Is it more dangerous to have such a big difference between systolic blood pressure and diastolic blood pressure? Pay special attention to these points in treatment.

A few days ago, Lao Xu, who had retired for many years, came to my office with great anxiety. It turned out that during the free physical examination in the community recently, the doctor found that his wife's blood pressure was very high, reaching 170 /68 mmHg, so he came to the hospital to ask if this situation needed further examination and treatment.

Photography: Chen Zhanbiao

I picked up the medical report he brought and looked at it. In addition to high blood pressure, there is actually hyperlipidemia. Lao Xu was very worried and asked me why his wife's blood pressure was so different from low blood pressure. Is this situation more dangerous?

Most patients in the Department of Cardiology are elderly people, so this problem is very common in Lao Xu. In fact, this is a typical isolated systolic hypertension in the elderly. At present, the prevalence of hypertension in the elderly in China is nearly 50%, which is the most important risk factor for the incidence and death of various cardiovascular and cerebrovascular diseases, and the elderly patients with isolated systolic hypertension account for about 60% of all elderly patients with hypertension.

Photography: Chen Zhanbiao

Hypertension in the elderly refers to: age ≥60 years old, continuous blood pressure increase or more than three times, systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥90 mmHg. Simple systolic hypertension is defined as systolic blood pressure ≥ 1.40 mmhg and diastolic blood pressure < 90 mmHg.

At present, we believe that for elderly hypertensive patients, the risk of increasing systolic blood pressure is far greater than that of increasing diastolic blood pressure, which is an important factor leading to cardiovascular and cerebrovascular diseases (such as stroke, myocardial infarction, heart failure, etc.). ).

Let's take a look at the characteristics of hypertension in the elderly:

1, simple systolic hypertension, large pulse pressure difference.

There is a great difference between systolic blood pressure and diastolic blood pressure, which is what we call an increase in pulse pressure difference. The main reason is the hardening of vascular wall in the elderly, which leads to the increase of aortic stiffness and elasticity, and the poor aortic elasticity in diastolic period, so it is often characterized by high systolic blood pressure, low diastolic blood pressure and increased pulse pressure difference. The appearance of this state often indicates that the patient has developed arteriosclerosis and obvious peripheral vascular disease.

2. Blood pressure fluctuates greatly and the circadian rhythm is abnormal.

Elderly patients have many basic diseases and different degrees of organ degeneration, and are more susceptible to environmental changes. Some old people's blood pressure measured in my clinic may be much higher than that measured at home, and it is often high in the morning, and there may be abnormal rhythm. Blood pressure is higher at night than during the day, which is more likely to cause damage to organs such as heart, brain and kidney.

Photography: Chen Zhanbiao

3, prone to orthostatic hypotension and postprandial hypotension.

Because the cardiovascular system of the elderly is gradually hardening, the sensitivity of baroreceptors is reduced. Sudden change of posture or taking a variety of drugs can easily lead to insufficient blood supply to the brain, postural hypotension, and even syncope or fall in severe cases. According to statistics, the incidence of postural hypotension in the elderly can reach 20%~50%. The prevalence of postprandial hypotension in the elderly is 24% ~ 36%, which is mainly caused by the increase of visceral blood flow and the decrease of cardiac output after eating.

4. White coat hypertension and pseudohypertension increased.

White coat hypertension in elderly patients is often caused by mental stress and increased sympathetic nerve activity after entering the hospital outpatient department, which leads to an increase in systolic blood pressure reactivity, and some of them are also related to basic diseases such as metabolic disorders such as blood lipids and blood sugar. Pseudohypertension is more common in the elderly with severely calcified arteries, and also in patients with diabetes and uremia. These conditions require careful screening and may require 24-hour ambulatory blood pressure and other tests. At the same time, self-testing blood pressure at home is advocated.

For the treatment of isolated systolic hypertension in the elderly, we need to pay attention to the choice of schemes. When there is low diastolic blood pressure, the treatment is more difficult, because most antihypertensive drugs will reduce both systolic and diastolic blood pressure, so besides lowering blood pressure, we should also consider reducing arterial stiffness and improving arterial elasticity. The drugs available include nitrates, statins, ACEI, etc.

When does isolated systolic hypertension begin to be treated?

1, systolic blood pressure ≥ 150 mmHg, and diastolic blood pressure between 60-90 mmHg, then 1 drug or combined drug therapy can be selected.

2, when the diastolic pressure < 60 mmHg:

If the systolic blood pressure is less than 150 mmhg, you can pay attention to observation and do not need medical treatment for the time being;

If the systolic blood pressure is 150 ~ 180 mmhg, single drug and low dose antihypertensive drugs can be used cautiously;

If the systolic blood pressure is ≥ 1.80 mmHg, use low-dose antihypertensive drugs, alone or in combination.

How to choose antihypertensive drugs for isolated systolic hypertension in the elderly?

1, and only low-dose diuretics, calcium antagonists, Pulitzer or sartans are used as antihypertensive drugs. If there are adverse reactions, other drugs in this group can be used instead.

2. If the standard dose of a drug has been used, but the blood pressure is still not up to standard, you can consider adding other drugs for combined application.

3.α receptor blockers are not recommended as the first-line drugs for patients with isolated systolic hypertension without complications, and elderly patients with hypertension complicated with benign prostatic hyperplasia can start using small doses; Beta blockers are not recommended as first-line drugs for patients over 60 years old with isolated systolic hypertension. If the condition requires it, it should generally be taken in small doses.

Of course, the specific medication should be individualized by professional doctors according to the patient's condition. At the same time, I also told Lao Xu to insist on self-measuring blood pressure at home and pay attention to non-drug treatment, including low salt and low fat, balanced diet, quitting smoking and drinking, weight control, reasonable exercise and maintaining mental health. And taking medicine according to the doctor's advice and controlling blood pressure at a reasonable level will greatly reduce the occurrence of various complications.

References:

1, knowledge of China elderly hypertension diagnosis and treatment experts (version 20 17)

3. 20 17 Canadian Guidelines for Diagnosis, Risk Assessment, Prevention and Treatment of Hypertension.