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CARDIOLOGY

Talk about the diagnosis and treatment of hypertension

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Expert introduction: Cui Bo, Chief Physician, Visiting Scholar, Department of Cardiology, University of California, Davis Medical Center
Worked at the Department of Cardiology, Hunan Provincial People’s Hospital, a teacher at the Medical College of Hunan Normal University.Member of the Echocardiography Group of the Hunan Provincial Cardiovascular Disease Committee, member and secretary of the Women’s Cardiovascular Disease Prevention Committee of the Hunan Women’s Physician Association, and a standing committee member of the Women’s Medical Association of Hunan Province.Engaged in clinical work for more than 20 years, he has rich clinical experience in the diagnosis and treatment of cardiovascular diseases such as hypertension, coronary heart disease, cardiomyopathy, heart failure, arrhythmia, etc. He is good at diagnosis, treatment and rescue of difficult and critical diseases of cardiovascular medicine.He has been engaged in cardiac ultrasound for more than 10 years. He has independently operated and diagnosed more than 6,000 cases of cardiac ultrasound. He has accumulated rich experience in the operation and diagnosis of cardiac ultrasound. He presided over one of the provincial health department projects and two of the hospital’s fund projects.Level continuing education projects, participating in a number of national and provincial research projects.More than 10 papers were published by the first author.Hypertension is the most common cardiovascular disease.According to the Fourth National Nutrition and Health Survey in 2002, the prevalence of hypertension in adults over 18 years old in China was 18.8%, but the awareness rate, treatment rate and control rate of hypertension were 30.2%, 24.7% and 6.1%, respectively.Essential hypertension, that is, hypertension, is the most important risk factor for severe end-stage diseases such as stroke, heart failure, and renal insufficiency, and is the leading cause of death in heart and brain diseases in China.Worldwide in 2001, elevated blood pressure levels led to 54% of stroke events and 47% of coronary heart disease events, and nearly half of these cardiovascular events occurred in people who were not diagnosed with hypertension.For patients with elevated blood pressure, one must determine whether there is hypertension, the second is whether it is essential hypertension or secondary hypertension, the third is the risk stratification of hypertension, and the fourth is the synthesis of hypertension.treatment.▲ Detection of high blood pressure: Detection of high blood pressure is the first step to improve the awareness rate, treatment rate and control rate of hypertension in the population.Hypertension can have no symptoms, but it can cause damage to the heart, brain, kidney and other organs until the occurrence of stroke, myocardial infarction and other events, and even lead to sudden death, so commonly known as “silent killer”; only detect high blood pressure, early prevention andTreatment can reduce the occurrence of cardiovascular and cerebrovascular events.At present, the blood pressure of the office is still used as the basis for the diagnosis of hypertension. If conditions are available, the blood pressure of the family or the monitoring of the blood pressure should be actively used to diagnose hypertension.Home blood pressure ≥ 135 / 85mmHg; dynamic blood pressure monitoring: daytime mean ≥ 135 / 85mmHg, evening mean ≥ 120 / 70mmHg, 24-hour blood pressure average ≥ 130 / 80mmHg; for the diagnosis of hypertension threshold.In order to rule out high blood pressure in Baida, find occult hypertension, assess the degree of blood pressure rise, circadian rhythm, etc., it is recommended to use dynamic blood pressure monitoring as the basis for clear high blood pressure.At present, the diagnostic criteria for hypertension used in China are still: systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg without using antihypertensive drugs.According to the high blood pressure, high blood pressure is divided into 1 to 3 grades.It is worth noting that when the systolic and diastolic pressures are of different grades, the higher grades are used as the standard.For example, the patient’s blood pressure is 140/110mmHg, and the diagnosis is hypertension level 3.▲ Identifying essential hypertension or secondary hypertension: Secondary hypertension refers to an increase in blood pressure caused by certain identified diseases or causes, accounting for about 5% of all hypertension.Comprehensive clinical screening is required when the following conditions are met: 1. Malignant hypertension; 2. Suspected clues such as limb pulse asymmetry, abdominal vascular murmur, hypokalemia, alkaline urine, full moon face,Buffalo back, paroxysmal blood pressure increased with tachycardia, headache, etc.; 3. The combination of drug treatment or poor control has been significantly increased in the near future; 4. Young patients with severe hypertension.Renal substantial hypertension is the most common secondary hypertension, followed by renal vascular hypertension, primary aldosteronism, pheochromocytoma, hypercortisolism and aortic coarctation.For patients suspected of being likely to have secondary hypertension, the following items can be selected as needed: plasma renin activity, blood and urine aldosterone, blood and urinary cortisol, blood adrenaline and norepinephrine, blood and urine catecholamines, renal angiography, renal and adrenal ultrasound, CT or MRI, sleep and respiratory monitoring.▲ cardiovascular risk stratification: clarify the diagnosis of hypertension, exclude secondary hypertension, the next step to determine the target organ damage of hypertension, accompanying clinical disease and cardiovascular risk factors for cardiovascular risk scores in patients with hypertensionThe layers, combined with the grades 1 to 3 of hypertension, are classified into low-risk, intermediate-risk, high-risk and high-risk groups.For example, it may be diagnosed as: high blood pressure level 3 high risk group hypertension heart disease heart expansion heart function level II.Hypertensive target organ damage includes: 1. left ventricular hypertrophy (cardiac ultrasound showing ventricular septum and/or left ventricular posterior wall > 11 mm or electrocardiogram suggesting left ventricular high voltage); 2. carotid ultrasound suggesting intima media thickness (IMT)) ≥ 0.9 mm or atherosclerotic plaque; 3. Carotid artery pulse wave velocity (PWV) ≥ 12 m / s; 4. Axillary arm index (ABI) < 0.9; 5. Impaired renal function: elevated creatinineOr estimated reduction in glomerular filtration rate, or proteinuria.The clinical diseases associated with hypertensive patients are: 1. Cerebrovascular disease: cerebral hemorrhage, ischemic stroke, transient ischemic attack; 2. Heart disease: angina pectoris, myocardial infarction, coronary revascularization, heart failure;3. Kidney disease: increased creatinine, proteinuria; 4. peripheral vascular disease; 5. retinopathy, hemorrhage or exudation; 6. diabetes.Cardiovascular risk factors for hypertensive patients: 1. Age > 55 years (male), > 65 years (female); 2. Smoking; 3. Impaired glucose tolerance and/or impaired fasting glucose; 4. Dyslipidemia;5. Family history of early onset cardiovascular disease (age first-degree relatives male <55 years old, female <65 years old); 6. abdominal obesity (waist male ≥90cm, female ≥85cm or obese (BMI≥28kg/m2);7. Increased blood homocysteine ​​(Hcy) (≥10μmol/L). For patients with hypertension grade 3, as long as 1-2 cardiovascular risk factors are included in the high-risk group; for clinical complicationsHypertension with diabetes mellitus is a very high risk group. Therefore, the hypertension of diabetic patients is high risk group no matter how many levels. For example, the diagnosis is 1. Hypertension level 1 high risk group 2. Type 2 diabetes ▲ hypertension comprehensiveTreatment: The basic goal of hypertension treatment is to achieve the target blood pressure to minimize the risk of cardiovascular and cerebrovascular disease and death. Target blood pressure: the blood pressure of general hypertension patients is below 140/90mmHg; the elderly (≥65 years old)The blood pressure of hypertensive patients drops below 150/90mmHg.If it can tolerate, it can be further reduced to below 140/90mmHg. The target value of blood pressure in patients with coronary heart disease and hypertension with diabetes or chronic kidney disease, heart failure or stable disease is <130/80mmHg.Under the circumstances, you can achieve blood pressure as soon as possible, and adhere to long-term compliance. 2-4 weeks after the start of treatment can assess whether the blood pressure is up to standard, if it has reached the standard, continue to maintain treatment; if it does not meet the standard, it is necessary to adjust the medication plan in time.Patients with poor or advanced age, long-term disease or target organ damage, complications, blood pressure compliance time can be extended. First, lifestyle interventions long-term adherence to lifestyle improvement is hypertension treatmentThe following points are suitable for all patients with hypertension: 1. Limited salt: the daily salt amount per person is <6g, the systolic blood pressure can be decreased by 2~8mmHg, and salt limitation is an important and effective measure for preventing and treating hypertension;Control weight: BMI should be controlled as much as possible at <24kg/m2, obese people can reduce systolic blood pressure by 10kg to 20mmHg; 3. Regular exercise: It is recommended to be at least 3 times a week.30~45 minutes; 4. Smoking cessation limit, mental health; 5. Folic acid supplementation supplemented by homocysteine. II. Treatment of antihypertensive drugs 1. Basic principles: small dose, combination, priority long-acting preparationAnd individualized treatment. In general, high blood pressure level 2 often requires two or more drugs, high blood pressure level 3 requires three or more drugs. Single-chip fixed combination preparation is conducive to improve blood pressure compliance rate andPatient compliance.2. Drug treatment of hypertension: At present, antihypertensive drugs are divided into five categories, namely calcium channel blockers (CCB), beta receptor antagonists, angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptors.Antagonists (ARB) and diuretics.(1) Calcium channel blocker: generally used as a dihydropyridine long-acting preparation, there is no absolute contraindication, there is strong antihypertensive effect, no adverse effect on glycolipid metabolism, can significantly reduce stroke events;Blood pressure, isolated systolic hypertension, diabetes mellitus, coronary heart disease, peripheral vascular disease and alcohol abuse patients; high sodium intake and non-steroidal anti-inflammatory drugs do not affect the antihypertensive effect, but also have anti-atherosclerotic effects.Can be used alone or in combination with other four drugs.(2) β-receptor antagonist: A selective β? receptor antagonist or a β receptor antagonist having both α receptor antagonism is generally used.Applicable to patients with different degrees of hypertension, especially in patients with moderate heart rate, young patients or hypertension with myocardial infarction, coronary heart disease, angina pectoris, tachyarrhythmia and chronic heart failure, the effect on elderly hypertension is relatively poor,Prevent sudden death in patients with high cardiovascular risk.For the most widely used cardiovascular drugs, it can be used in patients with hypertension, coronary heart disease, heart failure, and arrhythmia.Pay attention to side effects such as bronchospasm and bradycardia; do not stop the drug suddenly at higher doses to avoid withdrawal syndrome.(3) Angiotensin-converting enzyme inhibitor (ACEI): There is more evidence for protecting target organs, and there is no adverse effect on glycolipid metabolism, which can improve insulin resistance and reduce urine protein.For patients with hypertension complicated with heart failure, myocardial infarction, atrial fibrillation, proteinuria, impaired glucose tolerance or diabetic nephropathy.It can be combined with a low-dose diuretic or a dihydropyridine calcium antagonist.For the application of a wide range of cardiovascular drugs, can be used in patients with hypertension, coronary heart disease, heart failure, atrial fibrillation.For bilateral renal artery stenosis, pregnancy, hyperkalemia are prohibited.Patients with creatinine clearance <30 ml/min or serum creatinine over 265 μmol/L, ie 3.0 mg/dl, should be cautious and should be regularly tested for serum creatinine and serum potassium levels.Adverse reactions were mainly irritating dry cough and angioedema.(4) Angiotensin II receptor antagonist (ARB): Applicability and contraindications are associated with angiotensin converting enzyme inhibitor (ACEI), which generally does not cause irritating dry cough, and long-term treatment compliance is high.A low-salt diet or combination with a diuretic can significantly enhance its antihypertensive effect.(5) Diuretics: Low-dose thiazide diuretics can enhance the efficacy of other antihypertensive drugs and is one of the basic drugs for refractory hypertension.It is suitable for mild to moderate hypertension and has a strong antihypertensive effect on isolated systolic hypertension, salt-sensitive hypertension, obesity or diabetes, menopausal women, heart failure and hypertension in the elderly.Hydrochlorothiazide can effectively reduce blood pressure, reduce cardiovascular events in patients with hypertension, and at the same time, the price is low. At present, the guidelines for hypertension prevention in the United States, Europe and China recommend hydrochlorothiazide as the first-line drug for the treatment of hypertension.(6) Fixed low-dose combination preparation: easy to use, and the patient's treatment compliance is high.China's traditional fixed compound preparation has a clear antihypertensive effect and low price, and can be used as an alternative to the base layer antihypertensive drugs, including compound reserpine and Zhenju antihypertensive tablets.There are also many fixed combinations of ACEI or ARB plus diuretics that can be considered for use.When using a fixed combination, it is necessary to grasp the contraindications and possible adverse reactions of its components.(7) Folic acid supplementation: Folic acid is also known as vitamin B9.For patients with hyperhomocysteinemia (HHcy), a small dose of folic acid (0.8 mg/day) is recommended.In China's eating habits, traditional cooking methods such as frying, frying and frying are used to inactivate the folic acid in the ingested vegetables. Therefore, the serum folic acid level of Chinese residents is significantly lower than that of other countries, resulting in an increase in plasma homocysteine ​​levels.Increased the risk of stroke.The Hcy level of hypertensive patients in China was significantly higher than that of normal people. The plasma Hcy≥10μmol/L was the standard, and the overall high Hcy incidence rate was 75%.Folic acid supplementation is currently the most effective and safe way to reduce homocysteine, with or without vitamin B12 or B6.Treatment of hypertensive patients with folic acid to reduce homocysteine ​​has been shown to significantly reduce the risk of stroke, and therefore accounts for 75% of all patients with hypertension, "H-type hypertension (high with elevated plasma homocysteine)Blood pressure) "The population is the key population for prevention and control of stroke in China.In summary, most of the uncomplicated patients can use the above five drugs alone or in combination, and the treatment should start with a small dose.Combination therapy of three antihypertensive drugs generally must contain a diuretic.For patients with myocardial infarction and heart failure with hypertension, first consider the choice of ACEI or ARB and beta receptor antagonists, and use enough dose to improve ventricular remodeling and prevent sudden death, the target of antihypertensive is <130/80mmHg;Poor control, CCB (recommended amlodipine besylate and felodipine).For patients with diabetes and/or proteinuria, ACEI or ARB is preferred to reduce and delay the progression of diabetic nephropathy with a hypotensive target of <130/80 mmHg.Third, follow-up and patient education.

Hypertensive patients require long-term follow-up to understand antihypertensive effects and adverse reactions.Considering that blood pressure is the basic goal of treatment, blood pressure is up to 3 people every 3 months, and those who are not up to standard are followed up every 2-4 weeks. If blood pressure is not up to standard, the treatment should be adjusted in time.Health education for people with high blood pressure, monitoring blood pressure, preventing and delaying the occurrence of high blood pressure.Strengthen the education of patients with hypertension and their families, emphasize self-management of patients with hypertension, encourage self-test blood pressure, and improve treatment compliance.In short, prevention and control of hypertension requires the joint efforts of the government, experts, and doctors at all levels.Hospitals and communities are the main battlefields for the prevention and treatment of hypertension, and the key to improving the “three rates” of hypertension is education.

ouyangshaoxia

The author ouyangshaoxia