Hypertension and Hrudroga
Prof. Muralidhar Sharma
based on the lecture available at–Hypertension and Hrudroga
Our Ayush department in its National Health Portal has given a full-page article about an ayurvedic review about hypertension. There it is named Vyanbala and they have suggested medicine also.
I’m not criticizing but I think you should be aware of this like how our field is being presented. These are the drugs that are presented in the given table. The important is there is no specific like how much of the dose and so on, it’s considered as if the treatment for 15 days or one month duration. It’s presented as if the hypertension can be cured. Also the complex issues related to the hypertension are not discussed is named as Vyanbala in that condition. Again, I will not say who is right or wrong because that kind of an argument is not our topic ,our present issue is how we can manage with the hypertension, the clinical conditions.
तत्र प्राणो मूर्ध्न्यवस्थितः कण्ठोरश्चरो
बुद्धीन्द्रियहृदयमनोधमनीधारणष्ठीवनक्षवथूद्गारप्रश्वासोच्छ्वासान्नप्रवेशादिक्रियः| A .S Su 20/6
सप्त सिराशतानि भवन्ति; याभिरिदं शरीरमाराम इव जलहारिणीभिः केदार इव च कुल्याभिरुपस्निह्यतेऽनुगृह्यते चाकुञ्चनप्रसारणादिभिर्विशेषैः; द्रुमपत्रसेवनीनामिव तासां प्रतानाः; तासां नाभिर्मूलं, ततश्च प्रसरन्त्यूर्ध्वमधस्तिर्यक् च ||Su Sha7/3
The quotation from Ashtanga Sangraha where Prana vata is considered to be having a function of Dhamani Dharana. The sustenance of the circulatory vessels. So the function of maintenance of a healthy condition of the circulatory vessels is done by the Pranavata. The functions of Sira according to Sushruta reflects idea of a blood circulation. This is another of the important, idea of blood circulation which we always attribute to William Harvey, it was described much earlier by Sushruta. The functions of the circulation, like the fluid going into the tissues, producing the nourishment and the same fluid coming back like a garden being nourished by the water channels or it could be the like streams of the vessels again coming back to the river or pond. So circular flow is already described in Ayurveda but unfortunately we are not able to present globally and whenever it comes to the question of circulation, the credit goes to Harvey. I’m not saying that the credit should not give, but at the same time the value of Sushruta also has to be highlighted wherever there is an opportunity. And I try to do that whenever I get the opportunity. The pulsation occurring in the vessels also were identified by Sushruta and they are described as one of the important functions of Siras.
व्यानेन रसधातुर्हि विक्षेपोचितकर्मणा|
युगत्पसर्वतोऽजस्रं देहे विक्षिप्यते सदा||
क्षिप्यमाणः खवैगुण्याद्र्रसः सज्जति यत्र सः|
तस्मिन्विकारं कुरुते खे वर्षमिव तोयदः|| A.H sha 68,69
Ashtanga Hridaya it is mentioning about the exact functions of circulatory conditions. Vagbhat had said that ‘Uchit karma’ that is an optimum pressure of the circulation is the function of Vyan vata. Two important components from Ayurvedic point of view, Pran vata which is responsible for the maintenance of the vessels i.e Dhamani dharan and Vyan vata responsible for the elasticity. Peripheral resistance and hydrostatic pressure are the two important factors. Elasticity or resistance is given by the vessels and the hydrostatic pressure, the pressure which is accepted by the heart are the factors which produces hypertension. These are described in Ayurved in two different contexts. But it may not be exactly in the same term like the pressure and objective measurement of pressure are not mentioned. But the value of that pressure and the abnormality which can produce due to that variation in the pressure can also are mentioned as Khavaigunya. If there is an abnormality of structure somewhere, the variation in the pressure and variation in the circulation can produce the disease at that level, multi organ failure or any organ could be involved. This is exactly Ayurveda have said. So virtually there is not much of a difference in the basic theory, but you have more of details and more of statistical data. I’m not denying the value of those. Those values are there. But at the same time, we should be proud of this heritage.If you search for that historical facts about the hypertension, the credit is given to Egyptian history where the Egyptian history says about rigid vessels and so on. I think we need to have some method by which whenever that history issue is recognized, the reference from Ayurveda also comes in or seen globally. Whether this has a practical value or not, what you are going to gain, these are all the second issues. But I think that records have to be put straight. Like the facts about the circulatory conditions and abnormality of the circulation were known in Ayurvedic point of view.
My perception of hypertension
आवृता वायवोऽज्ञाता ज्ञाता वा वत्सरं स्थिताः||
प्रयत्नेनापि दुःसाध्या भवेयुर्वाऽनुपक्रमाः| A.H. Ni 16/57
These are purely my consideration and open for debate and the controversy. In my practice. when I prescribe the medicines, when I select the medicines for the hypertension and manage the hypertension ,I consider this as one of variation of Anonya avarana. Prana and Vyana, they have Anonya avarana very obviously that should result in the hypertension conditions. Vagbhat has clearly mentioned that Avarana can remain silent for about a year and then it produces an incurable condition. Hypertension is a silent killer. That’s the word which is used now and Vagbhat has clearly mentioned Avruta Vata remain silent without being recognized for a year and then it raises incurable disease. It’s exactly the same issue only language words are different.
Symptomatic Hypertension as Avarana varieties
Major complication of hypertension is Hridroga
Jara (Senile changes are the sequel of hypertension)
हृद्रोगो विद्रधिः प्लीहा गुल्मोऽतीसार एव च||
तस्मादावरणं वैद्यः पवनस्योपलक्षयेत्||Ch .Chi 28/236,237
The complications which can occur due to the hypertension. Cardiovascular pathologies we consider as one of the major complications of the hypertension. It is mentined by Vaghbhat that if Avarana could not be recognized or managed can produce these complications like Hridroga, Vidhradhi,etc. And hence I consider hypertension as Anonya Avarana.
Spectrum of hypertension patients in practice
The percentage which I have shown in that table is not an exact percentage, rough average percentage of variety of the patients who come to us. We are living in the present situation and many of those facts cannot mitigate. We get a few of the patients who are newly diagnosed by as a hypertension. Majority of the patients are already diagnosed as hypertension and they have either treatment. There are certain patients who are diagnosed as hypertension by somebody else. But they will have some soda bottle like emotion and they come to Ayurveda. So you’ll get a few of patients of that category. So now I discuss this issue because we need to have a strategy which would be suitable to each of these contexts. There are many of the patients who are already on antihypertensive drugs and they are stable and are normal other wise. But occasionally they say that I try to switch over from a contemporary medicine to the Ayurvedic medicine. There are a few of the patients who are taking antihypertensive medication,but they are not stabilized and still have hypertension. And they say that whether Ayurvedic medicine can help them or not, that would be another category of the patients. Patients who are already an antihypertensive drugs but they are coming to you for some other treatment, may not be about that usually arthritis and so on. So it may not be that category that’s another of the conditions. Very few patients who come with acute complications like cerebrovascular accidents. Of course in our hospital we get more patients of acute cerebrovascular accidents. But otherwise in a general Ayurveda practice they will be lesser. Patients with having secondary hypertension, they are also comparatively lesser in our practice.
- Acute End organ involvement conditions like CVA Coronary ischaemia – Limitations for stand alone Ayurvedic treatment
- Patients on antihypertensive drugs with stabilized status – Preferably no modification.
- On antihypertensives but not stabilized / With complications like CVA
- Maintain the existing regime and plan the management
Patients coming with acute end organ failure like CVA,but the time factor is an important factor there is I consider as there is a limitation for Ayurveddic treatment. I don’t depend upon only Ayurvedic management. There it depends like whether the patient accepts or not. We need some other immediate emergency management.
Later once the patient’s condition is stabilized then we may have our management. So that’s part where we do not have a definite strategy and the strategy is to ensure that the patient’s life is saved and the damage to the organs are minimized. Because after all the patient coming to the cerebrovascular accident, even a few minutes of time has a significance. You have standard protocols of managing that condition and save the life of the patient and that should be utilized. I don’t consider that there is much of a role with our treatment. So my point of view I do not have much of a role but I do give them medicines but the primary core part of the treatment would be the other way.
Then second category of the patients who are on antihypertensive drugs with the stabilized status .Otherwise they do not have any pathology but all of a sudden they would have an emotion about Ayurveda and they come to me. I always suggest that you continue the same treatment .Reasons are simple as most of the times they may not have the same patience continued for a longer duration. That’s what I said soda bottle emotion or they may not be so regular with our medicines. The other medicines are easily available so they can sustain with that treatment easily. So I try to avoid them. But if the patients insist, then we’ll have a treatment. The next category is of patient on antihypertensive medication but not stabilized and with the complications. My idea is to maintain the existing regimen, I will not stop those anti pregnancy drugs. Along with that we may plan our management and co prescription of our drugs. I have described our drugs along with other antihypertensive drugs in large number of patients. I have not come across any complications. So we can freely prescribed the our drugs with other drugs. That’s all the confidence which I have.
Other conditions ,these are certain of the areas which I consider as some reservations. The other conditions where we have to consider the hypertension and management. I have found patients with a symptom related to hypertension, they are relatively easy to be managed whereas patients who are asymptomatic in such condition the response with our drugs are compared lesser. So asymptomatic patients that the patient do not have any symptoms but they have recorded high pressure. That’s the point where you have a real problem. I categories the patients of symptoms of hypertension into the first category is Udanavruta Prana. Anonya avarana of all vatas is considered to be hypertension.
निःश्वासोच्छ्वाससंरोधः प्रतिश्यायः शिरोग्रहः|
हृद्रोगो मुखशोषश्च प्राणेनोदान आवृते||
उदानेनावृते प्राणे वर्णौजोबलसङ्क्षयः|A.H Ni 16/236, 237
Dyspnoea on exertion and cardiac enlargement as a presentation of Hypertension –
Udana avruta prana
Features are breathlessness and many of the patients of hypertension coming with the dyspnea on exertion or they have a cardiac enlargement. As per 2014 guideline of hypertension and identification of the hypertension, to confirm whether patient needs treatment or not, one of the criteria was the thickness of the ventricular wall. If echocardiography suggest thickness of the ventricular wall more than 10mm of Hg,whether the patient’s circulatory pressure is more or not, needs some supportive treatment because there is a load on the heart.Later in the 2017 guidelines, that part is removed again. I’ll come back to that issue as controversy. Anyway, so such of the conditions I consider them as Udanavruta Prana and in that condition my prescription would be Chandraprabha vati, Punarnava mandoora, Avipathikara Choorna. The responses are usually good but not very consistent.Some of the patients they show a very good response and some of the patients do not show very satisfactory response. Patients who have already a significant cardiomegaly, the responses are poorer. If ventricular thickness is not much high then. And of course the other part like lifestyle and diet are very important. Wherever possible,I recommend that patients to undergo yoga. Yoga and exercises have a very significant role to play.This category of the patients that still has a more value .The other parts of the lifestyle, like diet they are also important in the management. So it’s not only about the drugs which are prescribed. But this is my prescription in case pf Udanvrita prana ,Avipattikar as Anuloman, Chandrprbha as Rasayana and Punarnava mandoor as Mootral aushadhi. In general all hypertension conditions I consider as Jara vyadhi because as I said, it’s signs of aging. The stress, oxidant induced damage and the oxidant induced damage is Jara vyadhi, so one Rasayan is always preferable. So I prescribe Chandrprbha as Rasayana in all hypertensive conditions. Avipattikar as Anuloman and Mootral aushadhi is the other part of the treatment.