АРТЕРИАЛЬНАЯ ГИПЕРТОНИЯ У ОЧЕНЬ ПОЖИЛЫХ: ЗНАЧЕНИЕ БИОЛОГИЧЕСКОГО ВОЗРАСТА

Популяция пожилых людей гетерогенна, и люди с одинаковым хронологическим возрастом  значительно различаются  по состоянию здоровья  и функциональному статусу. Планирование терапевтических вмешательств  у людей старческого возраста  невозможно без учета их влияния на физические и когнитивные функции человека. Несмотря  на убедительную доказанность  неблагоприятного  прогностического  значения  повышенного  артериального   давления (АД) у людей среднего  возраста, его влияние на прогноз у очень пожилых продолжает обсуждаться, равно как и вопрос, следует ли лечить  артериальную  гипертонию  (АГ)  в  старческом  возрасте, и если да, то насколько интенсивно. В статье представлены результаты наблюдательных и рандомизированных клинических исследований, которые позволяют судить о том, что не хронологический, а биологический возраст становится важным критерием для принятия решения о тактике лечения АГ у пожилых людей. В статье подробно  обсуждаются  механизмы,  участвующие в  регуляции  АД, а также влияние АД на риск заболеваемости и смертности у пациентов старческого возраста. Приводятся выдержки из существующих рекомендации  по антигипертензивной терапии, а также обсуждаются вопросы лечения АГ у пациентов старшего возраста, требующие дальнейших исследований.

1. Nikolich-Žugich J, Goldman DP, Cohen PR, et al. Preparing for an Aging World: Engaging Biogerontologists, Geriatricians, and the Society. J Gerontol A Biol Sci Med Sci. 2016; 71(4): 435-4.

2. Fields LE, Burt VL, Cutler JA, et al. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 2004; 44: 398-404.

3. Boytsov SA, Balanova YA, Shalnova SA, et al. Arterial hypertension among individuals of 25-64 years old: prevalence, awareness, treatment and control. By the data from ECCD. Cardiovascular Therapy and Prevention 2014; 13(4): 4-14. Russian (Бойцов С. а., Баланова Ю. а., Шальнова С. а. и др. артериальная гипертония среди лиц 25-64 лет: распространенность, осведомленность, лечение и контроль. По материалам исследования ЭССе. Кардиоваскулярная терапия и профилактика 2014; 13(4): 4-14).

4. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34: 2159-219.

5. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of the European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens 2009; 27: 2121-58.

6. Franklin SS, Pio JR, Wong ND, et al. Predictors of new-onset diastolic and systolic hypertension: the Framingham Heart Study. Circulation 2005; 111: 1121-7.

7. Piccirillo G, Cacciafesta M, Viola E, et al. Influence of aging on cardiac baroreflex sensitivity determined non-invasively by power spectral analysis. Clin Sci (Lond) 2001; 100: 267-74.

8. Chesterton LJ, Sigrist MK, Bennett T, et al. Reduced baroreflex sensitivity is associated with increased vascular calcification and arterial stiffness. Nephrol Dial Transplant 2005; 20: 1140-7.

9. Monahan KD, Dinenno FA, Seals DR, et al. Age-associated changes in cardiovagal baroreflex sensitivity are related to central arterial compliance. Am J Physiol Heart Circ Physiol 2001; 281: H284-9.

10. Okada Y, Galbreath M, Jarvis SS, et al. Response to creatine kinase and pressor response to orthostatic tolerance. Hypertension 2013; 61: e24.

11. Okada Y, Galbreath MM, Shibata S, et al Q. Relationship between sympathetic baroreflex sensitivity and arterial stiffness in elderly men and women. Hypertension 2012;59:98-104.

12. Franklin SS. Elderly hypertensives: how are they different? J Clin Hypertens (Greenwich) 2012; 14: 779-86.

13. James MA, Potter JF. Orthostatic blood pressure changes and arterial baroreflex sensitivity in elderly subjects. Age Ageing 1999; 28: 522-30.

14. Bertinieri G, Grassi G, Rossi P, et al. 24-hour blood pressure profile in centenarians. J Hypertens 2002; 20: 1765-9.

15. Vloet LC, Pel-Little RE, Jansen PA, Jansen RW. High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals. J Gerontol A Biol Sci Med Sci 2005; 60: 1271-7.

16. Beckett NS, Peters R, Fletcher AE, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358: 1887-98.

17. Feldstein C, Weder AB. Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients. J Am Soc Hypertens 2012; 6: 27-39.

18. Kamaruzzaman S, Watt H, Carson C, Ebrahim S. The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study. Age Ageing 2010; 39: 51-6.

19. Valbusa F, Labat C, Salvi P, et al.; PARTAGE Investigators. Orthostatic hypotension in very old individuals living in nursing homes: the PARTAGE study. J Hypertens 2012; 30: 53-60.

20. Poon IO, Braun U. High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther 2005; 30: 173-8.

21. Lindeman RD, Tobin JD, Shock NW. Association between blood pressure and the rate of decline in renal function with age. Kidney Int 1984; 26: 861-8.

22. Odden MC, Tager IB, Gansevoort RT, et al. Hypertension and low HDL cholesterol were associated with reduced kidney function across the age spectrum: a collaborative study. Ann Epidemiol 2013; 23: 106-11.

23. Lewington S, Clarke R, Qizilbash N, et al.; Prospective Studies Collaboration. Agespecific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360: 1903-13.

24. Clarke R, Shipley M, Lewington S, et al. Underestimation of risk associations due to regression dilution in long-term follow-up of prospective studies. Am J Epidemiol 1999; 150: 341-53.

25. van Bemmel T, Gussekloo J, Westendorp RG, Blauw GJ. In a populationbased prospective study, no association between high blood pressure and mortality after age 85 years. J Hypertens 2006; 24: 287-92.

26. Poortvliet RK, Blom JW, de Craen AJ, et al. Low blood pressure predicts increased mortality in very old age even without heart failure: the Leiden 85-plus Study. Eur J Heart Fail 2013; 15: 528-33.

27. Poortvliet RK, de Ruijter W, de Craen AJ, et al. Blood pressure trends and mortality: the Leiden 85-plus Study. J Hypertens 2013; 31: 63-70.

28. Mattila K, Haavisto M, Rajala S, Heikinheimo R. Blood pressure and five year survival in the very old. BMJ (Clin Res Ed) 1988; 296: 887-9.

29. Satish S, Freeman DH Jr, Ray L, Goodwin JS. The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc 2001; 49: 367-74.

30. Dorresteijn JA, van der Graaf Y, Spiering W, et al. Secondary Manifestations of Arterial Disease Study Group. Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease: J-curve revisited. Hypertension 2012; 59: 14-21.

31. Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med 2012; 172: 1162-8.

32. Sabayan B, van Vliet P, de Ruijter W, et al. High blood pressure, physical and cognitive function, and risk of stroke in the oldest old: the Leiden 85-plus Study. Stroke 2013; 44: 15-20.

33. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013; 381: 752-62.

34. Benvenuto LJ, Krakoff LR. Morbidity and mortality of orthostatic hypotension: implications for management of cardiovascular disease. Am J Hypertens 2011; 24: 135-44.

35. Glynn RJ, Chae CU, Guralnik JM, et al. Pulse pressure and mortality in older people. Arch Intern Med 2000; 160: 2765-72.

36. Pastor-Barriuso R, Banegas JR, Damin J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139: 731-9.

37. Luukinen H, Koski K, Laippala P, Kivelд SL. Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med 1999; 159: 273-80.

38. Fagard RH, De Cort P. Orthostatic hypotension is a more robust predictor of cardiovascular events than nighttime reverse dipping in elderly. Hypertension 2010; 56: 56-61.

39. Rockwood MR, Howlett SE, Rockwood K. Orthostatic hypotension (OH) and mortality in relation to age, blood pressure and frailty. Arch Gerontol Geriatr 2012; 54: e255-60.

40. Penninx BW, Ferrucci L, Leveille SG, et al. Lower extremity performance in nondisabled older persons as a predictor of subsequent hospitalization. J Gerontol A Biol Sci Med Sci 2000; 55: M691-7.

41. Guralnik JM, Ferrucci L, Pieper CF, et al. Lower extremity function and subsequent disability: consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci 2000; 55: M221-31.

42. Vermeer SE, Prins ND, den Heijer T, et al. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med 2003; 348: 1215-22.

43. Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults. Neuroepidemiology 2006; 26: 52-60.

44. Baezner H, Blahak C, Poggesi A, et al. LADIS Study Group. Association of gait and balance disorders with age-related white matter changes: the LADIS study. Neurology 2008; 70: 935-42.

45. Hajjar I, Quach L, Yang F, et al. Hypertension, white matter hyperintensities, and concurrent impairments in mobility, cognition, and mood: the Cardiovascular Health Study. Circulation 2011; 123: 858-65.

46. Launer LJ, Masaki K, Petrovitch H, et al. The association between midlife blood pressure levels and late-life cognitive function. The Honolulu-Asia Aging Study. JAMA 1995; 274: 1846-51.

47. Qiu C, Winblad B, Fratiglioni L. The age-dependent relation of blood pressure to cognitive function and dementia. Lancet Neurol 2005; 4: 487-99.

48. Korf ES, White LR, Scheltens P, Launer LJ. Midlife blood pressure and the risk of hippocampal atrophy: the Honolulu Asia Aging Study. Hypertension 2004; 44: 29-34.

49. Debette S, Seshadri S, Beiser A, et al. Midlife vascular risk factor exposure accelerates structural brain aging and cognitive decline. Neurology 2011; 77: 461-8.

50. Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol 2011; 10: 819-28.

51. Skoog I. Highs and lows of blood pressure:a cause of Alzheimer’s disease? Lancet Neurol 2003; 2: 334.

52. Sabayan B, Oleksik AM, Maier AB, et al. High blood pressure and resilience to physical and cognitive decline in the oldest old: the Leiden 85-plus Study. J Am Geriatr Soc 2012; 60: 2014-9.

53. Qiu C, Winblad B, Fratiglioni L. Low diastolic pressure and risk of dementia in very old people: a longitudinal study. Dement Geriatr Cogn Disord 2009; 28: 213-9.

54. Euser SM, van Bemmel T, Schram MT, et al. The effect of age on the association between blood pressure and cognitive function later in life. J Am Geriatr Soc 2009; 57: 1232-7.

55. Feldstein CA. Association between chronic blood pressure changes and development of Alzheimer’s disease. J Alzheimers Dis 2012; 32: 753-63.

56. Lawes CM, Vander Hoorn S, Rodgers A; International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371: 1513-8.

57. Dumurgier J, Elbaz A, Dufouil C, et al. Hypertension and lower walking speed in the elderly: the Three-City study. J Hypertens 2010; 28: 1506-14.

58. Newman AB, Arnold AM, Sachs MC, et al. Long-term function in an older cohort-the cardiovascular health study all stars study. J Am Geriatr Soc 2009; 57: 432-40.

59. Shah RC, Wilson RS, Bienias JL, et al. Blood pressure and lower limb function in older persons. J Gerontol A Biol Sci Med Sci 2006; 61: 839-43.

60. Rosano C, Longstreth WT Jr, Boudreau R, et al. High blood pressure accelerates gait slowing in wellfunctioning older adults over 18-years of follow-up. J Am Geriatr Soc 2011; 59: 390-7.

61. Hajjar I, Lackland DT, Cupples LA, Lipsitz LA. Association between concurrent and remote blood pressure and disability in older adults. Hypertension 2007; 50: 1026-32.

62. Richmond R, Law J, Kay-Lambkin F. Higher blood pressure associated with higher cognition and functionality among centenarians in Australia. Am J Hypertens 2011; 24: 299-303.

63. Taekema DG, Maier AB, Westendorp RG, de Craen AJ. Higher blood pressure is associated with higher handgrip strength in the oldest old. Am J Hypertens 2011; 24: 83-9.

64. Viswanathan A, Rocca WA, Tzourio C. Vascular risk factors and dementia: how to move forward? Neurology 2009; 72: 368-74.

65. Jochemsen HM, Muller M, Visseren FL, et al.; SMART Study Group. Blood pressure and progression of brain atrophy: the SMART-MR Study. JAMA Neurol 2013; 70: 1046-53.

66. Muller M, Jochemsen HM, Visseren FL, et al; SMART-Study Group. Low blood pressure and antihypertensive treatment are independently associated with physical and mental health status in patients with arterial disease: the SMART study. J Intern Med 2013; 274: 241-51.

67. Iadecola C, Davisson RL. Hypertension and cerebrovascular dysfunction. Cell Metab 2008; 7: 476-84.

68. Strandgaard S, Paulson OB. Cerebrovascular consequences of hypertension. Lancet 1994; 344: 519-21.

69. Muller M, van der Graaf Y, Visseren FL, et al. SMART Study Group. Blood pressure, cerebral blood flow, and brain volumes. The SMART-MR study. J Hypertens 2010;28:1498-505.

70. Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a communitydwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011; 59: 383-9.

71. Rutan GH, Hermanson B, Bild DE, et al. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group. Hypertension 1992; 19(6 Pt 1): 508-19.

72. Ooi WL, Hossain M, Lipsitz LA. The association between orthostatic hypotension and recurrent falls in nursing home residents. Am J Med 2000; 108: 106-11.

73. Graafmans WC, Ooms ME, Hofstee HM, et al. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol 1996; 143: 1129-36.

74. Mehrabian S, Duron E, Labouree F, et al. Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci 2010; 299: 45-8.

75. Romero-Ortuno R, Cogan L, Foran T, et al. Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people. J Am Geriatr Soc 2011; 59: 655-65.

76. Diehr P, Williamson J, Burke GL, Psaty BM. The aging and dying processes and the health of older adults. J Clin Epidemiol 2002; 55: 269-78.

77. van Bemmel T, Holman ER, Gussekloo J, et al. Low blood pressure in the very old, a consequence of imminent heart failure: the Leiden 85-plus Study. J Hum Hypertens 2009; 23: 27-32.

78. Bejan-Angoulvant T, Saadatian-Elahi M, Wright JM, et al. Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. J Hypertens 2010; 28: 1366-72.

79. Peters R, Beckett N, Forette F, et al. HYVET Investigators. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol 2008; 7: 683-9.

80. McGuinness B, Todd S, Passmore P, Bullock R. Blood pressure lowering in patients without prior cerebrovascular disease for prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2009:CD004034.

81. Staessen JA, Thijs L, Richart T, et al. Placebocontrolled trials of blood pressure-lowering therapies for primary prevention of dementia. Hypertension 2011; 57: e6-7.

82. Staessen J, Bulpitt C, Clement D, et al. Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly. BMJ 1989; 298: 1552-6.

83. Benetos а, Bulpitt CJ, Petrovic M, et al. An Expert Opinion from the European society of hypertension-European union geriatric medicine society Working group on the management of hypertension in very old, frail subjects. Hypertension 2016; 67: 820-5.

84. Tkacheva ON, Runikhina NK, Kotovskaya YV, et al. аrterial hypertension management in patients aged older than 80 years and patients with the senile asthenia. Consensus experts of Russian Association of Gerontologists and Geriatrics, Gerontological Society of the Russian Academy of Sciences, Russian Medical Society of Arterial Hypertension. Cardiovascular Therapy and Prevention 2017; 16(1): 8-21. Russian (Ткачева О. Н., Рунихина Н. К., Котовская Ю. В. и др. лечение артериальной гипертонии у пациентов 80 лет и старше и пациентов со старческой астенией. Согласованное мнение экспертов Российской ассоциации геронтологов и гериатров, Геронтологического общества при Российской академии наук, Российского медицинского общества по артериальной гипертонии. Кардиоваскулярная терапия и профилактика 2017; 16(1): 8-21).

85. Kostis JB, Espeland MA, Appel L, et al. Does withdrawal of antihypertensive medication increase the risk of cardiovascular events? Trial of Nonpharmacologic Interventions in the Elderly (TONE) Cooperative Research Group. Am J Cardiol 1998; 82: 1501-8.

86. Langford HG, Blaufox MD, Oberman A, et al. Dietary therapy slows the return of hypertension after stopping prolonged medication. JAMA 1985; 253: 657-64.

87. Ekbom T, Lindholm LH, Odon A, et al. A 5-year prospective, observational study of the withdrawal of antihypertensive treatment in elderly people. J Intern Med 1994; 235: 581-8.

88. Walma EP, Hoes AW, van Dooren C, et al. Withdrawal of long-term diuretic medication in elderly patients: a double blind randomised trial. BMJ 1997; 315: 464-8.

89. Grinstead WC, Francis MJ, Marks GF, et al. Discontinuation of chronic diuretic therapy in stable congestive heart failure secondary to coronary artery disease or to idiopathic dilated cardiomyopathy. Am J Cardiol 1994; 73: 881-6.

90. Reuben DB, Tinetti ME. Goal-oriented patient care-an alternative health outcomes paradigm. N Engl J Med 2012; 366: 777-9.