Lecture Note: “Hypertension and Hrudroga” (Part-2) by Prof. Muralidhara Sharma

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Hypertension and Hrudroga
(Part-2)

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

End organ damages in hypertension

I’m just giving you the statistics because hypertension is absolute statistics. Don’t think that it ends with the statistics alone. This is only a prelude.  Another of the major complication of the hypertension is a multi-organ failure, end organ failure conditions that it could be. It could damage any other organ, not only the brain or the heart, kidneys and so on. We categorize it as end organ failure conditions. In the end organ failure conditions also the difference between normal and high blood pressure incidences are not very huge, when the blood pressure is within that moderate range . But when it is a very high pressure of course the difference is high.

Hypertension and coronary risk factors

KM, Wilson PWF, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83:356–62.

  This is one of the maximum number of studies statistics about the risks .The issue is that the columns that the blue line suggests about diastolic blood pressure and the red line is about the systolic blood pressure.  The factors which can increase the blood pressure and this is studied throughout the span of years. The important is cholesterol, high density levels smoking and the other factors which can produce the hypertension. Important is if habits mentioned in graph  are negative then virtually you may not have a hypertension, chances are that your systolic and diastolic pressure normal. As smoking and the dietetic factors increase which are actually precipitating the hypertension, the incidence of the hypertension increases. So after all the basic issue is hypertension is related to the diet and the habits like smoking alcohol and so on. Many factors are identified.

Cardiovascular Diseases in India Compared With the United States Dorairaj Prabhakaran, Kavita Singh, Gregory A. Roth, Amitava Banerjee, Neha J. Pagidipati and Mark D. Huffmanournal of the American College of CardiologyVolume 72, Issue 1, July 2018 DOI: 10.1016/j.jacc.2018.04.042

This is a huge study  history which has studied the hypertensive patients in India, U. S. A. and the global The blue lines suggests about the global, the midline is about India and last line is about the USA studies. Interesting and this is in a span of time. The first is 1960 and the last column is 2016 which has studied about the possible factors which have produced the hypertension in these three different setups i.e global average, India and then USA statistics.

The last 2016 column, there the red color is higher and that suggests about the dietetic factors. Dietetic factors which are still cause for the hypertension. Whereas in USA in in the earlier stage 2016 conditions, the dietetic factors were more. They have studied and learned that and people now are getting into  the dietetic factors and it’s regulated. It’s not the drugs or medicines which are promoted over there. Whereas in India the dietetic factors are still the most important factors which are producing the hypertension and we are depending on one of the drugs for controlling the hypertension. This is the controversial issue. Again, I’m not going to all the details and discussion of that part, but we need to be aware of this issue also. When we identify our role in the management of hypertension, all these factors count.

Dyslipidemia -cause of hypertension

Era of Cholesterol

  • 1910 Human Atherosclerotic Plaques Contain Cholesterol
  • 1913 High Cholesterol Diet Causes Atherosclerosis in Rabbits
  • 1919 Heart Attacks Recognized in Humans
  • 1933 Feedback Inhibition of Cholesterol Synthesis Demonstrated
  • 1938 Familial Hypercholesterolemia Described
  • 1950 Cholesterol Biosynthetic Pathway Elucidated
  • 1951 High Fat Diets Raise Plasma Cholesterol in Humans
  • 1953 Risk Factor Concept Advanced

Era of LDL

  • 1955 LDL Identified as Risk Factor for CHD
  • 1973 LDL Receptor Discovered
  • 1976 HMG CoA Reductase Inhibitors (Statins) Discovered
  • 1981 Statins Increase LDL Receptors in vivo
  • 1987 First Statin (Mevacor) Approved for Human Use
  • 1994 Statins Decrease Heart Attacks and Prolong Life
  • 1997 SREBP Pathway Elucidated
  • 2006 PCSK9: Destroyer of LDL Receptor
  • 2012 LDL –C Risk factor

There are lots of theories on why hypertension occurs. One of the most controversial and troublesome theories is troublesome because every time the picture changes is the theory of dyslipidemia abnormality of the fat metabolism being responsible for hypertension. The whole concept has changed from 1980 to 2013 and the latest theory is only the low-density lipids that are responsible for hypertension, and there to LDL C another variety can be that is ideidentified nd considered to be responsible for hypertension, but this also is non-conclusive still a significant number of people who have normal lipid levels having hypertension. A significant number of people who have an abnormally high lipid profile, they may not be hypertensive and they may not have any of the complications. The whole picture has been changed from a simple cholesterol, to different varieties of the lipid throughout and this also has produced some impact on the market. A  bit of that  will be explain to later ,about the impact of the market and how we can make use of that issue. That’s one of the one of the most dependable theories of why the hypertension occurs.

Stress as a cause of hypertension

Abel, J. A., and Larkin, K. T. (1991). Assessment of cardiovascular reactivity across laboratory and natural settings. Journal of Psychosomatic Research, 35, 365 – 373

 Another cause is considered to be physical stress, psychological stress or so on. A study was done about the factors of the stress as being a cause of hypertension. Generally people would say like those who have a short temper are prone for hypertension. But statistics has proved other way, persons with the short temper may not be having the hypertension but those who are suppressing their emotions, they keep silent tend to have the hypertension more anyway but this is not statistically significant. Other parts like how the statistics and mood issues that part also try to refer to a bit more detail later but this is about stress being a cause of the hypertension.

Of course it’s universally accepted like lifestyle factors and it’s often said that hurry, curry and so on. The other usual terms use which are considered to be the cause of the hypertension and related the hypertension is the beginning, then you have the atherosclerosis ,cardiovascular accidents and so on. So you’ll have a series of the complications which are occurring.

Oxidative stress -hypertension

Vascular Pharmacology Volume 116, May 2019, Pages 45-50

One more of the theory and I would consider it important is the oxidative stress hypertension. It is the latest theory and it’s considered that during the metabolism some free radicals are produced and these free radicals they present in the body and they tend to produce the damage to the mucosa cells of the blood vessels and then hence they produce the hypertension. This is considered also as a factor of the aging, oxidants and free radicals is related to the aging. So hypertension in essence is a sort of premature aging when you age earlier, it could be the hypertension.

Secondary hypertension – Prevalence

Endocrine hypertension: Changing paradigm in the new millennium Manash P Baruah1, Sanjay Kalra2, Ambika Gopalakrishnan Unnikrishnan3Indian Journal of Endocrinology and Metabolism, Vol. 15, No. 8, , 2011, pp. 275-278

 The other cause for the hypertension is a secondary hypertension, a pathology of other organs like kidney disorders or thyroid disorders being the cause for the hypertension where it’s not primary hypertension and target of the treatment there would be totally different. It’s not about only about regulating the pressure, you need to consider those. They are considered secondary hypertension and comparatively secondary hypertension are very few. The major portion of the pie chart is suggestive of the primary while those small parts  over there represents the secondary causes.

 The important when a patient of hypertension comes in, you need to know like whether the other organs are damaged and whether it could be a cause for the hypertension or not. Secondary hypertension the whole approach to the treatment will be different and whatever we discuss as the management may not be applicable in that condition. Whereas our focus would be only other primary hypertension as such.

Secondary hypertension – Prevalance

Chobanian AV, Bakris GL, Black HR, et al.; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–1252.

 Among the secondary hypertension one of the most important process as we see practically in the clinical field is due to drug or medicines related. Drug in the sense not the addiction forming drugs, drugs which are prescribed and what we see in the regular clinical practices, estrogen drugs, then the drug use like cocaine and so on, then non-steroidal anti -inflammatory drugs, many of psychiatric drugs and the many of sympathomimetic drugs that are used in the respiratory disorders, also are considered as a cause for the hypertension. Statistics says there are herbal drugs also which can increase the hypertension. Among the herbal drugs which are studied already is Lashun is shown as a drug which produces hypertension. Licorice extract is also known to be inducing the hypertension.  In USA licorice containing food substances are banned. That’s a very interesting issue. The issue is because licorice extract is known to induce the hypertension whereas Madhuyashti as such we use in the treatment of hypertension. So whenever we think of a secondary hypertension it’s not only about the organic damage, you need to have it detailed history of the medicines the patient is taking. Also among the medicines which we see here among our patients the most common are the non-steroidal anti-inflammatory drugs. These are now being sold on the counter and people are now having this as they use the salt in their hood, they use these drugs quite frequently. Another estrogen containing drugs which are also used for regulation of fertility.

Malignant Hypertension

15 things which increase the B P

The malignant hypertension where the exact causes are not known but all of a sudden blood pressure shoots up and then produces the damage to the tissues .Acute emergencies related to the malignant hypertension which can produce retinal damage, myocardial pathology and so on. A patient coming to you with the hypertension you need to know like whether the patient is in that malignant stage or not. If the patient has a malignant hypertensive condition, it’s an acute emergency which needs to be handled as early as possible. Time would be a very important factor.

15 things which increase the B P

  • Your Doctor
  • Added Sugar
  • Loneliness
  • Sleep Apnea
  • Not Enough Potassium
  • Pain
  • Herbal Supplements
  • Thyroid Problems
  • Retained urine
  • NSAIDs [Drugs]
  • Nasal decongestants
  • Dehydration
  • Hormonal birth control
  • Quarrelling
  • Antidepressants

https://www.webmd.com/hypertension-high-blood-pressure/ss/slideshow-high-blood-pressure-effects

The 2017 High Blood Pressure Guideline: Risk Reduction Through Better Management Nov 15, 2017Cardiology Magazine

These are not very important things. I have copied it from a popular blog site which has given the idea of the causes of the hypertension and among the different causes of the hypertension first one is your doctor.  The 15 factors which are mentioned by the blog site that I have just copied it is, only the thing that I have specified is that you’re a doctor. It could be related to the bill.

That’s about certain of confusing issues but I’m not intending to confuse you and I try to give you some clarity about that .Because the hypertension issue what is considered normal and so on. There is also a controversy about the management how to manage. The latest guidelines in the management of hypertension which is drawn by AHA only.  If a patient is having normal blood pressure, a guideline is you try to promote optimal lifestyle habits, don’t go into medical treatment. It’s all non-pharmacological treatment is suggested at that level. In the elevated BP, the current standard when the pressure is in between 120 to 129 mm of Hg systolic pressure and diastolic is lower than 80 mm of Hg, recommendation is to use no drugs to be used. It’s only the lifestyle only when you use and reassess,if the blood pressure doesn’t come down, then you may think of the other regimens.

 In the stage one hypertension condition, pharmacological intervention is not recommended. Now I stress these issues because we will have certain related issues discussed later. The first attempt is a non-pharmacological intervention. No medicines are prescribed. It’s about the lifestyle it’s about the diet, exercise and so on. So all that role of yoga and so all the issues come in. The pharmacological intervention is limited only for the class III or stage II hypertension where the complications are there or  already the patient has developed the complications or in III stage malignant hypertension conditions. Then a direct pharmacological intervention is suggested otherwise the pharmacological intervention is not recommended by the global recommending committees. That’s all the point.

  The best of proven non pharmacological interventions for the prevention of hypertension is   recommended by WHO. The first is about the exercise exercises. When you do a rigorous exercise you expect the blood pressure to reduce by about 10 millimeters of mercury. Then there is a DASH diet against the hypertension which is considered a universal.  This diet can reduce blood pressure by around 11 mm of mercury. Solution about the psychological stress and their issues that the optimal pressure can be reduced. So non pharmacological intervention after all relate to the diet exercise and modification of the lifestyle where you regulate your time for sleep, regulate the time of rest and so on. That’s recommended as the non-pharmacological intervention.

Foods to avoid during hypertension

Diet which has to be avoided-

  Spicy ,sugar containing, salt containing diet are the ones which are known to increase the blood pressure.

Dietary Approach to Stop Hypertension [DASH]

 DASH diet of the approach to stop hypertension. This is a global or universally accepted. every Nutritionist  speaks about that issue quite significantly and this contains only simple issues. You have to have green and green products, fruits, vegetables and low fat dairy products. Dairy products should be low fat and meat is not generally preferred. But when it is to be taken then lean meat, that  do not contain much of the fat. Nuts, seeds and legumes are to be given. Facts and sweets are allowed only 2-4 times per week and not more than that. That’s how it has to be suggested as the dash and most of the times we do the totally opposite. The fat and other substances are taken more , sodium contents are taken more and that could be the cost for the increase in the circulatory pressure.

Ayurvedic view on hypertension

 I think I will not be able to cover all the issues but I have tried to pick up certain issues which would be important to come to our point.From ayurvedic point of view to access hypertension is another of the controversy. Sushruta ,Charaka never had that sphygmomanometer. So quite natural that they would never be able to mention hypertension directly or such a situation. But that’s not the issue. The diseases were existing. So I’m very sure the diseases were identified and they had identified the disease and try to manage them. So that’s what we are trying to see. Like what could be the management or what could be the identification of the disease by Charak or Sushruta and then how we can adapt to the present practice. We have plenty of Ayurveda literature about the hypertension. Almost around 15 national level conferences were conducted in Ayurveda field about hypertension. At the end that could not be any conclusion, like what should be the name or what should be the identification of the disease of hypertension by Ayurvedic means.

  • Dhamani Prapurana.
  • Raktagata Vata.
  • Siragata Vata
  • Avritta Vataroga
  • Vyana Bala
  • Dhamani Pratichay
  • Raktavata
  • uccharaktachapa,
  • RaktavritaVata,
  • PranavritaVyana,
  • Vyanavrita Prana,
  • Shleshmavrita Vyan

These are all the different varieties, different terms used by different committees and by different authors.

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