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認識高血壓

發佈日期:2013-12-31
發佈單位:華揚醫院-行政部
認識高血壓

人體的器官組織,每一個細胞,無時無刻都須要有足夠的營養和原料,例如葡萄糖和氧氣,以維持細胞本身的生存,或製造新的物質供應給別的細胞。營養和原料溶解在血液中,順著大大小小的血管運送到每一個細胞。而驅動著血液從心臟出發,流至器官組織的動力,就是心臟收縮和血管阻力互相作用產生的血壓。可以說,要保持器官組織細胞有足夠的血液灌流,須要血壓維持在一定的程度以上。

→高血壓的傷害

但是血壓過高,也會對血管造成傷害。可以分為直接傷害和間接傷害兩種。直接傷害是血管本身長期暴露在過高的壓力下,一方面管壁漸漸增厚,失去了彈性,較易折裂,一方面管腔變窄,血流減少。間接傷害是高血壓會使血管壁的內皮細胞受損,如果再合併有糖尿病,血脂肪過高,抽煙,或體質的關係,脂肪會沈積在管壁的內皮下層,形成粥狀硬化塊,造成血流減少,甚至完全塞住血管,使得下游的組織壞死。就是所謂的梗塞。

因此高血壓的傷害是全身性的,最明顯受損的器官是腦部、心臟、視網膜、腎臟以及大動脈和股動脈。造成的疾病包括中風、心絞痛、心肌梗塞、心臟衰竭、視網膜出血剝離、尿毒症、剝離性動脈瘤、間歇性跛行等等。往往一位病患同時合併有不同程度的數種疾病,而增加治療上的困難。

→血壓的變動性

以前正常血壓訂在140/90毫米汞柱以下,現在知道血壓控制在130/85以下更好,對器官的傷害會減到最少。事實上血壓並非一成不變,而是隨著身體或精神的活動而起伏,往往在睡眠中深夜三、四點最低,清晨六點慢慢上升,在早上10點多到正午最高。活動過後,須要休息5~10分鐘血壓才穩定,測量才有意義。電子血壓計量取的數值往往比水銀血壓計偏低,因此常要互相比對後,才知道自已的血壓究竟是否控制得宜。另一方面,在醫院量取的血壓往往高於家居血壓,因為情緒氣氛不同之故。詳盡規則地記錄家居血壓,能夠提供醫師調整藥物很好的參考資料。有時候家居血壓與門診血壓差距過大,何者才是病患的常態,會造成很大的困擾。此時攜帶式24小時血壓監測,記載一天中血壓的變動情況,又避開了醫院這令人緊張的環境,常能提供較為客觀的答案。近年來對攜帶式24小時血壓監測應用日廣,發現以此量得的血壓,更能預測器官受損的程度。

→高血壓病患的檢查

百分之九十五的高血壓都是特發性的,也就是並沒有確切的原因直接造成血壓的上升。但有接近百分之五的高血壓是次發性的,有其直接的病因。例如腎上腺長了分泌留鹽激素的腺瘤,開刀切除腺瘤,可能血壓就此正常;但也有找到了確切原因,卻無法根除的,例如腎絲球體腎炎造成腎實質病變引起的高血壓,既不能割掉腎臟,還是須要終身服用藥物控制。

不管次發性高血壓的比率有多少,對於每一個高血壓病例,醫師都會儘可能找尋可以矯治的原因。但並非只有實驗室的檢查才算檢查,事實上醫師對病患的病史詢問,敲敲打打,加上聽診器的理學檢查,常常可以釐清一大部份的線索,例如聽到腹部有血流嘈雜音,腎血管狹窄就是首要的考慮,再針對這方面繼續追查下去。高血壓病患的檢查,大致可分為三個方向,第一是病因方面,如果懷疑腎血管狹窄,最確定的檢查是血管攝影。第二是評估目標器官傷害的程度,例如檢查眼底視網膜的血管病變,以心臟超音波衡量心肌的肥厚等等。第三是有無與高血壓密切相關的病痛,例如糖尿病、高血脂症等等,可能會使動脈硬化加速進行,所以也要和治療高血壓一併控制。

→高血壓的治療

發覺自己有高血壓,第一步就是要從改善生活習慣著手。飲食求清淡,不要太鹹,鹽份的多少和血壓的高低有直接的關係。煙一定要戒,因為抽煙不但影響血壓,也會加速動脈硬化的進行;酒要適量,能不喝最好。要有規律的作息,以及足夠的睡眠。而且一個星期至少三次,每次30分鐘以上的運動也會改善循環,有利於血壓的控制。少部份的高血壓病患,改善生活習慣後,能夠有正常的血壓,但是大部份的高血壓病患,還是須要加上藥物治療,才能控制得宜。降血壓藥物種類很多,同一類中,藥效的長短,代謝的途徑,也有差異。如何選擇呢?那是醫師的職責,但有幾個原則可資遵循。

第一、量身訂做依病患的身體狀況選擇,例如合併心臟衰竭的高血壓病患,不宜使用貝他阻斷劑,而利尿劑則很適合。
第二、從低劑量開始。穩定、最高的藥效,可能一、二個星期後才能達到,所以除非血壓很高,或是目標器官有立即受損的可能,否則宜有充份時間的追蹤,再增高劑量,或加上別的藥物。
第三、兩種以上低劑量的降血壓藥,比單獨一種高劑量的藥物效果較好,也能避免副作用。
第四、選擇長效的藥物以一天一次最好。主要是藥效的發揮穩定、持續,血壓不會有大的波動,也能避免忘記服藥的困擾。

→幾點觀念

血壓的控制,有幾個觀念或做法,特別值得提出來討論,其一、病患往往認為舒張壓高才可怕,收縮壓高比較無妨,其實收縮壓和舒張壓對器官的影響都是一樣的,都要控制在正常範圍內才好。並不是年紀大,血壓高就是應該的,而是同樣要在140/90以下才適宜。尤其有腎臟病或糖尿病,最好控制在130/85以下。其二、病患不想吃藥,因為擔心“一旦開始吃藥,終身就要吃藥”,這是根本錯誤的觀念。須要終身服藥,是因為自己的血壓高,須要終身加以控制之故,藥物何辜?如果不吃藥控制血壓,造成目標器官的傷害,那才是後悔莫及。大多數的高血壓是不能停藥的,因為身體需要它,藥物劑量可以依控制程度調整減低,但如果完全停用,以後血壓還是會上升。其三、不同藥物的劑量不能互相比較,有的病患拒絕藥物的原因是“以前我吃的藥只有2毫克,現在這種藥一顆就100毫克”。其四、適合個人的藥就是好藥,並不是最近研發出來的新藥就優於現有的藥。媒體上常有新藥的報導,不見得適用於每個高血壓病患。國人常樂於推薦自己的經驗,“我吃得很好,你也吃吃看”。最聰明的做法是和醫師討論。其五、信任醫師,多做溝通,治療過程不順遂時,最好回去與原來的醫師討論,才能逐步調整最適合自己的療法。有的病患長期在南部治療,偶而到了台北要找名醫看病。如果新的醫師都沒有病患以前服藥的資料,如何在短時間內給予最適當的處置?

高血壓對於我們的身體,就像家中有一個負面影響的成員,既不能簡單地聲明脫離關係就能了事,就要打起精神,好好想辦法把傷害減到最少,還要付諸實行,而且是一輩子的事,所以各位病友們,大 家一起加油吧!
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