降血压药的分类和品种

降血压药的分类和品种 1、利尿降压药——如氢氯噻嗪(双氢克尿塞)，属中效利尿剂，其降压效果温和稳定，也能增强其他降压药的降压作用，故常与其他降压药合用。但本药对血脂、血糖代谢不利，高脂血症、糖尿病人、高尿酸者一般不宜用，万一要用应慎重。另一新型制剂如吲达帕胺(钠催离、寿比山)，兼有轻度钙拮抗作用，对血糖、血脂等的代谢影响较少，但对磺胺类药过敏者忌用。利尿降压药的另一副作用是易引起低血钾症。 2、B-受体阻滞剂——老药心得安已少用，新一代当前常用的为倍他乐克(美托洛尔)和比索洛尔(康可)、卡维地洛等。这类药对血脂、血糖等的代谢也有不利影响，且对心跳慢、有痰喘病以及心脏有传导阻滞者不宜用。 3、钙离子拮抗剂(CCB)——常用的为二氢吡啶类如硝苯地平(心痛定、圣通平)、尼群地平、尼卡地平。此外，还有马丽地平、尼古地平等7个。此类药的副作用是易致面红、心悸、头晕头痛、脚踝水肿，但不影响服药。目前多用其长效制剂(每天仅服药一次)，如硝苯地平缓释或控释片(拜新同、欣然)、氨氯地平(络活喜、安内贞)、非洛地平(波依定)，拉西地平(司乐平)、伊斯拉地平等，也不影响血脂、血糖代谢。另外，还有两种非二氢吡啶类的钙the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 拮抗剂如地尔硫卓(恬尔心、合心爽)和维那帕米尔(异搏定)。前者对合并有冠心慢性心肌缺血的高血压者可选用，后者对患高血压并有室上性心动过速者适用。 4、血管紧张素转换酶抑制剂(ACEI)——代表药为卡托普利，其作用时间短，需一天服药三次。目前多用长效的如依那普利(依苏、悦宁定)、赖诺普利(利压定)、苯拉普利(洛汀新)、培哚普利(雅施达)、福森普利(蒙诺)。此外还有阿拉普利等8个，都属于这一类。其中常用的洛汀新和蒙诺作用时间长，且可通过肝和肾双通道排泄，对血脂和血糖没有不良影响。 5、血管紧张素?受体拮抗剂(ARBs)——属新一代降压药，对血糖、血脂的代谢也无不利影响，故对伴有糖尿病、高脂血症的高血压患者可放心选用，尤其对用ACEI类药引起剧烈干咳者适用。这类药当前国内在用的有氯沙坦(科索亚)、缬沙坦(代文)、替米沙坦(安内强)、厄贝沙坦(安搏维)、坎地沙坦脂片(迪之雅)、厄贝沙坦分散片等。 6、a1受体阻滞剂——这类药最初以哌唑嗪为代表，因易引起起始剂量反应、直立性低血压和晕倒，且要逐渐不断增加剂量，故对老年人应该少用。现有新型长效剂如多沙唑嗪、非洛唑嗪等，每日服药一次即可。 7、一些降血压的老药及其复方制剂。这类药有作用于中枢神经或交感神经系统或交感神经节后阻滞的药物，the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 如利血平、降压灵、呱乙啶、甲基多巴、可乐宁等。某些血管扩张剂如肼苯达嗪、敏乐定等均已基本上为新型降压药所替代或刷新，与之有关的一些复方制剂如复方降压片、复方利血平、氨苯喋啶(北京0号)、复方罗布麻片、珍菊降压片等，皆系多种药物的小剂量合成，都不同程度含有小剂量利尿剂或镇静剂、中药、维生素等。这些药只适用于轻、中度高血压病人。 老年人选用降压药的原则和用药注意事项 理想的降血压药物，应符合下列条件:(1)降压效果好，副作用轻，血压降低的谷/峰比值要大于50%;(2)能防止或逆转患者生命重要器官的损害;(3)对血脂、血糖、尿酸的代谢无不良影响，能改善胰岛素的抵抗，不引起低血钾;(4)药物作用时间长(半衰期长)，每天只需服药一次。 由于老年高血压患者常伴有冠心病、糖尿病、高脂血症等，故使用降血压药物需因人而异，并在选择药物上多加注意。 1、宜以降压作用温和、持久、效果好且副作用轻的药作为基础用药。对血压降低的要求不宜过猛、过速，一般要先用小剂量，然后视血压情况，逐渐适当增加剂量，或联合两种以上降压药同用，务使血压降到较安全水平(<140/80)，糖尿病者还应适当低于此值。 the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 2、目前老年人高血压病的治疗，多主张联合用药。据统计，单一种药对血压的有效控制率为45~55%，而联合二种药应用则为75~80%。联合用药既可减少单味药物使用的剂量，且可协同有效地干扰多种升压机制，延长作用时间和相互抵消或减少某些不良的副作用，更好地保护心、脑、肾等脏器。 3、降压药物应坚持长期服用。即使服后降压效果满意且血压相对稳定，也只能相应调整剂量，不能轻易或突然停药。否则，易发生撤药综合征，血压可迅速反弹甚或更高，还可导致焦虑、心律失常、心绞痛等。 4、老年人由于调节血压的压力感受器敏感性减低，血压易有较大幅度的波动，也易并发心脑血管事件，故对降压疗效的评定，不宜凭一时或一次的血压水平而定，而应系统地多次测定观察，即使血压有所波动也应保持在相对较安全的范围内。 5、老年人服降压药应个体化，结合患者病情组合用药。当前多倾向以钙拮抗剂(CCB)和血管紧张素转换酶抑制剂(ACEI)或血管紧张素?受体拮抗剂(ARB)为首选，如服用后降压效果仍不够理想，可适当增加小剂量的利尿剂。 6、对心跳快、有交感神经兴奋的易激动的高血压患者，或合并有冠心病、心绞痛、心脏早搏者，可在首选药the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 用基础上，加服?茁-受体阻滞剂(如倍他乐克等)。但此类药对高脂血症、高血糖者不宜选用，且对心跳过慢，有气喘病、心脏房室传导阻滞者忌用。 7、小剂量的噻嗪类利尿剂——双氢克尿塞和任何一种降压药合用，都有较好的协同降血压效果。但本药较大剂量长期应用对糖尿病、高脂血症和肾功能不全者是不宜的，也可招致低血钾。 8、降血压药应尽可能不要在夜间服用。当然对有晨间高血压者可视情另作别论。 老年高血压病特点及降压药应用 张小群 高血压是当今世界最广泛流行的心血管疾病，又是引起冠心病、脑率中和肾功能衰竭的重要危险因素。及早防治老年高血压，提高老年人生存质量，延年益寿具有重要价值。 1 老年高血压血液动力学特点及其对心血管的影响 有专家认为，老年高血压的血液动力学改变取决于高血压类型。来自中年期原发性高血压者，多属舒张期型高血压，其特点是心排出量减少，外围阻力增高。伴发主动脉硬化的收缩性高血压，心排出量常不减少，甚至反而增加，外围血管阻力多属正常the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 甚至降低。由于老年血压多以收缩压增高为主，可增加心脏作功和加重左室后负荷，对左室功能起负效应作用，易诱发心力衰竭;加上胶原和淀粉和淀粉样纤维沉着，可导致心肌变硬和顺应性降低，致使收缩间期延长。此外，随年龄增长，心脏对儿茶酚胺的刺激反应也有损伤，这也许与心肌的肾上腺素能受体数量减少和敏感性降低有关。 老年人动脉壁可发生许多变化，这些变化包括动脉内膜和中层变厚。伴弹性蛋白，脂质和钙含量增加，内皮细胞表面不规则和内膜下间隙细胞侵润。老年高血压对上述改变明显。 2 老年高血压的体液特点 老年高血压时，80%为低肾素型高血压。因周围血浆肾素活性(PRA)随年龄增长而降低，年龄超过60岁以上高血压患者约半数PRA降低。至于血浆醛固酮水平。有资料表明:老年人醛固酮水平比中年人显著降低。血管腔内的血容量，心缩搏出量，肾血流量及血浆、肾素均比年青高血压低。老年人肾小球滤过率降低、稀释功能下降、保纳功能降低。老年人压力感觉器的敏感性下降，因而自动调节功能障碍而致血压增高。再因老年人活动少，脂肪较多，也是引起血压增高原因之一。老年人继发高血压则相对减少。 3 老年高血压的诊断标准 老年是一个生物学分界概念。目前我国将60岁或以上者列为老年人范畴。老年人高血压诊断标准与中年人相同。但老年人the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 单纯收缩压升高而舒张压不高现象比较多。1993年WHO将单纯收缩期高血压(ISH)(?140/<90)定为一型。将140-160/<90，定为该型的亚组，称临异性单纯收缩期高血压。此型多伴动脉硬化。如由中年期原发性高血压延延续而来者，则多属舒张型高血压。即舒张压?95mmHg。但也有不少患者属于收缩压和舒张压均增高的混合型。此外，少数可伴发主动脉关闭不全或肾动脉硬化所致肾血管性高血压。老年人比年青人多见。若有下列情况，应考虑其它性质的继发性高血压;舒张期高血压出现在55岁以后。(原发性高血压出现年龄往往在此以前)。或原来控制得很好的高血压突然恶化，DBP?120mmHg，视网膜严重病变，自发性低血钾，多提示嗜铬细胞瘤。 对老年高血压诊断易注意漏诊和误诊。由于动脉硬化，听诊在第一音后往往有较大间隙，会将第一音漏掉而漏诊。还有老年人体位改变，立位或坐位时不高，而卧位血压高。所以要侧坐和卧位两种姿势的血压。有时因大血管硬化，血压波动大。还应测双上肢血压，在不同时间测3次。对疑有高血压者，应结合病史症状作心电图，X线，心超声检查确诊。 4 老年高血压的治疗 老年高血压有主张贯彻整体治疗原则，药物治疗与心理治疗，生活规律，合理饮食相结合。事实证明，长期正规治疗(不无故停药，换药或减量)，对防治高血压及其严重并发症很有效。对轻度高血压可先采用非药物治疗。 the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 4.1 非药物治疗 4.1.1 减轻体征，限制钠盐;肥胖与高血压有明显关系，减轻体重可使血压下降。同时，限制钠盐。我国饮食摄钠量平均为15克/d，远超过WHO建议3,5g/d。 4.1.2 补充钾盐 高血压的发生率与钾的摄入量成负相关。补充钾盐降低血压，因为:1、钾可减少血浆肾素活性;降低交感神经活性;2、血钾浓度增加使阻力血管的紧张素?受体减少，使血管扩张。 4.1.3 补钙，补镁 高血压病人应保持足够的钙摄入。起到抑制甲状旁腺分泌高血压因子(PHF)作用。同时补充镁。低镁伴有的血钾、对降低药可产生耐药性。给予镁治疗，也可降压。 4.1.4 脂肪、纤维和素食;1、食物中减少脂肪，可使扩张血管的前列腺素增加;2、多食性纤维素食，钾盐含量高，同时减少钠，蛋白质摄入，对高血压有利。 4.2 药物治疗 对以上非药物治疗3,6月不能降压，就采用降压药治疗。把舒张压控制在100mg以下，对单纯收缩期高血压?180mmHg，无论有无症状也需治疗，宜将血压降至140mmHg以下。 对于老年高血压治疗原则:不仅积极降压，更重要是保护靶器官。防止心脑肾损害及严重并发症。另一方面，要考虑长期用药的副作用，对不同程度高血压及不同个体。其病因，病理的主要环节以及对药物的反应。必须注意用药个体化，同时注意以下the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 几点:(1)老年高血压多有全身动脉硬化，降压不可操之过急。以免影响重要脏器血供，诱发肾功不全，心肌梗塞，脑血管意外。(2)老年人植物神经功能差，避免使用交感神经阻滞剂，注意发生体位性低血压。(3)老年心肌收缩力和窦房结功能减弱，因此，避免单用抑制心肌收缩力和影响心脏传导降压药。(4)老年多伴肾功能减退，降压药应控制在常规量1/2,2/3左右。以免造成药物毒性反应。(5)避免用强利尿剂，防止电介质紊乱。 4.2.1 利尿剂 适合浮肿、心力衰竭老年患者。常用双氢克尿量。此药不引起体位性低血压。缺点干扰代谢，血糖增高，引起低钠、低钾、目前主张用吲达帕胺2.5mg/gd，此药毒利尿又钙拮抗，可以经肾、胆汁排出。肾衰也适用。对糖，血脂无影响，正被选为一线降压药。对老年高血压使用利尿药，推荐用小剂量，定期测血钾、血脂、电介质和血糖。 4.2.2 β阻滞剂，适应心动过速，劳力型心绞痛对老年高血压降压较青年高血压差。因前者多属低肾素型高血压，故不作为首选。β阻滞剂能减慢心率，对抗心律失常，对高肾素型高血压或肾性高血压，伴有心绞痛、心肌梗塞适宜。可选择β阻滞剂如阿替洛尔，美托络尔，降低外周阻力。临床上用杓型高血压采用比索珞尔5,20mg/gd，能有效控制24小时血压及晨醒的高峰血压,1,，还可采用卡维地洛，此药不影响血脂，血糖，且能增加心排血量。降低外周阻力，也是治疗心衰的新药,2,。对β阻滞剂，老年高血压用药付作用较多，因可使左室损害和支气管the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 收缩。故对有窦房结病变，左室功能不全和阻窦性肺气肿老年高血压不宜使用。 4.2.3 CCB能扩张阻力血管、增加心脑肾血流。逆转左室肥厚量抑制硬化形成，对脂、糖代谢影响小，降低支气管平滑机张力，适应伴冠心病、糖尿病、重症高血压治疗。推荐是尼莫地平30mgtid，硝华吡淀10,20mgtid，或选择硝苯吡啶缓释症30mgqd，尼索地平5mg.qd、氨氯地平2.5mg,10mg.qd，老年高血压主张长效制剂使用方便，降压平稳，且硝苯吡啶控释后和氨氯地平降低血压不影响昼夜节律，降压效应谷/峰比较满意,3,。拉西地平降低夜间血压，也能有效控制高峰期血压，宜用均型同时有冠心病患者,1,。但本药有头晕，面朝红，浮肿、心动过速，故应小剂量开始，或合用利尿剂或ACE减轻,2,。 4.2.4 ACE1 能递转左心室肥厚，对高血压伴糖尿病可减轻肾小球硬化，改善胰岛素敏感和糖耐量异常，具有保钾作用，对心衰适用。但对双侧肾动脉狭窄不用。老年人用量宜小，防直立性低血压。常用药物;卡托普利12.5mg/日，依那普利2.5mg/日，长效制剂赖诺普利5mg/日，培哚普利1mg/日。24小时降压显而稳定。付作用有低血压，高血钾，避免与含钾利尿合用;干咳高达10,20%,2,。曾有专家指出，吸入色甘酸钠可有效，或更换其它ACE1。曾有专家指出，吸入色甘酸钠可有效，或更换其它ACE1，消除药源性咳嗽,4,。 4.2.5 α阻滞剂 易致直立性低血压。最大优点不致糖代谢the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 紊乱，能降低LDL和HPL，能降低血糖和胰岛素水平。适用高血压并冠心病，糖尿病者。新型药多沙唑嗪1,16mg/日，四喃唑嗪能改善尿流情况，对伴前列腺可作首选,5,。但此药易产生低血压，老年人慎用。 4.3 降压药选择及联合应用 目前认为老年高血压可选择利尿剂、ACE1抑制剂、钙拮抗剂较行之有效宜。β阻滞剂及α阻滞剂付作用多，老年患者应慎用。 对伴有各种并发症老年高血压降压选择。如表 并发症 选择药物 充血性心力衰竭 利尿剂、ACE1 糖尿病 ACE1、钙阻滞剂，α阻滞剂 肾功能不全 利尿剂、钙阻滞剂 心绞痛 β阻滞剂、钙阻滞剂ACE1 高脂血症 α阻滞剂，钙阻滞剂，ACE1 脑血管病 利尿剂、β阻滞剂，钙阻滞剂 关于联合用药，对单用药效果不佳，采用换药或联合用药。:利尿剂+β阻滞剂;ACE1或CCB;β阻滞剂+CCB或α阻滞剂;CCB+ACE1。其优点是纳多种药物入一丸。发挥协同作用，提高疗效，减少药量和付作用。缺点是各药剂量恒定，难以单独调整。为提高患者服药依从性和保持血中药浓度，现提倡缓解，长效降压药，达到全天候治疗。目前市面上出现全新血管the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine 紧张素受体拮抗剂，如芦沙坦50mg/d，能平稳24小时血压，对 轻中度高血压有效。包括肾功能不全和接受透析治疗病人。且咳 嗽副作用小。 the needs of future rehabilitation centre. facilitates future expansion of the hospital-wide voice communications, reducing costs due to expansion. Taking into account the special nature of public hospital, from a security point of view, the internal network of centres for the rehabilitation of the project system and Internet construction independently. to protect data within medical rehabilitation center from influence of external network, ensure safe and reliable medical information. Intranet for the hospital's internal network and not the hospital external link external network and an external network and data Association, two independent sets of network equipment. Medical network to four-room for 2 large Gigabit switches at the core, double-machine