血压(BP)是指循环血液对血管壁的压力。这种压力大部分是由于心脏通过循环系统泵送血液所产生的。在没有特别说明的情况下,“血压”通常指体循环大动脉中的压力。血压通常用收缩压(一次心跳期间的最大值)和舒张压(两次心跳之间的最小值)来表示,并以高于环境大气压力的毫米汞柱作为单位。
血压和呼吸频率、心率、氧饱和度以及体温一样,是生命体征之一。成年人静息状态下的正常收缩压约为 120 millimetres of mercury (16 kilopascals) ,舒张压约为80 millimetres of mercury (11 kilopascals) ,缩写为“120/80”mmHg "。从1975年至今,全球年龄标准化平均血压大体保持不变。男性为127/79 mmHg,女性为122/77 mmHg。[1]
传统的血压测量方式是使用水银血压计进行无创测量。[2] 临床上,听诊法仍然被普遍认为是无创血压测量的金标准。[3] 然而,半自动测量法已经普及,主要是因为水银血压计潜在的汞毒性,[4] 尽管成本更高,其易用性和对动态血压或家庭血压测量的适用性也影响了这一趋势。[5] 早期水银血压计的自动化替代品存在较大误差,但经过国际标准验证的现代仪器在两种标准化读数方法之间的平均差异已小于5 毫米汞柱,标准偏差小于8 毫米汞柱。[5] 这些半自动方法大多使用示波法测量血压。[6]
血压受心输出量、总外周阻力和动脉僵硬度的影响,并根据环境、情绪状态、活动和相对健康/疾病状态而变化。 短期内,血压由压力感受器调节,压力感受器通过大脑影响神经和内分泌系统。
过低的血压称为低血压,持续过高的血压称为高血压。引起低血压或高血压的原因很多,可能是突发性或持续性的。长期高血压可诱发许多疾病,包括心脏病、中风和肾衰竭。 长期高血压比长期低血压更常见,后者通常只有在引起症状时才被诊断出来。
类型 | 收缩压, mmHg | 舒张压, mmHg |
---|---|---|
理想 | < 120 | < 80 |
正常 | 120–129 | 80–84 |
正常偏高 | 130–139 | 85–89 |
1级高血压 | 140–159 | 90–99 |
2级高血压 | 160–179 | 100–109 |
3级高血压 | ≥ 180 | ≥ 110 |
单纯收缩期高血压 | ≥ 140 | < 90 |
当血压高于115/75 mmHg时,患心血管疾病的风险逐渐增加,[7] 低于这一水平时则证据有限。[8]
观察性研究表明,动脉压维持在正常血压范围下限的人能更好地保持长期心血管健康。关于使用药物将高血压患者(尤其是老年人)血压降低至多少为最佳血压水平,医学上一直存在争议。[9]
下表显示了欧洲心脏病学会(ESC)高血压管理专题组和欧洲高血压学会(ESH)血压分类办公室对血压的最新分类(2018年)。[10] 美国心脏协会对18岁及以上的成年人采用了类似的阈值,[11] 但在2017年11月,美国心脏协会修订了血压类别的定义,将更多人纳入了高血压人群。[12]
血压时刻在波动,通常在24小时内呈现昼夜节律,[13] 早上和傍晚读数最高,夜间读数最低。[14][15] 夜间血压无法正常下降就意味着未来患心血管疾病的风险更大,有证据表明夜间血压比白天血压更能预测心血管事件。[16] 血压在更长的时间内(几个月到几年)变化,这种可变性预示着不良结果。[17] 血压也会随着温度、噪音、情绪压力、食物或液体的消耗、饮食因素、身体活动、姿势的变化(如站立、药物和疾病)而变化。[18] 由于血压的可变性和动态血压测量的预测价值,一些权威机构,如英国的国家健康和护理卓越研究所,开始提倡使用动态血压作为诊断高血压的首选方法。[19]
其他各种因素,如年龄和性别,也会影响一个人的血压。左臂和右臂的血压测量值往往相差不大。然而,偶尔会有大于10 mmHg的情况,可能需要进一步检查,例如外周动脉疾病或阻塞性动脉疾病。[20][21][22]
低血压尚无统一的诊断标准,不过一般低于90/60 mmHg即为低血压。[23] 临床上,只有出现症状时,才会被诊断为低血压。[24]
胎儿血压
妊娠期间,胎儿的心脏而非母亲的心脏增加了胎儿的血压,促进胎儿血液循环。怀孕第20周时,胎儿主动脉的血压大约是30 mmHg, 怀孕第40周时,增加到约45 mmHg。[25]
足月婴儿的平均血压:[26]
童年
阶段 | 大致年龄 | 收缩压, mmHg | 舒张压, mmHg |
---|---|---|---|
婴儿 | 1~12个月 | 75–100 | 50–70 |
幼儿和学龄前儿童 | 1~5岁 | 80–110 | 50–80 |
学龄期儿童 | 6~12岁 | 85–120 | 50–80 |
青少年 | 13~18岁 | 95–140 | 60–90 |
儿童血压的正常范围低于成人,且取决于身高。[28] 根据不同国家儿童的血压分布,确定了儿童参考血压值。[29]
老年人
在大多数社会的成年人中,收缩压从成年早期开始上升,直至70岁或以上;[30][31] 舒张压往往也同时开始上升,但在中年,大约55岁开始下降。[31] 平均血压从成年早期开始上升,中年达到稳定,而脉压在40岁后明显上升。因此,在许多老年人中,收缩压经常超过成人正常血压范围,[31] 如果舒张压在正常范围内,这称为单纯收缩期高血压。脉压随着年龄的增长而上升,这归因于动脉硬度的增加。[32] 增龄性的血压增长变化是不健康的,在一些孤立的未涵化的群体中未观察到这一情况。[33]
Site | Normal pressure range (in mmHg)[34] |
|
---|---|---|
Central venous pressure | 3–8 | |
Right ventricular pressure | systolic | 15–30 |
diastolic | 3–8 | |
Pulmonary artery pressure | systolic | 15–30 |
diastolic | 4–12 | |
Pulmonary vein/ Pulmonary capillary wedge pressure |
2–15 | |
Left ventricular pressure | systolic | 100–140 |
diastolic | 3–12 |
血压通常指体循环中的动脉压。然而,静脉系统和肺血管中的压力测量在重症监护医学中起着重要作用,但是需要使用导管进行侵入性压力测量。
静脉血压是指静脉或心脏心房的血管压力。它比动脉压低得多,一般右心房压为5 mmHg,左心房压为8 mmHg。
静脉压力的变化包括:
血压控制障碍包括高血压、低血压和血压波动过大或不适应。
动脉高血压可以作为其他问题的指标,并可能产生长期的不良影响。有时可能引起严重的问题,例如高血压急症。
动脉压力水平给动脉壁带来机械压力。较高的压力会增加心脏负荷,加剧动脉壁内的不健康组织生长(动脉粥样硬化)。压力越高,心脏负荷就越大,动脉粥样硬化就越容易发展,心肌随着时间的推移会增厚、增大并且变弱。
持续高血压是中风、心脏病发作、心力衰竭和动脉瘤的危险因素之一,也是慢性肾衰竭的主要原因。即使动脉压小幅升高也会导致预期寿命缩短。在非常高的压力下,平均动脉压比平均水平高出50%或以上,如果不得到适当治疗,患者只能生存几年。[41]
过去,人们最关注的是舒张压;但是现在人们认识到高收缩压和高脉压(收缩压和舒张压之间的数值差)也同样是危险因素。在某些情况下,过度舒张压的降低实际上可能会增加风险,这可能是由于收缩压和舒张压之间的差异增大。如果收缩压升高(大于140 mmHg),舒张压正常(小于90 mmHg),它被称为“单纯性收缩期高血压”,可能会引起健康问题。[42][43]
对于心脏瓣膜返流的患者,病情的严重程度可能与舒张压的变化有关。 在一项对心脏瓣膜返流患者的研究中,对每个人间隔2周的测量结果进行比较,当舒张压升高时,主动脉和二尖瓣返流的严重程度增加,而当舒张压降低时,严重程度降低。[44]
血压过低称为低血压。如果引起的迹象或症状,如头晕,晕厥,或在极端情况下,循环休克,则需要药物救治。[45]
动脉压低的原因包括:[46]
直立性低血压
站立时血压大幅下降(收缩压/舒张压持续下降大于20/10 mmHg)被称为直立性低血压(体位性低血压),这意味着身体无法补偿重力对循环的影响。站立会导致下肢血管中的静水压增加。横膈膜下静脉(静脉池)的扩张导致大约500毫升的血液从胸腔和上身重新流出。这导致中心血容量的快速减少和心室预负荷的减少,反过来又减少了中风容量和平均动脉压。通常可以通过多种机制来补偿,包括自主神经系统的激活,增加心率、心肌收缩力和全身动脉血管收缩以保持血压,并引起静脉血管收缩以降低静脉顺应性。静脉顺应性降低也是由于静脉平滑肌张力的内在肌源性增加,以适应下体静脉的高压。其他代偿机制包括静脉-小动脉轴突反射、“骨骼肌泵”和“呼吸泵”。这些机制通常在一分钟以内稳定血压。[47] 如果这些补偿机制失效,动脉压和血流量下降超过某一点,大脑灌注就会严重受损(即血液供应不足),导致头晕、头晕、虚弱或昏厥。[48] 通常这种补偿的失败是影响交感神经系统的疾病或药物所致。[47] 在经历过大重力(重力负荷)后,也观察到了类似的效果,例如特技飞行或战斗飞行员“拉重力”时经常会遇到的极端静水压超过身体补偿机制能力的情况。
血压的正常波动是有适应性的,也是必要的。明显高于正常值的压力波动与白质高强度有关,这一发现会引起局部脑血流减少[49] 并提高脑血管疾病的风险。[50] 在高血压组和低血压组中,与波动较小的情况相比,较大程度的波动与脑血管疾病的增加成正相关,这表明需要考虑血压波动的临床管理,即使在血压正常的老年人中也是如此。[50] 老年人和接受过血压药物治疗的人更有可能出现较大的血压波动。[50]
在每次心跳期间,血压在最大值(收缩压)和最小值(舒张压)之间变化。[51] 体循环的血压主要是由于心脏的泵送作用。[52] 平均血压的差异驱动血液循环流动。平均血流速度取决于血压和血管对血流的阻力。在没有流体静力效应的情况下(例如站立),由于能量的粘性损失,当循环血液通过动脉和毛细血管离开心脏时,平均血压降低。平均血压在整个循环中下降,尽管大多数情况发生在小动脉和小动脉中。[53] 尽管在毛细血管中观察到一些传输的脉动,但在动脉循环的较小部分脉动也减小了。[54]
重力通过静水压力(例如站立时)影响血压,静脉瓣膜、呼吸和骨骼肌收缩产生的泵也影响血压,尤其是静脉。[52]
简单来说,体循环动脉压血流动力学基于平均动脉压和脉压。对血压的影响主要体现在对心输出量[55] 和对体循环血管阻力的影响。心输出量是每搏输出量和心率的乘积,每搏输出量受血容量的影响。短期内,血容量越大,心输出量越高。这可以部分解释食盐摄入量与血压升高之间的关系,即食盐摄入量的增加可能会增加血容量,从而可能导致动脉压升高。然而,这因人而异,且关键取决于自主神经系统反应和肾素-血管紧张素系统。[56][57][58] 从长期来看,血容量和血压之间的关系更加复杂。[59] 简而言之,全身血管阻力主要由小动脉和小动脉的口径决定。血管的阻力取决于哈根-泊肃叶方程描述的血管半径 (阻力∝1/半径4)。因此,半径越小,阻力就越大。影响阻力的其他物理因素包括:血管长度(血管越长,阻力越大)、血液粘度(粘度越高,阻力越大)[60] 以及血管的数量,尤其是众多小动脉和毛细血管。动脉狭窄增加了血流阻力,然而这种阻力的增加一般不会使系统血压上升,因为它对总系统阻力的贡献很小,尽管它可能会大大降低下游血流。[61] 被称为血管收缩剂的物质会降低血管的口径,从而增加血压。血管扩张剂(如硝酸甘油)增加血管口径,从而降低动脉压。从长期来看,重塑的过程也有助于改变小血管的口径,并影响对血管活性剂的抗性和反应性。[62][63] 毛细血管密度的降低,称为毛细血管稀疏,在某些情况下也可能导致阻力增加。[64]
实际上,每个人的自主神经系统和其他调节血压的系统,特别是肾脏,[65] 应对和调节所有这些因素,因此,尽管上述问题很重要,但很少单独行动,并且给定个体的实际动脉压的反应从短期和长期来看会有很大差异。
平均动脉压是心动周期内血压的平均值,由心输出量、体循环血管阻力和中心静脉压决定:[66][67][68]
在实际计算中,CVP(较小)的影响通常被忽略,因此
最大动脉压可以通过测量收缩压和舒张压来估计 舒张压 [68]
脉压是测量的收缩压和舒张压之间的差值,[69]
脉压是心输出量(即心跳)脉动性质的结果。脉压的大小通常归因于心脏的冲程容积、动脉系统的顺应性(扩张能力)——主要归因于主动脉和大弹性动脉——以及动脉树中的流动阻力的相互作用。[69]
我们对动脉压的内源性调控了解还不是很全面,但已对下列调节动脉压的机制做出了很好的描述:
正如RAS和醛固酮释放之间的联系所示,这些不同的机制不一定相互独立。当血压下降时,许多生理级联反应开始,以便将血压恢复到更合适的水平。
目前,血管紧张素转换酶抑制剂和血管紧张素ⅱ受体拮抗剂(也称为血管紧张素受体阻滞剂)在药理学上靶向血管紧张素转换酶。醛固酮系统直接被醛固酮拮抗剂螺内酯靶向。利尿剂可以靶向液体滞留;利尿剂的抗高血压作用是由于它对血容量的影响。一般来说,压力感受器反射不是高血压的目标,因为如果被阻断,个体可能会出现直立性低血压和晕厥。
非人哺乳动物的血压与人的血压相似。相反,心率明显不同,主要取决于动物的大小(较大的动物心率较慢)。[75] 和人类一样,动物的血压因年龄、性别、时间和环境而异:[76][77] 在实验室或麻醉中进行的测量可能不能代表自由生活条件下的数值。大鼠、小鼠、狗和兔子被广泛用于研究高血压诱因。[78]
物种 | 收缩压, mm Hg |
舒张压, mm Hg |
心率, 每分钟心跳次数 |
---|---|---|---|
牛 | 140 | 70 | 75–146 |
猫 | 155 | 68 | 100–259 |
狗 | 161 | 51 | 62–170 |
山羊 | 140 | 90 | 80–120 |
豚鼠 | 140 | 90 | 240–300 |
小鼠 | 120 | 75 | 580–680 |
猪 | 169 | 55 | 74–116 |
兔 | 118 | 67 | 205–306 |
大鼠 | 153 | 51 | 305–500 |
恒河猴 | 160 | 125 | 180–210 |
绵羊 | 140 | 80 | 63–210 |
猫和狗的血压如果高于150 mmHg(收缩压)和/或95 mmHg(舒张压),则可被诊断为高血压。[77]
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