Lecture Note: “Hypertension and Hrudroga” (Part-1) by Prof. Muralidhara Sharma

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Hypertension and Hrudroga
(Part-1)

Prof. Muralidhar Sharma
based on the lecture available at–Hypertension and Hrudroga

I consider hypertension as a disease of ‘Rasavah Srotas’.The concept of this disease itself is a unique feature. Initially, in the earlier days of physiology, people knew that there was something like a circulating pressure but it could not be measured. Also, its importance in the disease was not known till 1896, when the pressure could be measured by a cuff Sphygmo manometer was invented. Till then the study of blood pressure was only in the experimental animals in the labs where animals would be sacrificed. A tube was inserted into the carotid artery and then the pressure was measured and so on. So it was never considered something of clinical importance. So, clinical significance of measuring blood pressure came into reality only after 1896. Still, it’s not yet an established one, only the idea of considering it as a disease was only after President Roosevelt’s accidental death. It was known that he had hypertension and very interestingly he was given a healthy certificate earlier, after having the certificate in his hand, He had a cerebrovascular accident all of a sudden in a meeting and then he died. That incident became a big issue, American president died with a health certificate in 1906.  From then onwards, the interest in this circulatory pressure and then its value. Its importance in the disease was to be considered. Earlier it was not considered a disease. It was considered a physiological parameter and a variable. The study about blood pressure started only after this kind of accident when President Roosevelt’s accidental death. The effort for the further study started after1948 with the Framingham committee. Even now Framingham committee and Framingham framework of assessing blood pressure is the most important nodal center throughout the globe which collects the statistics. After all, hypertension is a disease of statistics, that’s what I say. Statistics is an interesting subject at the same time, it’s a very dangerous subject also. But the problem would be because it is a disease of the statistics. There would always some confusion as statistics is always miss leading. I usually quote this example of the statistics, suppose a surgical procedure has 1% success rate and a surgeon  assures the patient that you have a high chance of survival because 99 of my patients earlier have died and you are my 100th patients. Statistically he has to survive but what about the common sense. So common sense and statistics will have always have an issue. This issue is very important with hypertension also. Core issue which we need to consider before we go into the ayurvedic idea and ayurvedic practice point of view.

 The whole issue about the what’s the normal blood pressure. About this issue itself, there’s a lot of controversy. Guidelines and the normal values were standardized and then announced throughout globally. And this is the timeline.

Blood Pressure Goals in Patients with CKD A Review of Evidence and Guidelines Alex R. Chang, Meghan Lóser, Rakesh Malhotra and Lawrence J. Appel CJASN January 2019, 14 (1) 161-169; DOI: https://doi.org/10.2215/CJN.0744061

Every almost every two or three years the normal blood pressure was revised. Normal blood pressure which we studied when I was a student in PG is totally different and all such people whom we consider as normal pressure, now they are in the severe category to hypertensive conditions who need a more energetic treatment. The latest of that 2017 A.H. A guideline  has categories the blood pressure under this category.

According to that category 120/ 80 mm of Hg is considered as a normal blood pressure, interestingly I think every clinician might have experienced that there are very rare chances of getting a patient above the age of 40 years having  blood pressure 120/80. Most of time, persons having blood pressure above 120/ 80 mm of Hg.   Particularly in Indian conditions. The number of people having the blood pressure above 120/ 80 mm of Hg are very common.

If we consider this as a criteria, almost 90% of the people at the age of 40 would be categorized as patients and they would be requiring some treatment. That’s one of the important issues.  The other categories as it would be the elevated is considered up to 130 mm of Hg systolic. There is another of the controversies. When we were studied like the diastolic pressure is more important than the systolic pressure because it produces a cardiac load, but now there is a gradual shift to the attention, even a single systolic pressure study also is to be considered as a hypertensive. So it creates lots of confusion issues. But the other categories, of course when it goes to the higher level, like when it goes above140 /90 mm of Hg then it has to be categorized as a hypertension. That’s almost universally agreed.

But when the American heart association declared that 120/80mm of Hg is the standard normal pressure. All the people over the globe didn’t agree. It’s not only me who comments on that, there are many people who commented on it. European associations and European doctors, they didn’t agree. So there had to be compromised formula like making up to a pressure of 120-90 mm of Hg as considered to be normal. And the categorization was slightly different in the European and the American Association.

 The problem would be to record the blood pressure when to be considered as normal. The blood pressure is such a variable factor which can vary significantly throughout the day. Roughly the blood pressure would have a significant fluctuation every almost every minute, maybe at very short duration. You’ll have a fluctuation so which of the blood pressure to be recorded are considered as the pressure of recording.

Ambulatory blood pressure variations

. So ambulatory pressure measurement is required. There was another of the controversy. This came into the picture like recording the blood pressure throughout the day indicates lots of fluctuation. So hence they came to a standard. The standard is to have a minimum three recordings, three recordings in the resting conditions and the three recordings should be done in different setup. Because there is one more term called as a white coat hypertension. White coat hypertension is an established term, either it could be because of the doctor or because of the environment and so on. Multiple variable factors can produce a significant change in the blood pressure. And hence there was another compromise that is to   take a minimum three recordings and the average of three recordings has to be considered normal pressure of that person. And then assess whether the patient requires a treatment or not. Still there was lots of controversy. And latest of the compromise formula is given in following table.

Compromised formula is if the patient doesn’t have any symptom then even up to a level of   by 140/90 mm of Hg can be considered as normal. If the patient has a symptom or allied complication, then it has to be considered as an abnormal. The latest of that trend is the most popular standard considering the eastern part of the country Southeast Asia is that ADA consideration is 140/80 mm of Hg. Then different associations they now consider, so wherever you go into the globe you may have different levels of the blood pressure as normal blood pressure, so there are lots of the controversies.

Indian doctors, they always follow American standards and  120/80 mm of Hg is considered as the normal and most of the patients whom you see here would be treated keeping that 120/80 mm of Hg as the target value.

Antihypertensive drugs market prediction

https://www.mordorintelligence.com/industry-reports/lobal-anti-hypertensive-drugs-market 

 The graph is the total market value of the anti hypertensive drugs. Every time the guideline is revised, the graph goes up and the prediction is by 2021 it will be3.5 lac billion dollars through out the globe would be the total cost of antihypertensive drugs. So I will not I will not go to a direct statement like it’s regulated by the market but the impact of the market is very visibly seen. But there is a coincidence or the other way every new guideline by AHA relates to a recession in the US. Once there is a recession in the U. S. a new guideline comes in and then okay I will not go beyond that because that becomes somewhat more critical . Moreover another important issue is as per the WHO statistics now available that second half of the picture  where the focus has to be, green color suggesting the asian area , the southeast Asia portion is the area where globally the trustees to market the antihypertensive drugs. They are considering that there will be a 12,5 compound acts annual  increase in the market for consumption and that compound C. A. G. R. Of 12.5 is considered to be very high in the industrial standards and that’s what happens.  I’m not making any direct statements about that. The interpretation and reading between the lines is left to you.

 The other aspect of controversy is WHO has given the statistics of incidents of the hypertension. As per this standard  as for 2016 standard. Now 2017 standard column would be almost of the same pattern. But the height of the column maybe slightly raised. The maximum incidence of the hypertension is Africa and then comes to the south asia. These are the two segments where hypertension is considered to be quite common statistically.

Life expectancy in hypertensives

 Blood Pressure in Adulthood and Life Expectancy With Cardiovascular Disease in Men and WomenLife Course Analysis

Oscar H. Franc, Anna Peeters Luc Bonneux and Chris de LaetOriginally published27 Jun 2005 https://doi.org/10.1161/01.HYP.0000173433.67426.9bHypertension. 2005;46:280–286

Why the hypertension needs to be treated? You know there are many people with high  blood pressure and still living normally and it’s considered as a silent killer. Most of the times a patient of hypertension would not have any symptom at all. So why the hypertension needs to be treated that again the statistics comes in. It’s all about the statistics. The statistics says that life expectancy after the hypertension gets reduce. I think you can read that the first claim is about a patient with the relatively moderate hypertension. But the life expectancy gets reduced. That last portion important is in that horizontal column , black colored area suggests the possibility of a complication, like either a coronary accident or cerebrovascular accident. So your life expectancy may be slightly normal, slightly lesser. Whereas the third line, suggests about the normal average life expectancy that’s considered as normal. But if you are having a hypertension is expected that it could be lesser.

  Higher the hypertension if the patient has a very significantly high hypertension, life expectancy would be shortened by almost around 30%. That’s the fourth line is just about the maximum impact of the hypertension. Fifth and six line again about the relatively high normal pressure. This is again based upon the statistics collected across, references are there.

 Emerging trends in hypertension epidemiology in India Rajeev Gupta, Kiran Gaur & C. Venkata S. Ram Journal of Human Hypertensionvolume 33, pages575–587 (2019)

he other important issue is the hypertension is considered to be a cause of the cardiovascular mortality, sudden death occurring due to incidence of cardiovascular pathology. Now, that possibility of  having a cardiovascular pathology still exists even if you consider the pressure as normal 120/80. This is about our latest guideline. first line is the statistical possibility of having a cardio vascular accident, coronary accident anytime as for the normal. Whereas the last line is about the stage four, that’s the highest of that blood pressure. If you compare the height of the columns of the 1st 2nd 3rd the difference is virtually very minimal and that difference is not statistically significant. Though there is a difference you can see you can appreciate by the column. This is about the total picture about why the hypertension needs to be considered. It’s hypertension is treated with an idea of preventing those complications like cerebrovascular accident and in those categories as the low and moderate hypertension conditions, that risk level is relatively very small and that small difference, whether it needs all that attention or not. Very high pressure i.e terminal hypertension,the difference is quite significant, definitely it needs to be prevented. Whereas in the other causes, whether we are really able to prevent that or not, that’s one of the issue.

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