老年冠心病合并高血压及糖尿病患者血压及血糖控制水平、影响因素及降压降糖药物应用现况调查

发布时间：2018-06-03 19:24

本文选题：冠心病 + 老年人　；参考：《中国人民解放军医学院》2016年博士论文

【摘要】：[目的]老年冠心病合并高血压及糖尿病患者是一类特殊的心血管疾病高危群体,高血压及糖尿病不仅是心血管疾病重要的危险因素,亦是引起冠心病患者预后不良的重要合并疾病,因此,对于了解此类同时合并有高血压及糖尿病的冠心病患者的血压血糖控制情况、影响因素及降压降糖药物治疗现状,进而给予针对性的二级预防治疗至关重要。目前,国内尚缺乏针对此类特殊的高危老年冠心病患者血压血糖控制情况、影响因素及降压降糖药物情况的流行病学报道,因此,本研究在《中国老年冠心病及其危险因素防治现状调查》的基础上对此类高危老年冠心病患者的血压血糖控制情况、影响因素及降压降糖药物使用情况进行调查分析,为提高老年冠心病二级预防的认知程度,改善此类高危患者的预后提供参考。[方法]2011年4至2011年7月对全国21个省市165家医院门诊的老年冠心病患者(≥60岁)进行多中心、非干预性、横断面的临床流行病学调查。1.纳入研究的7962例老年冠心病患者中,共筛选出1379例高血压合并糖尿病有效患者,对此类高危患者的的降压治疗、不同目标值的降压达标率、血压控制的相关影响因素、降压用药方式以及指南推荐的规范用药等进行现况调查。2.1379例高血压合并糖尿病的老年冠心病患者中1018例自愿接受糖化血红蛋白(HbAlc)检查,分析此1018例患者不同血糖达标率及相关影响因素及降糖药物使用情况。[结果]1.老年冠心病合并高血压及糖尿病患者血压控制及影响因素、降压药物使用现况调查结果(1)纳入研究的7962例老年冠心病患者中,共筛选出1379例高血压合并糖尿病有效患者,占17.3%；(1)降压目标值130/80mmHg,达标率为17.1%：血压140/80mmHg,达标率为27.5%；血压140/90mmHg,达标率为39.6%；血压150/90mmHg,达标率为51.7%；年龄≥70岁的患者中不同目标降压达标率都随年龄的增加而逐渐增高,年龄85岁的患者的降压达标率为最高,男女患者的不同目标降压达标率相接近,男性稍高于女性。(2)以血压140/90mmHg为达标目标值,单因素分析显示血压达标患者与血压未达标患者之间在年龄、文化程度、体质量指数(BMI)、静息心率、心血管疾病家族史、吸烟史、饮酒史、高血压家族史、血脂异常、缺血性脑卒中/TIA比例存在显著的统计学差异(P＜0.05)；多因素Logistic回归方程显示：小学及以下(OR=1.572,95%CI:1.321～3.131).BMI≥28.0kg/m2(OR=2.437,95%CI:1.438～ 4.329)、静息心率≥80次／分(OR=1.832,95%CI:1.130～2.431).吸烟史(OR=1.335, 95%CI:1.112～1.960)、饮酒史(OR=1.295,95%CI:1.041～1.554)、血脂异常(OR=1.790,95%CI:1.243～1.902)与患者血压未达标呈正相关(P0.05),而年龄80岁(OR=0.586,95%CI:0.417～0.854)则与患者血压未达标呈负相关(P0.051。(3)1379例患者中,接受降压治疗的患者1317例,治疗率为97.8%,降压药物使用中血管紧张素转换酶抑制剂(ACEI)使用率为37.6%、血管紧张素受体拮抗剂(ARB)为43.6%、ACEI/ARB总计为76.8%；钙离子拮抗剂(CCB)(65.5%)、β-受体阻滞剂(44.6%)、噻嗪类利尿剂(26.3%)；以上降压药物在不同年龄段、性别及高血压病程之间分布无明显差异,但随着年龄的增大β-受体阻滞剂使用率呈现降低的趋势。在降压方式中使用二联降压的方式最常见,占41.2%,其次为三联及以上用药降压占34.9%、单药降压仅占23.9%；随着年龄的增大及高血压病程的增长患者出现单药降压方式逐渐降低,而采用联合降压方式逐渐增多的趋势,而患者在男女性别之间降压方式的选取基本相似。在单药降压方式中最常见是CCB(占8.8%)；双联降压方式最常见的组合是CCB+ARB类(占11.7%)：三联及以上降压方式最常见的组合是CCB+ARB类邯-受体阻滞剂(9.2%)；高血压指南推荐的规范用药人数987例,占76.6%；二联降压方式中规范联合用药的比例为71.9%；三联及以上降压方式中规范联合用药的比例为66.1%。2.老年冠心病合并高血压及糖尿病患者血糖控制及影响因素、降糖药物使用现况调查结果(1)1018例患者平均HbAlc水平为(7.33±2.12)%,其中HbAlc6.5%及7.0%的比例分别为23.5%(239/1018)和51.2%(521/1018),男女性别之间HbAlC%水平及血糖达标率无明显差异。≥80岁患者中HbAlc7.0%比例略高于其与两组,(2)单因素分析显示：文化程度、糖尿病病程、BMI、静息心率、饮酒史、血脂异常、血压未达标与患者HbAlc6.0%具有相关性(P0.05)；而年龄、BMI、文化程度、静息心率、饮酒史、血脂异常、血压未达标与患者HbAlc7.0%具有相关性(P0.05)；多因素Logistic回归方程显示：初中、小学及以下、BMI≥28.0kg/m2、静息心率≥80次/分、血脂异常、舒张压、收缩压与患者HbAlc6.5%呈独立正相关(P0.05),而小学及以下、糖尿病病程、BMI≥28.0kg/m2、静息心率≥80次/分、血脂异常、舒张压、收缩压与患者HbAlc7.0%呈独立正才目关(P0.05)。(3)本调查中此类患者总体治疗率为94.1%(958/1008)；降糖药物治疗中使用最多的药物为a糖苷酶抑制剂(使用率为51.3%),其次为双胍类(46.7%)和胰岛素(46.7%)；以联合用药方式为主(占63.9%)；仅口服降糖药物(OAD)的占53.0%；仅使用胰岛素(INS)的有13.9%%,INS+OAD的占31.2%。仅使用INS患者的血糖达标率为47.5(HbAlc7.0%);仅使用OAD患者的血糖达标率为59.5%；使用INS+OAD患者的血糖达标率为34.3%；单一用药血糖达标率为60.2%；联合用药的血糖达标率为42.8%。[结论]1.老年冠心病合并糖尿病高血压患者接受降压的治疗率较高,但不同目标值的降压达标率差异较大且血压达标率偏低。2.老年冠心病合并糖尿病高血压患者的血压达标率受到多种因素影响,丈化程度偏低、肥胖、心率偏快、吸烟、饮酒史、血脂异常可能是影响患者血压达标的危险因素。3.老年冠心病合并糖尿病及高血压患者主要的降压药物以ARB/ACEI类为主,CCB其次,利尿剂使用偏少,主要的药物治疗方式以联合降压为主,遵循指南治疗建议的意识有所提高,但仍需加强。4、老年冠心病合并糖尿病高血压患者接受降糖的治疗率较高,但整体的血糖达标率偏低。5、此类患者的血糖达标率亦受到多种因素影响,文化程度偏低、肥胖、心率偏快、血脂异常、血压偏高可能是影响患者血糖不达标的独立危险因素。此类患者各种治疗方案的血糖达标率差异较大,且在降糖药物治疗方面存在一定不足之处,应当进一步加强此类糖尿病患者的管理以提高血糖达标率,进一步提高此类患者的二级预防治疗的效率。
[Abstract]:[Objective] the elderly patients with coronary heart disease combined with hypertension and diabetes are a special group of high risk of cardiovascular diseases. Hypertension and diabetes are not only important risk factors for cardiovascular disease, but also important combined diseases that cause poor prognosis in patients with coronary heart disease. The control of blood pressure in the patients with heart disease, the influencing factors and the current status of antihypertensive drug treatment are of great importance to the two level prevention and treatment. At present, there is still a lack of blood pressure control for such special high risk elderly patients with coronary heart disease, which affects the epidemiological reports of the conditions of the factors of blood pressure and hypoglycemic drugs. Therefore, on the basis of the investigation of the prevention and control of the risk factors of coronary heart disease and its risk factors in the elderly, this study investigates and analyzes the blood pressure and blood pressure control, the influencing factors and the use of antihypertensive drugs in these high risk elderly patients with coronary heart disease, in order to improve the cognitive degree of the two grade prevention of coronary heart disease in the elderly and improve the risk of such high-risk patients. The prognosis provides reference. [methods from 4 to July 2011]2011, the elderly patients with coronary heart disease (over 60 years old) in 165 hospitals in 21 provinces and cities of the country were polycentric, non intervention, and cross-sectional clinical epidemiological survey of.1. was included in 7962 elderly patients with coronary heart disease, and 1379 cases of hypertension combined with diabetes were selected. The antihypertensive treatment for high risk patients, the rate of different target values, the related factors of blood pressure control, the way of antihypertensive drugs and the standard medication recommended by the guide, 1018 cases of elderly coronary heart disease patients with hypertension and diabetes mellitus.2.1379 were voluntarily received glycosylated hemoglobin (HbAlc), and the analysis of this 1018 was analyzed. There were 1379 cases of hypertension and diabetes in 7962 elderly patients with coronary heart disease (1) the results of blood pressure control and influencing factors of hypertension and diabetes in the elderly patients with coronary heart disease and diabetes mellitus (1) among the elderly patients with coronary heart disease. Effective patients, accounting for 17.3%, (1) the target value of blood pressure 130/80mmHg, the target rate of 17.1%: blood pressure 140/80mmHg, the standard rate of 27.5%; blood pressure 140/90mmHg, the standard rate is 39.6%; blood pressure 150/90mmHg, the standard rate is 51.7%; the age of age more than 70 years of age increase, the age of 85 patients The rate of pressure reaching the standard was the highest, and the rate of reducing the blood pressure of the male and female patients was close to the standard, and the male was slightly higher than the female. (2) the blood pressure 140/90mmHg was the target value. The single factor analysis showed the age, the education level, the body mass index (BMI), the resting heart rate, the family history of cardiovascular disease, the history of smoking, Drinking history, family history of hypertension, dyslipidemia, and ischemic stroke /TIA had significant statistical difference (P < 0.05); the multiple factor Logistic regression equation showed that primary and below (OR=1.572,95%CI:1.321 to 3.131).BMI > 28.0kg/m2 (OR=2.437,95%CI:1.438 to 4.329), resting heart rate more than 80 times / score (OR=1.832,95%CI:1.130 ~ 2.431) Smoking history (OR=1.335, 95%CI:1.112 ~ 1.960), drinking history (OR=1.295,95%CI:1.041 ~ 1.554), blood lipid abnormality (OR=1.790,95%CI:1.243 ~ 1.902) had a positive correlation with the patients' blood pressure failure standard (P0.05), and the age 80 years (OR=0.586,95%CI:0.417 ~ 0.854) was negatively correlated with the patients' blood pressure failure (P0.051. (3) 1379 patients, receiving antihypertensive treatment. In 1317 patients, the rate of treatment was 97.8%, the use of angiotensin converting enzyme inhibitor (ACEI) was 37.6%, angiotensin receptor antagonist (ARB) was 43.6%, ACEI/ARB was 76.8%, calcium antagonist (CCB) (65.5%), beta blocker (44.6%), and thiazide diuretic (26.3%); the above antihypertensive drugs were in different years. There was no significant difference in the distribution of age, sex and hypertension, but with the increase of age, the use of beta blockers decreased. The most common way of using two hypotension in the way of lowering blood pressure was 41.2%, followed by 34.9% of the three and above drugs, and only 23.9% of the single drug hypotension; with the increase of age and high blood pressure. The way of reducing the pressure of single drug gradually decreased and the way of combined hypotension gradually increased, and the choice of the way of depressurization between men and women was basically similar. The most common one in the way of single drug hypotension was CCB (8.8%); the most common combination of double hypotension was CCB+ARB (Accounting for 11.7%): triad and The most common combination of the way of lowering blood pressure is the CCB+ARB type Handan receptor blocker (9.2%); the standard medication number recommended by the hypertension guide is 987, accounting for 76.6%, and the proportion of the standardized combined drugs in the two hypotensive way is 71.9%, and the standardized combination of the three and above hypotensive methods is 66.1%.2. elderly coronary heart disease with hypertension and sugar. The blood glucose control and influencing factors and the current status of the use of hypoglycemic drugs (1) the average HbAlc level in 1018 patients was (7.33 + 2.12)%, of which the ratio of HbAlc6.5% and 7% was 23.5% (239/1018) and 51.2% (521/1018). There was no significant difference in the level of HbAlC% between male and female sex and the rate of blood glucose standard. The proportion of HbAlc7.0% in patients over 80 years old was slightly different. Higher than the two groups, (2) single factor analysis showed: cultural degree, the course of diabetes, BMI, resting heart rate, drinking history, blood lipid abnormality, blood pressure unstandard and patient HbAlc6.0% (P0.05); age, BMI, educational level, resting heart rate, drinking history, blood lipid abnormality, blood pressure failure and HbAlc7.0% (P0.05); Factor Logistic regression equation showed: junior high school, primary school and below, BMI > 28.0kg/m2, resting heart rate more than 80 / sub, blood lipid abnormality, diastolic pressure, systolic pressure and HbAlc6.5% independent positive correlation (P0.05), while primary and below, diabetes course, BMI > 28.0kg/m2, static heart rate more than 80 / sub, dyslipidemia, diastolic pressure, systolic blood pressure and HbAlc7. 0% (P0.05). (3) the overall treatment rate of this kind of patient was 94.1% (958/1008), and the most used drugs were a glucosidase inhibitor (51.3%), followed by guanidine (46.7%) and insulin (46.7%), combined with a combination of drugs (63.9%), and only 53 of the oral hypoglycemic drugs (OAD) accounted for 53. .0%; the only use of insulin (INS) for 13.9%% and INS+OAD for 31.2%. only used INS patients to reach 47.5 (HbAlc7.0%); the standard rate of blood glucose in only OAD patients was 59.5%, the standard rate of blood glucose in patients with INS+OAD was 34.3%, and the standard rate of blood glucose in a single drug was 60.2%, and the rate of blood sugar in the combination was 42.8%.[conclusion]1.. The treatment rate of hypertension patients with coronary heart disease and diabetes is higher, but the different target values are different and the rate of blood pressure is low, the standard rate of blood pressure in.2. elderly patients with coronary heart disease combined with diabetes hypertension is affected by many factors, the degree of hypertension is low, obesity, heart rate is fast, smoking, drinking history, blood Lipid abnormality may be the risk factor that affects the standard of blood pressure in the patients.3., the main antihypertensive drugs in the elderly patients with coronary heart disease and diabetes and hypertension are mainly ARB/ACEI class, CCB is the second, the use of diuretics is less, the main way of drug treatment is combined with hypotension, and the consciousness of following guidelines for treatment is improved, but it still needs to strengthen the.4, and still need to strengthen.4, old and old. The rate of hypoglycemic treatment in patients with coronary heart disease combined with diabetes is high, but the overall standard rate of blood glucose level is low.5, and the standard rate of blood glucose in this type of patients is also affected by many factors, low cultural degree, obesity, fast heart rate, abnormal blood lipid, high blood pressure may be an independent risk factor affecting the patients' blood glucose level. There are some differences in the standard rate of blood sugar in various treatment programs, and there are some shortcomings in the treatment of hypoglycemic drugs. We should further strengthen the management of this type of diabetes to improve the rate of blood glucose standard, and further improve the efficiency of the two stage prevention and treatment of such patients.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.4;R544.1;R587.1

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