Cappelleri Claudia, Janoschka Alin, Berli Reto, Kohler Sibylle, Braun-Dullaeus Ruediger C, Heuss Ludwig T, Wolfrum Mathias
Department of Internal Medicine, Spital Zollikerberg, Zollikerberg, Switzerland Oxford Heart Centre, Oxford University Hospitals, Oxford, United Kingdom Department of Internal Medicine/Cardiology and Angiology, Magdeburg University, Magdeburg, Germany.
Medicine (Baltimore). 2017 Aug;96(34):e7692. doi: 10.1097/MD.0000000000007692.
Elevated blood pressure (BP) is frequently diagnosed in very elderly hospitalized patients. Accurate diagnosis of hypertension is challenging in the hospital environment, due to the "white coat effect," and both overtreatment and undertreatment can adversely affect clinical outcome. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has the potential to avoid the "white coat effect" and accurately guide the management of hypertension. However, effects of the hospital environment on ABPM are unknown in the very elderly. We set out to enroll 45 patients, age ≥70 years, with elevated conventional BP during hospitalization in this observational study. It was prespecified by protocol to assess initially the difference between 24-hour BP during hospital-admission and home follow-up. Subsequent analysis should investigate the change in anxiety (Hospital Anxiety and Depression Scale-A [HADS-A]) after discharge, the correlation with change in 24-hour BP after discharge, and the prevalence of orthostatic hypertension. Thirty-one patients were included in the final analysis (age 83.5 ± 4.4 years; 71% female). Twenty-four-hour BP decreased significantly after hospital discharge (systolic from 133.5 ± 15.6 to 126.2 ± 14.4 mm Hg [millimeter of mercury], P = .008; diastolic from 71.0 ± 9.0 to 68.3 ± 8.6 mm Hg, P = .046). Anxiety level (HADS-A) decreased significantly after discharge, from 7.5 (interquartile range [IQR]: 4.0-13.8) to 5.0 (IQR: 4.0-8.0, P = .012). The change in anxiety was a predictor of change in systolic BP after discharge (F[1,20] = 5.9, P = .025). Sixty-one percent of the patients had significant orthostatic hypotension during hospital stay. In conclusion, 24-hour BP in very elderly patients is lower in the home environment than during hospitalization. This phenomenon seems to be directly linked to a lower anxiety-level at home. Reassessing hypertension at home may decrease the need for (intensified) antihypertensive medical therapy in a substantial number of patients. This is particularly important in the very elderly, who have a high prevalence of symptomatic and asymptomatic orthostatic hypotension, making them prone to hazardous effects of antihypertensive therapy.
老年住院患者中高血压的诊断较为常见。在医院环境中，由于“白大衣效应”，高血压的准确诊断颇具挑战性，过度治疗和治疗不足均可能对临床结局产生不利影响。24小时动态血压监测（ABPM）有潜力避免“白大衣效应”，并准确指导高血压的管理。然而，医院环境对老年患者ABPM的影响尚不清楚。在这项观察性研究中，我们纳入了45例年龄≥70岁、住院期间常规血压升高的患者。根据研究方案预先设定，首先评估入院时24小时血压与家庭随访时24小时血压之间的差异。后续分析应调查出院后焦虑情绪的变化（医院焦虑抑郁量表-A [HADS-A]）、与出院后24小时血压变化的相关性以及体位性高血压的患病率。最终分析纳入了31例患者（年龄83.5±4.4岁；71%为女性）。出院后24小时血压显著下降（收缩压从133.5±15.6降至126.2±14.4毫米汞柱[mmHg]，P = 0.008；舒张压从71.0±9.0降至68.3±8.6 mmHg，P = 0.046）。出院后焦虑水平（HADS-A）显著下降，从7.5（四分位间距[IQR]：4.0 - 13.8）降至5.0（IQR：4.0 - 8.0，P = 0.012）。焦虑情绪的变化是出院后收缩压变化的预测因素（F[1,20] = 5.9，P = 0.025）。61%的患者在住院期间出现显著的体位性低血压。总之，老年患者在家中的24小时血压低于住院期间。这种现象似乎与家中较低的焦虑水平直接相关。在家中重新评估高血压可能会减少相当一部分患者（强化）抗高血压药物治疗的需求。这在老年患者中尤为重要，因为他们有症状性和无症状性体位性低血压的高患病率，使他们容易受到抗高血压治疗的有害影响。
