本文選題：冠心病 + 老年人��； 參考：《中國人民解放軍醫(yī)學(xué)院》2016年博士論文

【摘要】：[目的]老年冠心病合并高血壓及糖尿病患者是一類特殊的心血管疾病高危群體,高血壓及糖尿病不僅是心血管疾病重要的危險因素,亦是引起冠心病患者預(yù)后不良的重要合并疾病,因此,對于了解此類同時合并有高血壓及糖尿病的冠心病患者的血壓血糖控制情況、影響因素及降壓降糖藥物治療現(xiàn)狀,進而給予針對性的二級預(yù)防治療至關(guān)重要。目前,國內(nèi)尚缺乏針對此類特殊的高危老年冠心病患者血壓血糖控制情況、影響因素及降壓降糖藥物情況的流行病學(xué)報道,因此,本研究在《中國老年冠心病及其危險因素防治現(xiàn)狀調(diào)查》的基礎(chǔ)上對此類高危老年冠心病患者的血壓血糖控制情況、影響因素及降壓降糖藥物使用情況進行調(diào)查分析,為提高老年冠心病二級預(yù)防的認(rèn)知程度,改善此類高危患者的預(yù)后提供參考。[方法]2011年4至2011年7月對全國21個省市165家醫(yī)院門診的老年冠心病患者(≥60歲)進行多中心、非干預(yù)性、橫斷面的臨床流行病學(xué)調(diào)查。1.納入研究的7962例老年冠心病患者中,共篩選出1379例高血壓合并糖尿病有效患者,對此類高�；颊叩牡慕祲褐委�、不同目標(biāo)值的降壓達(dá)標(biāo)率、血壓控制的相關(guān)影響因素、降壓用藥方式以及指南推薦的規(guī)范用藥等進行現(xiàn)況調(diào)查。2.1379例高血壓合并糖尿病的老年冠心病患者中1018例自愿接受糖化血紅蛋白(HbAlc)檢查,分析此1018例患者不同血糖達(dá)標(biāo)率及相關(guān)影響因素及降糖藥物使用情況。[結(jié)果]1.老年冠心病合并高血壓及糖尿病患者血壓控制及影響因素、降壓藥物使用現(xiàn)況調(diào)查結(jié)果(1)納入研究的7962例老年冠心病患者中,共篩選出1379例高血壓合并糖尿病有效患者,占17.3%；(1)降壓目標(biāo)值130/80mmHg,達(dá)標(biāo)率為17.1%：血壓140/80mmHg,達(dá)標(biāo)率為27.5%；血壓140/90mmHg,達(dá)標(biāo)率為39.6%；血壓150/90mmHg,達(dá)標(biāo)率為51.7%；年齡≥70歲的患者中不同目標(biāo)降壓達(dá)標(biāo)率都隨年齡的增加而逐漸增高,年齡85歲的患者的降壓達(dá)標(biāo)率為最高,男女患者的不同目標(biāo)降壓達(dá)標(biāo)率相接近,男性稍高于女性。(2)以血壓140/90mmHg為達(dá)標(biāo)目標(biāo)值,單因素分析顯示血壓達(dá)標(biāo)患者與血壓未達(dá)標(biāo)患者之間在年齡、文化程度、體質(zhì)量指數(shù)(BMI)、靜息心率、心血管疾病家族史、吸煙史、飲酒史、高血壓家族史、血脂異常、缺血性腦卒中/TIA比例存在顯著的統(tǒng)計學(xué)差異(P＜0.05)；多因素Logistic回歸方程顯示：小學(xué)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)、靜息心率≥80次／分(OR=1.832,95%CI:1.130～2.431).吸煙史(OR=1.335, 95%CI:1.112～1.960)、飲酒史(OR=1.295,95%CI:1.041～1.554)、血脂異常(OR=1.790,95%CI:1.243～1.902)與患者血壓未達(dá)標(biāo)呈正相關(guān)(P0.05),而年齡80歲(OR=0.586,95%CI:0.417～0.854)則與患者血壓未達(dá)標(biāo)呈負(fù)相關(guān)(P0.051。(3)1379例患者中,接受降壓治療的患者1317例,治療率為97.8%,降壓藥物使用中血管緊張素轉(zhuǎn)換酶抑制劑(ACEI)使用率為37.6%、血管緊張素受體拮抗劑(ARB)為43.6%、ACEI/ARB總計為76.8%；鈣離子拮抗劑(CCB)(65.5%)、β-受體阻滯劑(44.6%)、噻嗪類利尿劑(26.3%)；以上降壓藥物在不同年齡段、性別及高血壓病程之間分布無明顯差異,但隨著年齡的增大β-受體阻滯劑使用率呈現(xiàn)降低的趨勢。在降壓方式中使用二聯(lián)降壓的方式最常見,占41.2%,其次為三聯(lián)及以上用藥降壓占34.9%、單藥降壓僅占23.9%；隨著年齡的增大及高血壓病程的增長患者出現(xiàn)單藥降壓方式逐漸降低,而采用聯(lián)合降壓方式逐漸增多的趨勢,而患者在男女性別之間降壓方式的選取基本相似。在單藥降壓方式中最常見是CCB(占8.8%)；雙聯(lián)降壓方式最常見的組合是CCB+ARB類(占11.7%)：三聯(lián)及以上降壓方式最常見的組合是CCB+ARB類邯-受體阻滯劑(9.2%)；高血壓指南推薦的規(guī)范用藥人數(shù)987例,占76.6%；二聯(lián)降壓方式中規(guī)范聯(lián)合用藥的比例為71.9%；三聯(lián)及以上降壓方式中規(guī)范聯(lián)合用藥的比例為66.1%。2.老年冠心病合并高血壓及糖尿病患者血糖控制及影響因素、降糖藥物使用現(xiàn)況調(diào)查結(jié)果(1)1018例患者平均HbAlc水平為(7.33±2.12)%,其中HbAlc6.5%及7.0%的比例分別為23.5%(239/1018)和51.2%(521/1018),男女性別之間HbAlC%水平及血糖達(dá)標(biāo)率無明顯差異。≥80歲患者中HbAlc7.0%比例略高于其與兩組,(2)單因素分析顯示：文化程度、糖尿病病程、BMI、靜息心率、飲酒史、血脂異常、血壓未達(dá)標(biāo)與患者HbAlc6.0%具有相關(guān)性(P0.05)；而年齡、BMI、文化程度、靜息心率、飲酒史、血脂異常、血壓未達(dá)標(biāo)與患者HbAlc7.0%具有相關(guān)性(P0.05)；多因素Logistic回歸方程顯示：初中、小學(xué)及以下、BMI≥28.0kg/m2、靜息心率≥80次/分、血脂異常、舒張壓、收縮壓與患者HbAlc6.5%呈獨立正相關(guān)(P0.05),而小學(xué)及以下、糖尿病病程、BMI≥28.0kg/m2、靜息心率≥80次/分、血脂異常、舒張壓、收縮壓與患者HbAlc7.0%呈獨立正才目關(guān)(P0.05)。(3)本調(diào)查中此類患者總體治療率為94.1%(958/1008)；降糖藥物治療中使用最多的藥物為a糖苷酶抑制劑(使用率為51.3%),其次為雙胍類(46.7%)和胰島素(46.7%)；以聯(lián)合用藥方式為主(占63.9%)；僅口服降糖藥物(OAD)的占53.0%；僅使用胰島素(INS)的有13.9%%,INS+OAD的占31.2%。僅使用INS患者的血糖達(dá)標(biāo)率為47.5(HbAlc7.0%);僅使用OAD患者的血糖達(dá)標(biāo)率為59.5%；使用INS+OAD患者的血糖達(dá)標(biāo)率為34.3%；單一用藥血糖達(dá)標(biāo)率為60.2%；聯(lián)合用藥的血糖達(dá)標(biāo)率為42.8%。[結(jié)論]1.老年冠心病合并糖尿病高血壓患者接受降壓的治療率較高,但不同目標(biāo)值的降壓達(dá)標(biāo)率差異較大且血壓達(dá)標(biāo)率偏低。2.老年冠心病合并糖尿病高血壓患者的血壓達(dá)標(biāo)率受到多種因素影響,丈化程度偏低、肥胖、心率偏快、吸煙、飲酒史、血脂異�？赡苁怯绊懟颊哐獕哼_(dá)標(biāo)的危險因素。3.老年冠心病合并糖尿病及高血壓患者主要的降壓藥物以ARB/ACEI類為主,CCB其次,利尿劑使用偏少,主要的藥物治療方式以聯(lián)合降壓為主,遵循指南治療建議的意識有所提高,但仍需加強。4、老年冠心病合并糖尿病高血壓患者接受降糖的治療率較高,但整體的血糖達(dá)標(biāo)率偏低。5、此類患者的血糖達(dá)標(biāo)率亦受到多種因素影響,文化程度偏低、肥胖、心率偏快、血脂異常、血壓偏高可能是影響患者血糖不達(dá)標(biāo)的獨立危險因素。此類患者各種治療方案的血糖達(dá)標(biāo)率差異較大,且在降糖藥物治療方面存在一定不足之處,應(yīng)當(dāng)進一步加強此類糖尿病患者的管理以提高血糖達(dá)標(biāo)率,進一步提高此類患者的二級預(yù)防治療的效率。
[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.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R541.4;R544.1;R587.1

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