|
Ohasama研究发现，家庭自测的单纯舒张期高血压（收缩压＜137 mmHg，舒张压≥84 mmHg）并不显著影响预后[2]。其他多项较早的研究也表明，只要收缩压＜140 mmHg，单纯舒张压增高（≥90 mmHg）并不影响患者预后[5-7]。 但多项有关国人的大规模研究（包括荟萃分析）及新近国外研究表明，单纯舒张期高血压依然会增加心血管事件及靶器官损害风险，只是其强度弱于混合性及单纯收缩期高血压[5, 8-10]。 因此，单纯舒张期高血压应该予以治疗。按照目前的指南，建议把舒张压降至90 mmHg以下。 提问3：选用何种药物治疗呢？ 回答3：舒张期高血压的治疗难点在于如何尽可能选择性降低舒张压，但实际上我们缺乏这样的药物。 舒张期高血压的治疗应该首先强调生活方式改变。增加体力活动、减少工作压力及减少体重是非常有效的降低舒张压的手段；规律的起居、改善睡眠质量及适当地应用抗焦虑药物也在部分患者起到很好的降低舒张压作用。 此外，从血压的形成机理来看，影响舒张压的主要因素是外周小动脉的阻力和心率。外周小动脉阻力越高、心率越快，舒张压就越高。正是因为如此，单纯舒张期高血压的治疗药物应尽可能选择减少外周阻力及减慢心率的药物。对于心率偏快的单纯舒张期高血压患者，笔者常选择非二氢吡啶类钙通道阻滞剂或卡维地洛（因其α-受体阻断效应能更好降低外周血管阻力）；对于心率不快的患者，则选用二氢吡啶类钙通道阻滞剂、血管紧张素转换酶抑制剂或血管紧张素Ⅱ受体拮抗剂。由于利尿剂及多数β-受体阻断剂会增加外周血管阻力，因此在单纯舒张期高血压患者应尽量避免使用。 参考文献 [1] HuangJ, Wildman RP, Gu D, et al. Prevalence of isolated systolic and isolateddiastolic hypertension subtypes inChina. Am J Hypertens,2004,17(10):955-962. [2] Hozawa A, Ohkubo T, Nagai K, et al. Prognosis of isolated systolic and isolated diastolic hypertensionas assessed by self-measurement of blood pressure at home: the Ohasama study.Arch Intern Med, 2000,160(21):3301-3306. [3] MidhaT, Lalchandani A, Nath B, et al. Prevalence of isolated diastolic hypertensionand associated risk factors among adults in Kanpur,India.Indian Heart J, 2012,64(4):374-379. [4] WangY, Xing F, Liu R, et al. Isolated diastolic hypertension associated riskfactors among Chinese in Anhui Province,China.Int J Environ Res Public Health, 2015,12(4):4395-4405. [5] LiY, Wei FF, Wang S, et al. Cardiovascular risks associated with diastolic bloodpressure and isolated diastolic hypertension. Curr Hypertens Rep,2014,16(11):489. [6] Pickering TG. Isolateddiastolic hypertension. J Clin Hypertens (Greenwich),2003,5(6):411-413. [7] StrandbergTE, Salomaa VV, Vanhanen HT, et al. Isolated diastolic hypertension, pulsepressure, and mean arterial pressure as predictors of mortality during afollow-up of up to 32 years. J Hypertens, 2002,20(3):399-404. [8] ManiosE, Michas F, Stamatelopoulos K, et al. Association of isolated systolic,isolated diastolic, and systolic-diastolic masked hypertension with carotidartery intima-media thickness. J Clin Hypertens (Greenwich), 2015,17(1):22-26. [9] NiiranenTJ, Rissanen H, Johansson JK, et al. Overall cardiovascular prognosis ofisolated systolic hypertension, isolated diastolic hypertension and pulsepressure defined with home measurements: the Finn-home study. J Hypertens,2014,32(3):518-524. [10] ArimaH, Anderson C, Omae T, et al. Effects of blood pressure lowering on majorvascular events among patients with isolated diastolic hypertension: theperindopril protection against recurrent stroke study (PROGRESS) trial. Stroke,2011,42(8):2339-2341. |
|
|
