systolic hypertension in the elderly
Introduction
Introduction to senile systolic hypertension Systolic hypertension (systolichypertensioninelderly) refers to the systolic blood pressure above normal level and normal diastolic blood pressure in the elderly over 60 years old. It is an independent type of disease and an independent risk factor for cardiovascular disease and stroke in the elderly. Important diseases affecting the health of the elderly must be given great attention. basic knowledge The proportion of illness: 5% (related to the elderly diet) Susceptible people: the elderly Mode of infection: non-infectious Complications: heart failure, arrhythmia
Cause
Causes of systolic hypertension in the elderly
Degenerative changes in the blood vessels of the elderly (25%):
With the increase of age, the arterial wall of the elderly is thickened. The large and middle arteries are characterized by atherosclerosis and vascular stenosis. The vasoconstrictor causes increased vascular resistance; the elastic fiber breaks, the calcium content increases, and the deposition of collagen material leads to the compliance of the aorta. Sexual decline, which causes blood pressure to rise. Vascular changes with age, arterial vascular lamellar degeneration, vascular wall/cavity ratio and lumen cross-sectional area shrink, small arteries and intima thickening, elastic plate increase and medial degeneration make vascular lumen narrow, arteries Wall thickening; large and middle arteries manifest as atherosclerosis, due to stenosis, vasoconstrictor causes increased vascular resistance; elastic fiber breaks, increased calcium content, collagen deposition leads to decreased arterial compliance, high intravascular Blood pressure further increases the stiffness of the arteries, making the systolic blood pressure more pronounced than the diastolic blood pressure.
There is also important evidence from the clinical point of view: the main reason for the rapid increase of early systolic blood pressure is the increase of peripheral vascular resistance, while in the advanced stage it is mainly due to the hardening of the aorta. First, in the elderly, the increase of pulse pressure and The decrease in diastolic pressure represents the hardening of the aorta. Second, with age, diastolic blood pressure does not reflect the resistance of the blood vessels. Third, the hardening of the aorta rather than the increase in small blood vessel resistance affects the blood flow of normal and hypertensive individuals. The main factors of kinetics, fourth, if no treatment is given to SHE, it will accelerate the development of arteriosclerosis, thereby promoting further hypertension and aggravating the vicious cycle of arteriosclerosis.
Older people have reduced sensitivity to carotid sinus and aortic arch baroreceptors (25%):
Reduces the body's ability to buffer blood pressure fluctuations. Baroreceptor sensitivity declines in the elderly, baroreceptor sensitivity in the carotid sinus and aortic arch is reduced, the sudden increase or decrease in blood pressure is weakened, and the body's ability to buffer blood pressure fluctuations is reduced.
Drug-induced tachycardia or bradycardia can be used to detect baroreceptor sensitivity, and baroreceptor sensitivity is reduced to cause orthostatic hypotension in the elderly, as plasma norepinephrine-positive blood pressure responsiveness increases with age. The afferent branch of the baroreflex is complete; therefore, the main cause of the change in sensitivity is the abnormality of the efferent branch. The atherosclerosis of the carotid artery and the aortic arch is the cause of the damage of the baroreceptor, so the abnormal reflection promotes the blood pressure of the elderly. It is elevated and has a certain relationship with the variation of blood pressure.
Sympathetic nervous system reactivity changes (20%):
The insulin resistance of the elderly and the degenerative changes of the kidney are involved in the pathogenesis of senile hypertension. Sympathetic nervous system reactivity changes Norepinephrine levels in plasma increase with age, plasma norepinephrine at 410 years old is 410pg / ml, twice as many as 10 years old, and plasma norepinephrine The increase is likely to be the result of increased secretion. When standing and clenching, the plasma levels of norepinephrine in the elderly are higher than those in the young, although the heart rate of the elderly is less favorable for norepinephrine than for young people. The level of norepinephrine increased during exercise. The increase in plasma norepinephrine was higher in normal subjects than in hypertensive patients. The plasma catecholamine levels in hypertensive patients were higher than those in normal blood pressure.
The elderly heart has poor reactivity to 1 receptor agonists, but has no change in response to 2 receptor agonists. The effect of 1 receptor antagonists on the elderly is worse than that of young people, mainly due to the post-receptor mechanism. In some vascular beds and kidneys, 2 receptor-mediated vasodilation is also reduced. With the increase of age, the reactivity of 1 and 2 receptors has not changed significantly. The vasodilation of the elderly is less responsive to acetylcholine. With the increase of age, the sympathetic nervous system changes mainly in the 1 receptor of the heart, cholinergic receptors, 1 receptors of blood vessels and 2 receptors. The increase of norepinephrine has nothing to do with the increase of blood pressure.
Kidney glomerular filtration rate (GFR) gradually decreases with age. Recent studies have found that the reduction of GFR is not necessarily the process of aging. In the elderly, changes in renal function cannot explain the cause of hypertension. .
Insulin resistance to normal body weight, hypertension without diabetes is similar to normal people's plasma basal insulin and C-peptide levels, but the response to glucose intake and mixed diet is significantly enhanced, insulin-promoted glucose uptake is reduced in hypertensive patients and insulin The metabolic clearance rate is low, but there is no change in the production of glucose in the liver. Elderly hypertensive patients, especially obese patients, have obvious insulin resistance. In elderly patients with hypertension and normal blood pressure, the level of calcium in fat cells is increased. Calcium channel blockers The leveling can normalize intracellular calcium levels and insulin reactivity, so in the elderly, changes in insulin reactivity and/or metabolism are associated with hypertension.
Impaired endothelial function The endothelial function of hypertensive patients is found to be impaired by injection of endothelium-dependent vasodilator acetylcholine, but its role in the pathogenesis of hypertension is unknown.
Obesity gradually increases with age, muscle tissue decreases, and adipose tissue increases. The increase of body mass index is weakly correlated with the occurrence of hypertension in the elderly.
Although in the elderly, with the increase of vascular resistance and mean arterial pressure around the exercise, the systolic blood pressure decreased by 14 mmHg after endurance training in the elderly with an average age of 71.5 years. Many studies found that after a large amount After exercise training, the systolic blood pressure drops significantly. Therefore, as the age increases, the reduction in exercise can increase the systolic blood pressure level.
Prevention
Senile systolic hypertension prevention
1, the elderly should pay attention to eliminate the risk factors of cardiovascular disease, avoid emotional excitement, quit smoking, drink less, and maintain weight close to the normal range is good for health.
2, in daily life, pay attention to limit the intake of sodium salt, adhere to moderate physical exercise.
3, once found that senile hypertension should adhere to regular medication, do not arbitrarily reduce or stop the drug.
Complication
Elderly systolic hypertension complications Complications heart failure arrhythmia
Elderly systolic hypertension is complicated by complications such as left ventricular hypertrophy, heart failure, and arrhythmia.
Symptom
Symptoms of systolic hypertension in the elderly Common symptoms High blood pressure, fatigue, palpitation, basal ganglia, vertigo, dyspnea, cardiac hypertrophy, heart failure, arrhythmia, dizziness
In elderly patients with systolic hypertension, systolic blood pressure, moderate increase is often asymptomatic, and in the health check, severe hypertensive patients may also have symptoms such as dizziness, dizziness, palpitation, fatigue, etc. Heart failure.
1, blood pressure changes:
It is generally believed that the 24-h dynamic blood pressure mean fluctuations of the elderly with normal blood pressure are the same as those of the young and middle-aged normal blood pressure. The peak time of blood pressure is 6am~10pm, and the low peak time is 10pm~6am, indicating that the day-night fluctuations of the elderly normal blood pressure are in line with the circadian rhythm. Sexual activities, but different from elderly hypertensive patients, Zhang Lin and other non-invasive automatic 24h ambulatory blood pressure monitoring technology, the blood pressure results of 70 elderly patients showed that the normal blood pressure group and the light and medium-sized hypertension group had obvious fluctuations in day and night blood pressure. Different, the former is rising during the day and falling at night, the latter is bimodal and double-valley; the fluctuation range is also different, the former systolic blood pressure fluctuation range <6.7kPa (50mmHg), diastolic blood pressure <5.5kPa (40mmHg), the latter Systolic blood pressure and diastolic blood pressure are greater than the fluctuation range of the normal group. Clinical trials also show that the peak-to-valley performance of senile systolic hypertension is completely opposite to normal, and morning hypertension occurs. It is worth noting that the blood pressure is also affected by the season. Influence, Jinchi Yufu used a portable 24h ambulatory blood pressure monitor to observe the seasonal changes of blood pressure in patients with essential hypertension. Measurement results: old During the whole day, the average blood pressure during the day was higher in summer than in summer, and was centered in autumn and spring. The spring group was higher in winter than in winter and summer. This was different from the old group. The seasonal variation of mean blood pressure was mainly in diastolic blood pressure in the Zhuangnian group. In the elderly group, systolic blood pressure is the main, especially in the elderly over 70 years old. Even in the antihypertensive treatment, the systolic blood pressure is still increased in winter. The above facts suggest that the treatment of senile systolic hypertension cannot ignore the blood pressure at night or morning. The effects of changes and seasons on high blood pressure.
2. Changes in the heart:
Older systolic hypertension increases left ventricular afterload and cardiac work, with collagen fiber increase and amyloidosis, which makes cardiac hypertrophy, diastolic and systolic function impaired, and is easy to induce heart failure. Clinical manifestations can occur after patients have activity. Painful, shortness of breath, easy to get tired, severe cases have paroxysmal nocturnal dyspnea, can not be supine, heart dullness is enlarged, heart sound is strong, the second heart sound of the aortic valve area is hyperthyroidism, sometimes can smell the gallop and the two lungs The symptoms and signs of left heart failure such as wet heart sounds at the bottom, and the incidence and characteristics of arrhythmia in patients with isolated systolic hypertension are not known. Kostis JB et al studied 4674 patients with isolated systolic hypertension, aged 60 years old, contracted. The pressure was 21.329.2kPa (160219mmHg), and the 12-lead electrocardiogram (basal value) ventricular ectopic beat (VPB) was recorded as 5.6%, and the 2-minute lead-lead ECG ventricular ectopic beat was 8.2%. In the 2 minute ECG record, 1.3% of patients had 6 to 10 VPBs, and 0.7% had more than 10 VPBs. The incidence of VPB was related to age. Those aged 80 years were higher than those <70 years old, and the number of episodes was higher. Men are more likely to occur than women The average number of VPB was higher than that of women. In addition, the incidence and frequency of VPB in patients with Q/QS waveform or left ventricular hypertrophy were higher, and patients with serum potassium <3.5 mmol/L had higher incidence of VPB. The results suggest that VPB can occur in elderly patients with systolic hypertension, especially in men with coronary heart disease, Q/QS waveform of ECG and left ventricular hypertrophy are associated with VPB, indicating that VPB occurs in these patients, possibly It is a certain role of coronary heart disease and left ventricular hypertrophy.
Examine
Examination of senile systolic hypertension
1, blood test
Serum blood lipids, blood sugar, uric acid, creatinine, serum potassium, sodium, and whole blood counts were measured to understand the risk factors associated with cardiovascular disease.
2, urine check
Can be used to determine the presence or absence of secondary systolic hypertension with evidence of primary disease and target organ damage.
3, ECG and dynamic ECG
It can be timely found that patients with systolic hypertension have left ventricular hypertrophy, arrhythmia and associated with myocardial ischemia, which is conducive to the assessment and treatment of the disease.
4, echocardiography
Echocardiography has a high value in understanding left ventricular structure and diastolic filling in elderly patients with isolated systolic hypertension. Saige A et al applied conventional M-mode, two-dimensional and pulsed Doppler echocardiography in 1201 cases of critical simple contraction in the elderly. Cardiac structure and function of patients with hypertension (systolic blood pressure 18.7 to 21.20 kPa; diastolic blood pressure <12.0 kPa), found good left ventricular systolic function, mild increase in left ventricular wall thickness and impaired diastolic filling measured by Doppler, indicating Critically systolic hypertension also has a mild effect on left ventricular structure and diastolic filling. Therefore, early echocardiography can detect changes in left ventricular structure and function.
5, chest X-ray
Routine examination to understand the size of the heart and lungs, with or without respiratory diseases.
Diagnosis
Diagnosis and diagnosis of systolic hypertension in the elderly
Diagnostic criteria
The diagnosis of systolic hypertension in the elderly is firstly the establishment of systolic hypertension, followed by the exclusion of systolic hypertension caused by other causes.
Precautions for blood pressure measurement in the elderly:
1, should be measured 3 times different days of blood pressure: because the elderly blood pressure fluctuations, especially systolic blood pressure, such as the results of only one measurement, it is impossible to reflect the real situation, should be similar in 3 different days, choose similar The environment, measured at the same time, is best checked by the same physician.
2, the effect of body position on blood pressure: the blood pressure of the elderly can change quite a lot with the body position. When standing up, the blood pressure is often lowered. When the seat systolic pressure is >21.3 kPa (160 mmHg), the standing blood pressure can drop by 2.7 kPa (20 mmHg). The incidence rate is as high as 30%, so the blood pressure of the patient's sitting position and standing position should be measured at the same time. The treatment decision should be based on the average of several sitting blood pressures.
3, should exclude the "pseudohypertension": due to severe sclerosis in the elderly, the cuffed balloon of the mercury column sphygmomanometer is difficult to oppress the blood flow, so the measured blood pressure reading is high, there are reports The blood pressure readings measured by the direct and indirect methods of the elderly can reach 4 kPa (30 mmHg) or more. If the patient has a high systolic blood pressure, but there is no indication of the target organ involvement, the "false hypertension" should be excluded. At this point, the cuff can be inflated so that the pressure is as high as 2.7 kPa (20 mmHg) above the patient's systolic pressure. If at this time, the stiff iliac artery can still be clearly touched, indicating the possibility of pseudohypertension, that is, the Osler test is positive, and should be further Blood pressure is measured directly by intra-arterial methods.
According to the above requirements, blood pressure systolic blood pressure > 21.3 kPa (160 mmHg), diastolic blood pressure < 12.0 kPa (90 mmHg) or 12.6 kPa (95 mmHg) can be established as systolic hypertension.
Differential diagnosis
Simple systolic hypertension is differentiated from systolic hypertension caused by other causes: high power circulation state or high cardiac output state may also increase heart rate, increase peripheral blood perfusion and increase systolic blood pressure, more common Such as physical activity under physiological conditions, increased systolic blood pressure caused by emotional excitement, can return to normal after rest; diseases such as hyperthyroidism, body arteriovenous fistula, etc., according to medical history, physical examination, laboratory results (such as T3, T4 ), etc., to rule out systolic hypertension caused by other causes.
