有心血管病,要特别防跌倒!美国心脏协会声明

2022-05-22 中国循环杂志 中国循环杂志

一项针对老年人的大样本回顾性分析得出结论,与无心衰的患者相比,有心衰的人跌倒的风险高14%。

跌倒,好似离我们很遥远,但事实上,每年每4位老人中就有1人跌倒,进而引起受伤、住院甚至死亡。

跌倒也是我国伤害死亡的第四位原因。在65岁以上的老年人的死亡原因中,跌倒致死排首位。

心血管相关和非心血管相关的跌倒风险均随年龄的增长而增加。在心血管病患者中,40%~60%有跌倒风险。

就这个问题,5月19日,美国心脏协会(AHA)专门发布了预防心血管病患者跌倒的科学声明。

声明指出,跌倒不仅会导致患者受伤,增加医疗费用,并且还影响生活质量。

在有心血管病的患者中,心衰和心律失常患者跌倒风险尤其较高,可能是由于心输出量减少、服用多种药物或与其他合并症的相互作用所致。

声明指出,常常在使用一些耐受性良好也有效的心血管药物时,如果患者所合并的疾病或服用的药物,影响血压或步态及平衡时,就可能促成跌倒。

另外,服用某些非心血管药物、环境温度变化、液体摄入、被家中地毯或宠物绊倒、认知障碍等,均会增加老年心血管病患者的跌倒风险。

这则声明也提出应对心血管病患者跌倒的相关策略,包括调整药物治疗、重新评估治疗计划、考虑非药物治疗方案以及正确管理心律失常。

心衰和房颤是跌倒的高危人群

在患有心衰的成年人中,跌倒率为43%,而其他慢病患者约30%。

一项针对老年人的大样本回顾性分析得出结论,与无心衰的患者相比,有心衰的人跌倒的风险高14%。

房颤患者也容易跌倒,与无房颤的患者相比,跌倒风险增加98%。

声明指出,降低患者跌倒风险,首先要识别风险因素,选择可能的适宜干预措施。

注意增加跌倒风险的药物

同时使用多种药物会增加跌倒的风险。

但临床上,跌倒导致骨折后在许多情况下,还会添加其他药物,从而进一步增加跌倒和骨折的风险。

增加跌倒风险的药物包括降糖药物、降压药物、抗心律失常药物、抗焦虑、抑郁和癫痫药物。

除此外,地高辛、利尿剂、抗精神病药、阿片类药物和安眠药也会增加跌倒风险。

降压药和袢利尿剂,是患者发生低血压和因直立性低血压跌倒的潜在因素。

与选择性β受体阻滞剂相比,服用非选择性β受体阻滞剂和α、β-受体阻滞剂的患者跌倒风险增加。

在炎热天气下,若饮水不足也可发生低血压。其他心血管药物,如地高辛、利尿剂和抗心律失常药可能会导致头晕、精神错乱、肌肉无力或视力模糊,也有跌倒的风险。

影响中枢神经系统的药物常与跌倒风险增加,包括抗镇静药物、抗精神病药、苯二氮?类药物和阿片类药物。

老年人应筛查体位性低血压

60岁以上人群中,有30%~60%还存在体位性低血压,这也是跌倒的危险因素。声明认为,老年人应筛查体位性低血压。

针对体位性低血压,声明建议:

饭后静坐30分钟,以避免餐后低血压;

停用恶化体位性低血压的药物;

管理水、盐摄入,确保血容量正常;

使用压力袜或腹部绑带;

站立时交叉腿,或做Valsalva动作;

夜间抬高床头(约15cm);

住院时避免不必要的卧床休息。

晕厥,无论是心血管系统还是神经系统相关疾病引起,均会随年龄增长而增加,并可能导致跌倒。

虚弱,定义为生理储备减少和对压力源的易感性增加,是老年人未来跌倒的重要风险因素。

虚弱在患有心血管病的成年人中非常普遍,一半心力衰竭患者虚弱,应将其视为所有心血管病患者跌倒的重要危险因素。

北京协和医院一项研究显示,23.9%的住院老年冠心病患者合并衰弱。

对于虚弱和肌肉减少症患者,则应优化治疗,进行心脏康复,以及加强锻炼。

总之,跌倒风险与药物、结构性心脏病、心力衰竭、低血压、心律不齐、行走困难或平衡失调、感觉和认知障碍、虚弱和环境因素(地面光滑或不平、地毯松散、宠物以及有障碍物、环境光线较暗、温度变化)有关。

*:包括低心脏指数、血管闭塞、血管扩张或急性夹层

图1预防与管理心血管病患者跌倒的方法

来源:

[1]QuinED,etal.PreventingandManagingFallsinAdultsWithCardiovascularDisease:AScientificStatementFromtheAmericanHeartAssociation.CardiovascularQualityandOutcomes,Originallypublished19May2022.

[2]张宁,朱文玲,刘晓红,等.住院老年冠心病患者合并衰弱的患病率及影响因素研究.中国循环杂志,2019,34:640-645.DOI:10.3969/j.issn.1000-3614.2019.07.004.

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    2022-05-22 ms6000001791212108

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