老年反杓型节律高血压患者的药物选择对血压控制及心脏重构的影响

Drug choice and influence on blood pressure and cardiac remodeling in elderly hypertensive patients with riser pattern circadian rhythm

目的观察老年反杓型血压节律者中,日间血压控制是否达标的影响因素、用药选择以及对心脏重构的影响。方法连续入选2016年1月至2019年1月在我院老年内科住院的年龄≥65岁的高血压患者,通过24小时动态血压监测(24 h ABPM)筛选出反杓型血压节律患者共300例,根据日间手测血压结果是否达标分为达标组148例和未达标组152例。比较2组患者的特征及药物使用的差异,通过超声心动图方法比较血压控制是否达标对心脏结构和功能的影响。结果2组日间手测血压比较,未达标组收缩压更高,而舒张压差异无统计学意义;ABPM结果显示,2组间除舒张压外,不同时段的平均收缩压和平均脉压之间差异均有统计学意义(均P<0.05)。2组患者中,年龄、性别、冠心病、外周血管疾病、肾功能不全共患病率、血脂水平之间差异均无统计学意义(均P>0.05);糖尿病共患病率、体重指数(BMI)、氮末端脑钠肽(NT-pro-BNP)水平在血压未达标组中明显高于达标组,差异均有统计学意义(均P<0.05)。药物治疗方面,绝大多数患者(272例,90.67%)为联合用药,钙离子拮抗剂、血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂(ACEI/ARB)以及α受体拮抗剂的应用比例差异均无统计学意义,而噻嗪类利尿剂和β受体阻滞剂的应用,在日间血压达标组较未达标组明显增多。应用超声心动图评估心脏结构功能,2组患者的左心室射血分数(LVEF)之间差异无统计学意义;室间隔厚度、左心室重量指数(left ventricular mass index,LVMI)、左心房内径、E/e’值在血压未达标组均高于达标组(均P<0.05)。结论在老年反杓型节律高血压患者中,噻嗪类利尿剂及β受体阻滞剂的应用更有利于血压降至目标值。血压控制未达标患者的NT-pro-BNP水平升高,且室间隔厚度、LVMI、左心房内径和E/e’值均明显升高,显示即使同为反杓型血压节律患者中,血压控制未达目标值对心脏重构的影响更加显著。

Objective To observe the influence factors as drug choice on blood pressure and cardiac remodeling in elderly hypertensive patients with riser pattern rhythm.Methods Totally 300 hospitalized hypertensive patients≥65 years screened out of riser pattern blood pressure circadian rhythm by 24 hours ambulatory blood pressure measurement(24 h ABPM)were consecutively enrolled.By manually monitoring the blood pressure during daytime,the enrolled patients were divided into controlled group(148 cases)and uncontrolled group(152 cases).The difference of antihypertensive treatment regimen and other characters of these two groups were recorded to compare the influence on cardiac remodeling.Results Higher systolic blood pressure(SBP)was recorded in uncontrolled group with no difference of diastolic blood pressure(DBP)between these two groups by manual measurement in daytime.Expect for DBP,there were significant difference of SBP and pulse pressure(PP)between two groups based on ABPM.And there was no difference between two groups in the items of age,gender,the level of lipid and comorbidities of coronary heart disease,peripheral vascular disease and renal dysfunction(all P>0.05).But for the comorbidity of diabetes,body mass index(BMI)and the level of NT-pro-BNP,the results were significantly higher in uncontrolled group than those in controlled group(P<0.05).As for the choice of drugs,βblocker and thiazide diuretics was more chosen in controlled groups than those in uncontrolled group.There were significantly difference among thickness of interventricular septum(IVS),LVMI,E/e’and diameter of left atrium between two groups,although the left ventricular eject fraction(LVEF)was almost equal according to echocardiography.Conclusion In the elderly hypertensive patients with riser pattern circadian rhythm,thiazide diuretics andβblockers were more frequently used in favor of antihypertensive therapy.The item of NT-pro-BNP was significantly increased combined with abnormal of thickness of IVS,LVMI and left atrial diameter(LAD),and E/e’which indicate negative effect on cardiac remodeling in uncontrolled group.