological knowledge to participate in operational research.
C. Community intervention is based on community-based research: community intervention is to change the unhealthy lifestyle of community population, and its interventions or plans, early diagnosis, treatment and control of hypertension must be able to be used by community service systems and social organizations. Accept, get their collaboration and be part of their job, through which they can put these plans or measures into practice across the community.
D. Establish an epidemiological surveillance system: Establishing a complete epidemiological surveillance system is important for community intervention. The monitoring content can be determined according to the research purpose. It can be disease surveillance, or it can be various exposure factors and prevention levels. monitor.
E. Emphasis on the feasibility of intervention programs and measures: The practicality of measures or plans in community interventions is an important guarantee to ensure their smooth implementation in the entire community. The measures or plans must be developed in the community. Based on the community analysis, the specific content of such measures or plans should be implemented through the community organizations themselves, so that they can become the behavior of the entire community.
2 Intervention strategies: Community intervention strategies for hypertension include population strategies and individual strategies (also known as high-risk strategies).
A. Mass Strategy: The population strategy refers to the prevention strategy based on the whole population and the multi-channel health education as the main means to reduce the risk factors related to disease occurrence in the population, instead of For high-risk individuals, population strategies have their own characteristics for different diseases, different countries and different regions.
The crowd strategy has the following characteristics:
a. Objective and goal: The purpose is to reduce the average blood pressure level of the whole population and reduce the incidence and prevalence of hypertension. The goal is to reduce the risk factors related to hypertension in the population, but in areas with high incidence of hypertension, the population The goals of the strategy should also include the detection, treatment and control of patients with hypertension.
b. The object and focus of health education: the use of radio, television, newspapers and magazines, bulletin boards and other media for multi-channel health education is the main means and the biggest feature of the crowd strategy.
c. Public education: The focus is on the health risks of hypertension, the preventability and prevention of hypertension.
d. Education of hypertensive patients: mainly includes: the harmfulness of hypertension, the occultity of hypertension, the importance of measuring blood pressure regularly, the necessity of lifelong treatment of hypertension, and the importance of changing unhealthy lifestyles for patients with hypertension The standard for blood pressure control.
e. Education of medical staff: Mainly through the way of continuing education, medical staff should not only keep abreast of the progress in the diagnosis and treatment of hypertension, but also pay attention to the application of these new knowledge in the clinical practice of patients with hypertension.
B. Individual strategy: Individual strategy, also called high-risk strategy, is to detect high-risk individuals or subgroups from the population, and appropriately give appropriate interventions to change their high-risk status, thereby reducing the occurrence and death of related diseases. purpose.
Since the population strategy is aimed at the whole community, most of them think that they are healthy and have no disease, they feel little benefit to various preventive measures, so the compliance of the intervention in the implementation will be affected to some extent. High-risk individuals are highly targeted, and interventions are easily accepted by them, resulting in better results. Therefore, in the prevention and treatment of hypertension, population strategies and high-risk strategies can complement each other in the implementation of preventive interventions. In the two strategies, the two strategies are closely combined to achieve the greatest success in community prevention.
Complication
Elderly hypertension complications Complications, myocardial infarction
As the disease progresses, blood pressure is persistently elevated, and the performance of target organs such as heart, brain and kidney is mainly divided into direct effects of elevated blood pressure and accelerated atherosclerosis (Table 4). Cardiovascular and cerebral vascular complications (stroke) are the most common, with an annual incidence of about 180/100,000, which is about 5 times that of myocardial infarction. The fundus changes can reflect the severity of hypertension. Currently, Keith-Wagener fundus grading is used. Method: Level 1, the retinal artery is thinned. Grade 2, retinal artery stenosis, arterial cross compression. Grade 3, retinal hemorrhage or cotton-like exudation. Grade 4, bleeding or exudate accompanied by optic disc edema.
Symptom
Hypertension symptoms in the elderly Common symptoms Weakness, weakness, polydipsia, polyuria, nausea, disturbance of consciousness, inattention, skin, pale retinal hemorrhage, head swelling
Symptom
include:
1 symptoms of high blood pressure itself.
2 need to exclude the special symptoms of secondary hypertension related diseases (such as pheochromocytoma with high blood pressure with headache, palpitations, pale skin and sweating, polydipsia, polyuria, primary aldosteronism Weak or paroxysmal muscle weakness and muscle paralysis.
3 There are no symptoms of various organs corresponding to complications of cardiovascular and cerebrovascular diseases.
Primary hypertension has a slow onset, early asymptomatic, 46.5% without any early symptoms, and only occasionally finds high blood pressure when medical examination or other medical treatment, there are quite a few patients, until the disease progresses to a considerable extent, Some incentives (such as work fatigue, emotional agitation, etc.) induce typical symptoms and seek medical treatment. At this time, the course of the disease is not early. Once the hypertension is known, the patient can produce various neurological symptoms such as headache, dizziness, and head swelling. Nausea, vomiting, tinnitus, vertigo, forgetfulness, inattention, irritability, nervousness, insomnia, boredom, fatigue, numbness of the limbs, stiff neck discomfort, palpitations, etc. Among them, dizziness accounts for 63.5%, headache accounts for 55.4%, palpitations Accounted for 39.8%, these symptoms are not directly caused by hypertension, some are caused by high-grade neurological dysfunction, no clinical specificity, and some may also have repeated bleeding in different parts of the body, common conjunctival hemorrhage, nosebleeds, A small number may have hemoptysis, these symptoms may not be consistent with blood pressure levels, and later symptoms are often caused by heart, brain, kidney dysfunction or serious complications.
2. Signs
It can be heard that the second aortic valve of the aortic valve is hyperthyroidism. The older one can have a metal tone, and can have a fourth heart sound. The aorta contractes early jet sound. When the hypertension lasts for a long time, there is a sign of left heart hypertrophy. Signs of organ failure such as brain and kidney.
In addition, a comprehensive physical examination should include the following:
(1) Determination of blood pressure: The elderly should pay special attention when measuring blood pressure: A. The elderly are prone to erect blood pressure drop and hypotension, so it is necessary to add standing blood pressure. After standing for 2 minutes, blood pressure is measured. The sphygmomanometer should be The same level of the heart (4th intercostal space), B. Pseudohypertension: The elderly are difficult to be blocked by the balloon of the mercury column cuff sphygmomanometer due to the hardening of the radial artery, and the false systolic blood pressure is increased. At this time, it should be highly suspected whether it is "pseudohypertension". It can be diagnosed by a simple Osler test, that is, the cuff is inflated so that the pressure exceeds the systolic blood pressure (2.6 kPa) or more, and if it is still able to reach the stiff radial artery. When it is pulsating, it indicates that the Osler test is positive, and there may be "pseudohypertension". At this time, arterial blood pressure can be directly measured by arterial puncture, and the value is significantly smaller than that of the cuff pressure reading.
(2) Measure height, weight, and calculate the square of body mass index (BMI) BMI = weight (kg) / height (m).
(3) Cardiovascular system examination, paying special attention to heart size, carotid artery, renal artery, peripheral artery and aortic lesions, and heart failure.
(4) There are signs of murmur and bronchospasm in the lung examination.
(5) Abdominal examination for vascular murmurs, enlarged kidneys and lumps.
(6) Fundus examination for hypertensive retinopathy, that is, arterial narrowing, arteriovenous cross-pressure, retinal hemorrhage, exudation and optic disc edema.
(7) Neurological examination for evidence of cerebral vascular damage, such as disturbance of consciousness, limb sensation and movement disorders.
In 1999, the WHO/ISH Guidelines for the Treatment of Hypertension and the Guidelines for the Prevention and Treatment of Hypertension in China defined hypertension as the absence of antihypertensive drugs, systolic blood pressure 18.6 kPa (140 mmHg) and/or diastolic blood pressure 12 kPa (90 mmHg). 3 times non-same blood pressure measurement, all in line with the diagnostic criteria of hypertension can be diagnosed, if the patient has a history of hypertension, is currently taking antihypertensive drugs, blood pressure is lower than 18.6kPa (140/90mmHg), also diagnosed as high Blood pressure, at the same time, should rule out secondary hypertension.
Examine
Examination of hypertension in the elderly
Laboratory tests include hematuria, biochemistry (serum potassium and sodium, urea nitrogen, creatinine, uric acid, fasting blood glucose, total cholesterol, triglyceride, and low- and high-density lipoprotein cholesterol), as follows:
Blood routine
Erythrocytosis can lead to elevated blood pressure, secondary hypertension caused by polycythemia or excessive use of erythropoietin. In addition, blood routine can reflect the overall health of patients, such as anemia when chronic renal insufficiency occurs.
2. Serum potassium
Normal value: 3.5 to 5.5 mmol/L.
(1) hypokalemia (<3.5mmol/L): when serum potassium <3.5mmol/L, and urinary potassium excretion >40mmol/L, suggesting an increase in aldosterone, plasma renin activity and blood, urinary aldosterone should be further determined. Combined with clinical localization diagnosis, the diagnosis of aldosteronism can be made. If the serum potassium is less than the critical or low level, it should be reviewed 2 or 3 times, except for the following cases: loss of potassium in the gastrointestinal tract or insufficient intake, such as renal potassium loss. Renal tubular acidosis, excessive mineralocorticoid disease, use of loop diuretics or thiazide diuretics.
(2) Hyperkalemia (>5.5mmol/L): Hyperkalemia may occur during the progression of renal insufficiency, but the kidney has a strong compensatory capacity for potassium excretion until glomerular filtration rate (GFR) Hyperkalemia occurs when <5ml/min, and long-term use of angiotensin-converting enzyme inhibitor (ACEI) should be alert to hyperkalemia.
3. Fasting blood sugar
Normal value: 3.9 to 6.2 mmol/L.
When using antihypertensive drugs in diabetic patients, drugs that may affect glucose tolerance should be avoided, such as high-dose thiazide diuretics. In addition, -blockers can reduce the heart rate caused by the release of catecholamines during hypoglycemia, and cause poor hypoglycemia. The symptoms mask the effect.
4. Blood uric acid
Normal value: 9 to 420 mol/L.
About half of untreated hypertensive patients have hyperuricemia, so gout is more common in hypertensive patients. Diuretics promote the reabsorption of uric acid in the proximal tubules of the kidney, resulting in increased blood uric acid levels, thereby enabling patients Induced gout attacks, patients with renal insufficiency, such as accompanied by a significant increase in blood uric acid, should be further examined to rule out lead poisoning nephropathy.
5. Blood lipids
Hypertensive patients with hyperlipidemia are much more common than normal people. According to the survey, serum total cholesterol levels are positively correlated with diastolic blood pressure. Serum cholesterol, especially the relative levels of LDL and HDL, are risk factors for cardiovascular disease. Triglyceride levels may be elevated when treated with thiazide diuretics and should therefore be included as one of the routine observations.
6. Urine routine
Urine routine examination is an important screening test in renal parenchymal diseases.
7. Serum creatinine (Cr) normal value: male 79.6 ~ 130.6 mol / L, female 70.7 ~ 106.1 mol / L
Cr is the terminal metabolite of creatine in muscle tissue. The amount of Cr produced is proportional to the mass of the muscle, so it is relatively constant. Cr is mainly discharged through glomerular filtration, but since Cr is also secreted by the renal tubules, the rate of low urine flow is low. It may be reabsorbed, so Cr is not an ideal indicator of glomerular filtration rate (CFR), but it is still a commonly used GFR practical indicator in clinical practice. It still uses blood Cr as a diagnostic emergency, chronic renal failure and chronic The main indicator of renal dysfunction staging.
8. Plasma urea (BUN) normal value: 1.8 ~ 6.8mmol / L.
Reflecting the evaluation of glomerular function and the overall level of renal function, blood BUN is affected by many factors, and any high-decomposition state such as infection, high fever, dehydration, gastrointestinal bleeding, etc. caused by any cause can cause blood BUN to rise, so Elevation of blood BUN is not necessarily the result of impaired glomerular filtration function, and differentiation is required.
Heart color ultrasound
Clinically, when there is left ventricular hypertrophy or other heart disease, echocardiography should be performed to more comprehensively evaluate the cardiac anatomy and function and determine the treatment plan.
2. Vascular ultrasound
If the aorta, carotid artery, and peripheral arterial disease are suspected, vascular ultrasound should be performed.
3. Kidney B ultrasound
If you have kidney disease, you should have a kidney B ultrasound.
4. Dynamic blood pressure monitoring
At present, the cuff sphygmomanometer is often used in clinical practice to measure blood pressure. Obviously, this kind of even blood pressure cannot reliably reflect the fluctuation of blood pressure and the situation in daily life and rest, so actively carry out dynamic blood pressure monitoring and master the law of blood pressure changes. It is necessary.
Normal people's blood pressure showed obvious diurnal fluctuations. The dynamic blood pressure curve showed a double peak and a valley, that is, the lowest blood pressure at night, and it rose rapidly after getting up in the morning. There was a peak at 6-10 h in the morning and 4-8 h in the afternoon, followed by a slow decline. The blood pressure diurnal fluctuation curve of hypertensive patients is similar, but the overall level is higher and the fluctuation range is larger.
Diagnosis
Diagnosis and diagnosis of hypertension in the elderly
Elevated blood pressure is a manifestation of disease, for many reasons, some reasons have been identified, and most of the reasons are unknown.
1. Increased systolic blood pressure and increased diastolic blood pressure
(1) elevated systolic blood pressure: tachycardia, complete atrioventricular block, aortic regurgitation, arteriovenous fistula, patent ductus arteriosus, severe anemia, hyperthyroidism.
(2) elevated diastolic blood pressure: renal hypertension.
2. Secondary hypertension
Secondary hypertension refers to hypertension caused by certain diseases or causes, accounting for 1% to 5% of all hypertensive patients. Because it is a symptom of the primary disease, it is also called symptomatic hypertension. In patients with hypertension, it is identified as primary or secondary, and its importance lies in many secondary hypertension, such as primary aldosteronism, pheochromocytoma, renal vascular hypertension, renin Secretory tumors, etc. can be cured by surgery or other methods, or the condition can be significantly improved. Early diagnosis can improve the cure rate or prevent the development of the disease.
The causes of secondary hypertension are as follows:
1 kidney: glomerulonephritis, pyelonephritis, collagen tissue disease, diabetes, congenital lesions (polycystic kidney).
2 Adrenal gland: primary aldosteronism, pheochromocytoma, hypercortisolism, adrenal hypersensitivity syndrome.
3 central nervous system: brain tumors, increased intracranial pressure, brain stem infection.
4 arteries: renal artery stenosis, aortic coarctation, multiple arteritis.
5 other: contraceptives, licorice, sympathomimetic, eclampsia, polycythemia, acromegaly, hypercalcemia, more common secondary hypertension:
(1) Chronic glomerulonephritis: a group of long-term disease diseases caused by a variety of primary glomerular diseases, clinical manifestations of hypertension, proteinuria, hematuria, edema, and finally develop into chronic renal failure, such as Patients with hypertension should be differentiated from primary hypertension with secondary renal damage. Kidney damage caused by hypertension occurs after 40 years of age; history of hypertension is unprecedented, no history of chronic kidney disease; urinary changes are light, renal tubules Functional impairment is earlier and heavier than glomerular dysfunction; in addition to kidney damage, it is often accompanied by cardiac complications.
(2) Chronic pyelonephritis: a type of atrophic reflux nephropathy. When the renal parenchyma is scarred, 50% of the blood pressure rises. Hypertension caused by chronic pyelonephritis should be associated with essential hypertension with pyelonephritis. Differentiated, pyelography in patients with chronic pyelonephritis can show irregular images of renal pelvis and renal pelvis, ureteral dilatation, bladder-ureteral reflux, unilateral pyelonephritis, and the characteristics of left and right kidney asymmetry are unique in diagnosis. If the renal biopsy shows renal tubular destruction, dilatation, renal interstitial inflammatory lesions, the diagnosis is correct.
(3) Diabetic nephropathy: Renal damage can occur in both type I diabetes and type II diabetes, hypertension, glomerular sclerosis, thickening of glomerular capillary basement membrane as the main pathological change, early renal function is normal, Only microalbuminuria, blood pressure is not necessarily elevated, the disease develops, there is obvious proteinuria, when the renal insufficiency, the blood pressure is elevated, when the essential hypertension with type II diabetes, there may also be proteinuria and kidney Decreased function, sometimes need to identify from the history of the disease, whether there are obvious diabetic lesions in the fundus.
(4) Polycystic kidney disease: a hereditary autosomal dominant lesion, 50% died of renal failure, 50% died of hypertension complications, such as stroke, myocardial infarction, heart failure, pathological changes: kidney volume Larger, a lot of real, medulla is destroyed, due to the expansion of the cyst caused by residual renal parenchymal ischemia, the early stage of the lesion often increased the secretion of renin, the latter is volume-dependent hypertension, identification: kidney B-ultrasound, polycystic kidney Family history, often with extracapsular polycystic changes (such as polycystic liver disease, etc.).
(5) Renal vascular hypertension: refers to hypertension caused by unilateral or bilateral renal artery trunk or branch stenosis, the most common type of secondary hypertension, the cause is not the same at home and abroad; Western countries are Atherosclerosis is the most common, accounting for about 65% of all cases, followed by renal artery fibromuscular dysplasia (35%); in China, arteritis is the most common (70%), fibromuscular dysplasia 20%, while atherosclerosis only accounts for 5%.
Clinically, elderly patients are often accompanied by obesity, hyperlipidemia, coronary heart disease or carotid plaque formation. If blood pressure suddenly increases significantly and is difficult to control, it should be considered based on long-term hypertension, kidney atherosclerotic plaque-induced kidney Arterial stenosis, it is necessary to do a detailed examination (assay, B-ultrasound, intravenous pyelography, etc.) to confirm the diagnosis and timely release the stenosis.
(6) Primary aldosteronism (original aldehyde): This disease is caused by adrenal cortical tumor or hyperplasia, which is caused by excessive secretion of aldosterone. Among them, tumors are the most common, accounting for 60% to 90% of patients with primary aldehydes. Mostly one side of adenoma, bilateral adrenal hyperplasia is 10% to 40%, less common is adrenal cancer, hypertension is the most important clinical manifestations, and increased aldosterone secretion caused by sodium retention, increased blood volume, high Blood pressure is volume dependent, mostly mild, moderate hypertension, and a few cases can develop severe or malignant hypertension. Potassium reduction is also an important manifestation of primary aldehydes, due to the large amount of aldosterone acting on the distally curved tubules causing sodium absorption and Potassium excretion increases, so urinary potassium loss increases, in the clinical manifestations of limb muscle weakness or paralysis, often a periodic episode, severe cases may have swallowing or breathing difficulties, in the cardiovascular system may have ventricular premature contraction, kidney The small tube concentrating function is reduced, which is characterized by increased urine output, thirst, polydipsia, laboratory examination of hypokalemia, increased urinary potassium excretion; blood and urine aldehyde localization examination can be used for radioactive iodinated cholesterol Adrenal or photographic scanning, B ultrasound and CT inspection.
(7) Pheochromocytoma: pheochromocytoma originates from the adrenal medulla or sympathetic nerves and other parts of the pheochromic tissue, which continuously or intermittently release a large amount of catecholamines to cause persistent or paroxysmal hypertension, hypertension It is the main clinical manifestation of this disease, and is characterized by paroxysmal hypertension. When it occurs, blood pressure rises sharply from the normal range to a high level, accompanied by headache, pale, sweating, tachycardia, etc. There are angina, arrhythmia, and even acute left heart failure or stroke. The duration of the attack is usually several minutes to several hours. It is caused by incentives such as mood swings, contact with tumor sites, changes in body position, etc. Normal, this disease is more common in young adults aged 20 to 40 years. The type of persistent hypertension is difficult to distinguish from essential hypertension. If accompanied by excessive sweating, low fever, palpitations, weight loss, etc., it is helpful for pheochromocytoma. Diagnosis, specific examination: measurement of adrenaline or norepinephrine in the blood, or determination of its metabolites in the urine (3-methyl-4-hydroxymandelic acid) significantly increased, further Kidneys and adrenal ultrasound, the lesion can nuclide and CT scan showed that the tumor is located.
(8) Cortisol: Adrenal cortical tumors or ACTH tumors secrete a large amount of ACTH to cause adrenal hyperplasia, excessive secretion of glucocorticoids, so that water and sodium retention causes high blood pressure, more common in women, there is centripetal obesity, full moon face, Hairy, thin skin and purple lines and other characteristics, laboratory tests: 24h urine 17-hydroxycorticosteroids or 17-ketosteroids increased, blood sugar increased, dexamethasone inhibition test and positive adrenal cortex stimulation test is helpful for diagnosis.
(9) hyperthyroidism (hyperthyroidism): some elderly patients with hyperthyroidism, often with systolic hypertension as the main symptoms, accompanied by fatigue, heat, sweating, hand tremor, weight loss, palpitations, tachycardia , neuroticism, hyperthyroidism symptoms, auxiliary examination: determination of serum T3, T4 increased, blood lipids and cholesterol decreased, most elderly patients with hyperthyroidism ECG can show non-specific manifestations of atrial fibrillation, can control blood pressure after treatment of hyperthyroidism, hyperthyroidism secondary hypertension should be used Treatment with -blockers, and antithyroid drugs or thyroidectomy according to the condition.
