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Lecture Note: “Hypertension and Hrudroga” (Part-4) by Prof. Muralidhara Sharma

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Hypertension and Hrudroga
(Part-4)

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

Another category of patients who present with hypertension is Pittavrutta Prana or Pittavruta  Udana. In both these conditions symptoms will be giddiness. In hypertensive patients, this is the most common kind of symptom that come across. It is suggestive of involvement of pitta. The features are described in the following shloka.

भ्रमो मूर्च्छा रुजा दाहः पित्तेन प्राण आवृते||

विदग्धेऽन्ने च वमनम्————————| A.Ni  16/42

In such conditions, my treatment is usually Chandraprabha as Rasayan and Kamdudha, Bhoonimadi Kwath targeting Pitta involvement. This category of patients, responds very well to Virechana. In the first category , Virechana may not have very consistent results. Whereas the category of the patients who present with Gidiness and up to the second degree of hypertension, within that range of which we can manage this kind of prescription gives a good response. Duration of the treatment depends upon the patient’s response. Frequent Virechan often can help to complete a resolution where the patient can live without any medicines. Samsarjana Karma is followed by Virechana which is quite important.

-उदानेऽपि भ्रमादयः|

दाहोऽन्तरूर्जाभ्रंशश्च———————-| A.Ni  16/43

 The next category of patients is Pittavrit Vyan condition where the patient would have generalized symptoms where the patient may have temporary weakness in the body. So is the transient ischemic attacks. This also is another very frequent clinical symptoms of the patients of hypertension. Many times we tend to get our patients are only that kind of a symptom message. Transient ischemic attack is totally different from cerebrovascular accident, where the patient may have numbness, loss of movement temporarily for a few hours or a few minutes and then the patient doesn’t recover up to after 15 minutes then only we consider a cerebrovascular pathology  till then it is transient ischemic attack.

Those who tend to have these kinds of attacks up to less than 15 minutes, many times they are not reported by the patient unless you ask some specific questions. And these are the patients where my prescription would  be Chandraprabha vati,Ekangaveera Rasa,Manjishtadi kwatha /Ashvagandharishta depends upon the other conditions of the patient. If the patient is  physically weak then I would prescribe Ashvagandharishta  otherwise general prescription  would be Manjisthadi kwath, consideringi Pitta involvement. Other treatment which I usually prescribe is Matra basti or Rajayapan Basti depending upon the patient’s condition. Patient who is are physically weak, the neurological deficit seemed to be persisting, then I prefer Rajyapan Basti. If it is the other way the Matra  Basti is  prescribed and there we can have a significant satisfactory outcome. I’m not saying that every patient of that category can be cured only with our medicine. There are certain limitations and the limitations have to be identified only by follow up. There is no other way of identifying those limitations prior to that.

Key points

Transient ischemic attacks and Neuritis – Pittavruta Vyana

The other variety of the hypertension that we come across are the obese patients. Obese patient are due to Kaphavritta Vyan Lakshan.

उदाने गुरुगात्रत्वमरुचिर्वाक्स्वरग्रहः|

बलवर्णप्रणाशश्च———————|A.H. Ni16/47

  The same symptoms present in patient of hypertension with obesity has been described by Vagbhat. The only point is we often considered obesity as the cause of the hypertension. Whereas the statement says the obesity may be also a result of the pathology. It could also be involvement of Vyanavrutta Prana where the same clinical symptoms are very beautiful described by Vahbhat. In Vyanavrutta Prana condition where patient could not walk freely , gait seems to be impaired due to  Gurugatrata i.e obesity .In these condition my prescription would be Chandraprabha vati ,Arogyavardhini and Avipathikara considering Agnimandya and Anulomana as major target of treatment. I usually prescribe Agni Chikitsa and Kshar basti in our hospital after admitting the patient. Kshar basti is preffered in the patient who are more obese while Matra Basti in moderately obese patient. In the patients who have more of Kapha Lakshana ,Tikshna Pachna Aushadhies would be used which also gives significant satisfactory result. I cannot claim that every patient can be managed successfully. It always has to be a case specific approach. There are still good number of patients who may not respond to these treatment.

Key Point:

Obesity and Hypertension

[ Dislipidaemia]

– Kaphavrita udana /Vyana /Prana

You may need to think of some alternative causes. The reasons could be reasons that patient may not be following the diet, patient may not be following her advice about the exercise and so on. So that’s another part. But from the clinical management point of view, I don’t consider this as a full proof prescriptions. So let me be very clear like these are not fool proof prescriptions. There are limitations and those limitations always have to be carefully watched out.

Hypertensive encephalopathy –Mada

यदा तु रक्तवाहीनि रससञ्ज्ञावहानि च|

पृथक् पृथक् समस्ता वा स्रोतांसि कुपिता मलाः||

मलिनाहारशीलस्य रजोमोहावृतात्मनः|

प्रतिहत्यावतिष्ठन्ते जायन्ते व्याधयस्तदा||

मदमूर्च्छायसन्न्यासास्तेषां विद्याद्विचक्षणः|

यथोत्तरं बलाधिक्यं हेतुलिङ्गोपशान्तिषु||

दुर्बलं चेतसः स्थानं यदा वायुः प्रपद्यते|

मनो विक्षोभयञ्जन्तोः सञ्ज्ञां सम्मोहयेत्तदा||

पित्तमेवं कफश्चैवं मनो विक्षोभयन्नृणाम्|

सञ्ज्ञां नयत्याकुलतां विशेषश्चात्र वक्ष्यते|| Ch. Su24/25 to 29

  The conditions which are seen, they are described in our text. Ayurveda texts have mentioned these complication in the context of Mada Vyadhi .The typical clinical symptoms are impaired consciousness and behavioral abnormalities. These are the typical conditions of hypertensive encephalopathy which are considered as Asadhya by Sushruta. In that condition  my management would be case specific.

  Many times I try to maintain the blood pressure. So this is my prescription. I try to ensure that the blood pressure is stabilized by other established regimens. I’m not going to the detail like which of the drug to be described and so on. So I do prescribed. So I’m not a pure Ayurvedist from that point of view because at that time the issue is about saving the life of the  patient and time duration.If necessary life support may be required .If the patient has a problem with the supporting the vital functions,life support is like oxygen and so on. Depending upon the status of the patient. But the other common prescription which I usually give is  mentioned below.

Chandraprabha

Ekangaveera

Abhraka 1gm

Tapyadi 5 gm

Godanti 25gm                      ½ tsf BD

Avipathikar 25 gm

Agnichiktsa Matra basti

Abhraka  bhasma and Tapyadi  is consider to be regimen for the treatment of Dhatukshayjanya and Margavarna. Both Dhatukshya and Margavarna needs to be treated.

Patients would have better recovery with this. In encephalopathy patients, they tend to recover better when we prescribe drugs along with the standard antihypertensive regimen. So I don’t say that I’m managing the hypertensive only with our drugs but when it is prescribed with other drugs, it helps faster recovery.

Agni chikitsa and Matra basti is standard protocol in our hospital in majority of the patients.A good number of patients have recognized this and a number of patients who come with that acute presentation to our hospital is gradually increasing. Earlier. it was like patients of stroke after having the treatment in other hospitals they come to the Ayurveda hospital only at the end for massage and so on. But the trend is gradually changing and that trend changing is because of this kind of approach. That’s what I say.

Management of hypertension complication

  Another area where we can have is patients with the significant number of hypertension complications. Patients who are on antihypertensive drugs and they tend to develop complications .The patients come to us for management where either  these complications either are not recognized or they are not managed it properly. There are some areas where definitely we can produce some change without modifying that antihypertensive drugs.

Beta blockers

Beta blockers often produce breathlessness. There are two important complications with beta-blockers, one is they tend to aggravate bronchoconstriction. Patients having bronchoconstriction tend to have an aggravation of the conditions and in that condition my prescription would be Chandraprabha and Shwas kuthar. Another important issue is patients with beta-blockers, have reduced compliance with the cardiovascular system and if you do not advise a restriction of the exercise, that limit of the exercise is not followed, they have a high risk of going into collapse. So every patient with the beta blocker should be recommended about the limits of the exercise, which you can do. If the patient goes beyond the limit, patient heart would not be able to respond to the increased demand for blood. When a normal person do more exercise, naturally heart beats more  to pump more blood  so that it can cope with that increased demand. Whereas under beta blockers this effect is reduced and that can produce complications. Hence you have to be advised that there is no other regimen, it’s about the regulation of the exercises.

 Alpha blockers

Alpha-blockers are rarely prescribed and most of the times you don’t get that as a common complication issue.

Calcium Channel Blockers–

These are other commonly prescribed drugs. In the majority of cardiologists, one of the common prescriptions is calcium channel blockers.The most common complication is bradycardia or significant hypotension. In such conditions, we may not withdraw that drug. Many times a patient who has already complications like a cerebrovascular accident or coronary pathology, withdrawal of the drug is virtually not possible. In that condition administration of Prabhakar Vati can give a significant result in the outcome. The patient can feel better and this is one of the areas where we can definitely have some change.

ACE inhibitors

ACE inhibitors are other drugs having  side effects like  angioedema, allergic reactions and hepatic pathologies. I consider this as Sheetpitta. In this condition my prescription would be Arogya Vardhini and Manjishthadi.

   The study is the usual prescription which reduces that complication.

ARB

The angiotensin receptor blocker drugs  can often produce postural hyportension conditions.In that condition the usual prescription would be  Chandraprabha and Saraswatarishta.The anxiety neurosis and giddiness kind of symptoms tend to occur.these condition can be managed.

Controversies and contradictions

 These are certain issues. I try to sensitize about these issues from the general clinical  practice point of view.

Sarpagandha and Hypertension:

 I think all our doctors are always very proud of Sarpagandha as an antihypertensive drug. But I do not prescribe Sarpagandha as a treatment for hypertension as I have many reservations. The reservation is Reserpine was identified as an alkaloid of hypertension in 1951. It’s not the reserpine only which is present in Sarpagandha. Many other alkaloids, among them, increases blood pressure. So, when you administer Sarpagandha as a whole, you will be prescribing both i.e reserpine as well as its antagonist. It’s an advantage as well as disadvantage.

 Sarpagandha in our text is described in the treatment of Vishahchikitsa and Bhootaabhishyanga. Sarpgandha was used in hypertension only after reserpine was invented. Till reserpine was invented Ayurvedic doctors were not aware of   Resperpine being used as an antihypertensive. So, if we are prescribing Sarpagandha for reserpine, I would say reserpine is better because exact standards of resepine are available like how much of it should be given. In crude Sarpagandha exact amount of reserpine is not known.  i These are the issues that I consider. I’m not criticizing those who are prescribing Sarpagandha at all.

 The other important issue is the adverse effects. I have earlier in my practice, prescribed Sarpagandha to a few patients, and I felt that it could produce a common adverse effect. One of the common adverse effects, which I observed is a gastrointestinal tract abnormality, a decrease in appetite, and typical Agnimandya lakshanas are produced. After observing these side effects in a huge number of patients I stopped prescribing it. So from my point of view, I don’t consider Sarpagandha as a treatment for hypertension. But again, I repeat that this is not a criticism of others who are prescribing Sarpagandha. Still, I’m just giving my view only.

Target pressure issues

Hypertension and Hrudroga
(Part-4)

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

This is another controversial issue. How much of the pressure is the target pressure?  The latest data from 2017 has identified a new phenomenon called the J curve, if diastolic pressure goes less than 60mm of hg or the systolic pressure goes less than 130 mm of Hg in a patient with hypertension after your management, the complications which can be produced due to hypertension raised almost equally as that of the possible complications which can be produced due to the hypertension.

Impact of Achieved Blood Pressures on Mortality Risk and End-Stage Renal Disease Among a Large, Diverse Hypertension PopulationAuthor links open overlay panelJohn J.SimMD∗JiaxiaoShiPhD†Csaba P.KovesdyMD‡KamyarKalantar-ZadehMD, PhD§Steven J.JacobsenMD, PhD†Volume 64, Issue 6, 12 August 2014, Pages 588-597

 The graph blue colored checkered line is the range of pressure blood pressure, which is considered statistically safe, as the risks are reduced. When the pressure goes beyond that higher level, it increases the risk of complications. But it’s not only in the increased rate, the other side curves of the graph almost raise more acutely when the pressure reduces beyond that limit. So over treatment of hypertension, where the end result of the pressure is lower, you are increasing the risk. The aim of the treatment of hypertension is to prevent complications and that purpose is not served. This is about only those patients who have primary hypertension, but there is no organic damage. Patients who have organic damage already, it is better not apply the same formula rigidly.

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