Lecture Note: “Hypertension and Hrudroga” (Part-5) by Prof. Muralidhara Sharma

0
236

Hypertension and Hrudroga
(Part-5)

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

Lower BP may raise the death risk

Another statistic indicates that when the blood pressure goes lesser than 120 / 80 mm of Hg, the percentage of the risk would be higher. The death rate per 1000 patients per year increases statistically. This is about the global statistics which are produced, it’s not only my view and hence one of the important is to which we have to be careful when we treat hypertension conditions that overtreatment should be avoided.

 So the target pressure which I consider in my practice is always 90 mm of Hg, as the diastolic pressure, and 150 mm of Hg as the systolic pressure. So I consider that as a safe limit for a patient who had hypertension and is on medical treatment and if I can maintain the pressure considering clinical conditions. When I record the pressure in my clinic, I will be adding a bit of white coat hypertension, which is not objectively measured. The standard protocol of recording the blood pressure thrice would be practically impossible in our clinical conditions. So I consider 150/ 90 mm of Hg as the target value when the blood pressure is being measured in the clinic.  I do not have an objective statistical incidence of complications in my patients, I feel it’s not much. It’s almost at the same level as hypertension management.

Recommendations for hypertension treatment in the 2014 guidelines for adults, according to major treatment group

   The latest standards prescribed universally in patients having pathology  like Dibetes Mellitus or chronic renal diseases are given in the table.

According to 2014 guidelines, for patients less than sixty years and without diabetes or a renal disorder, the target diastolic pressure is less than 90 mm of Hg. I have quoted it from the global standards. Patients age more than 60 years, without diabetes or a renal disorder then the target systolic pressure of 150 mm of Hg and diastolic pressure of 90 mm of Hg are considered as the normal. So when I say 150 /90 mm of Hg is universal for all. In case of all adult patients with diabetes or a renal disorder the target blood pressure should be 140/90 mm of Hg. This is the target value of the blood pressure when you treat the hypertension and it is not the 120/ 80mm of Hg which is considered normal is the target value.

So that’s about the whole issue of confusion and the need for all that prelude which we have considered.

Overtreatment –Survey by Association of Physicians in India [API]

 Hypertension Management and Antihypertensive Withdrawal – A Perspective Sanjeev Mangrulkar1, Pushkar Khair2, Vinayak Hingne2, Pavan Hanchnale2 The journal of Association of physicians India Vol 63 May 2015

It’s not a criticism on any other part. This is from a survey by associations of physician of India API of India. This survey was done in 2015. And based upon the survey, while treating the patients we should be aware of this issue  that most of our patients are over treated. I’m taking up only two of the questions. One of the question is what the value of the blood pressure above which you would consider starting an antihypertensive drug, is inquired with the different category of the physicians, cardiologists and so on. The important is 70% of the practitioners said that they would readily start the pharmacological drugs for the treatment of hypertension when the pressure is 140/90 mm of Hg. This is not really this universal guideline. But I have referred earlier that you need to have to start with a non-pharmacological intervention for reasonable time and then start with antihypertensive drugs.   So very obviously majority of our patients when they come to us are unnecessarily prescribed with the anti-hypertensive drugs.

Another question in that survey is about once the patients has antihypertensive drugs, whether the patient needs to be given the antihypertensive drugs for the whole life or not? The family physicians, cardiologists and the physicians, they had a different sort of opinion. But those who said like the need to be continued for the whole life would be quite significant which is also not true. But this kind of practice exist.

 It’s not a criticism on the other practices but when patients comes to us we need to have consider these issues. It is not necessary that the patients need to continue the hype hypertensive drugs for the whole life, definitely the medicines can be discontinued, if there is a regular monitoring and maybe with supportive treatment. So when we start with   Ayurvedic treatment and then manage the patients for hypertension, I do consider this issue. If a patient has already an organic damage like a cerebrovascular accident or a coronary pathology, I may not discontinue the antihypertensive drugs because that even slight fluctuation can result in more complications. But you have a good number of patients who do not have those complications. Definitely I do consider discontinuation of those antihypertensive drugs, if the patients are ready for regular follow and an observation. If the patients are not ready for follow up then I will not take the risk. You have a good number of patients where we can have this kind of way advantage given to the patient. Again, all this is not a criticism of the existing practice, but it’s about the facts which are existing in the practice and how we can have some change in the outlook of the practice.

Echocardiography and ventricular thickness as a guide for treatment

2013 ESH/ESC Guidelines and JVC 7 guidelines  –

Evidence of Left Ventricular hypertrophy and Atrial dilatation as a secondary evidence of need for treatment of hypertension.

JVC 8 guidelines of 2017 has not referred to the issue

Essential hypertension was the word which we used to study earlier. But since 2014, the guidelines have removed the word, they do not use the word ‘essential’ because they do not consider that hypertension as an essential factor. But you’ll have a good number of patients who have a significant higher maybe category two blood pressure, 150/ 90 mm of Hg or occasionally even 150/100 mm of Hg. But once the pressure is reduced even by 10 millimetres of mercury, they will feel lots of giddiness or uncomfortable. So this is one of the area and most of the times such patients one or the other day, they come to an Ayurveda doctor for the opinion they will have that kind of aversion and number maybe lesser. It’s not that they have a huge number, but this is one of the issue. And very often you’ll have that question like whether the patient with the high pressure requires the treatment or not. This is a point which I just referred to earlier. In the 2014 guidelines one of the criteria considered as the left ventricular hypertrophy. But now that guideline is removed. So it’s not only who me who cries foul about that. There are many other doctors who are criticizing that kind of withdrawal from the guideline. But I still consider this guideline is a useful one. So whenever you have such a controversy, whether the patient requires, I follow this guideline, I refer the patient for echocardiography and if the echocardiography has shown a significant evidence of the backlog in the ventricles, then only I would recommend the patient to continue the treatment again. Whether my treatment or modern treatment existing, that’s exactly the strategies which I have suggested earlier. But if the patient doesn’t have a significant hypertrophy, then I would recommend the patient not to go for any medical treatment. Of course, the lifestyle dietary factors are the important issues they are advised and regular monitoring would help. And many of the such patients we can have a normal leading life where the patient doesn’t have to take the medicines, taking the medicines every day, makes the patient feel ill and that’s what we can and contribute to the patient from that point of view.

Familial hypercholesterolemia -2011

  • chest pain with activity
  • xanthomas,
  • corneal arcus

Then another of the controversial highly debated and very popular issue is cholesterol. The familial hypercholesterolemia is one of the frequently identified condition and the incidents here is considered to be more. So there are many people who have a normal diet where there is virtually fat content in the diet is lesser.  But still the cholesterol levels are more and that’s considered familial hypercholesterolemia which was named in 2011. This is another of the category where the patients would be prescribed lots of medicines. It’s not about the criticism but trying to get an opportunity for us in the management.

  The familial hypercholesterolemia incidents also is supposed to be very high in Eastern countries. The incidence in India represented by first column in the graph is very high compared to others.

Association of cholesterol levels with cardiovascular mortality in patients with pre-existing CHD In India.

Recent trends in epidemiology of dyslipidaemias in India. Rajeev Gupta Ravinder S.Rao Anoop Misra SaminK.Sharma Indian Heart Journal Volume 69, Issue 3, May–June 2017, Pages 382-392

 The complications association of the cholesterol with the complications like coronary pathology, the death rate per 1000 person year. It’s important the death threat in the younger age of less than 60 is not significant. The death rate is less than 50 is not significant. The death rate increases rapidly after the age of 60, if the cholesterol level is more, You’ll have a good number of patients in the young age of  15, 16 having the higher cholesterol and then they are being prescribed the drugs.

Hypercholesterolemia awareness, treatment and control among urban adults in India.

Recent trends in epidemiology of dyslipidemias in Indiia. RajeevGuptaa Ravinder S.RaoaAnoopMisrabSaminK.SharmacI ndian Heart JournalVolume 69, Issue 3, May–June 2017, Pages 382-392

I’m not going to criticise it but there are certain facts which we need to consider. Awareness about the cholesterol is increasing very rapidly, more than 17% of the population  are known to be a aware of the cholesterol level and bothered about the cholesterol level and many times they will be more sensitive about that cholesterol level than the doctors.  The issue is about the prescription.

Statin Prescriptions per 1,000 Population And 1,000 Patients with Coronary Heart Disease (CHD), February 2006–January 2010

Despite Increased Use and Sales of Statins in India, Per Capita Prescription Rates Remain Far Below High-Income Countries

 Niteesh K. Choudhry, Sagar Dugani, William H. Shrank, Jennifer M. Polinski, Health AffairsVol. 33, No. 2:

 I’m not going to all the controversial but at times I cannot avoid that. The earlier prescription for hypercholesterolemia was ‘Clofibrate’. Statins were invented in 2008 and 2009 , after FDA approval the statins are prescribed for cholesterol. These days almost every patient who has visited or may be has gone on the road of a cardiologist practitioner, will have a statin prescription whether he has visited or not. So it’s considered to be a universal health improver and practically promoted.

 The column that’s about the over and rapid prescription of statins.

 Statins have very common adverse effect and that effect is the damage to the skeletal muscles. The patients would have a pain in the muscles very common and it’s not really arthritis pain but the patient will continue to have that pain in the bones, muscles and so on, vague symptoms. Most of the times the patients are sent for investigation of vitamin D 3 and this is again a fad. There is a linkage between cholesterol, statins and vitamin D3. Statin is a common prescription and vitamin D3 is common investigation and caused quite a huge sum and you’ll get a kickback also. Then there this is the whole vicious cycle and most of the patients set up that category of the patients, they will end up in Ayurvedic hospital. Because general feeling in the patients for the pain and neurological condition is Ayurvedic treatment is better. So that’s one of the fertile area for practitioner that is statin induced complications.

 Simple clue to identifying exactly the statin level is to assess CPK level, it would be at the range of 100-200, not very high. Not considered to be sign of myopathy, but just above normal. If we have that kind of result. I don’t have to ask the question like whether the patient is taking statin or not, 100% sure the patient will be taking statin. Such patients having that statin induced complications, they will be responding very well with our prescriptions. It can   produce a significant change in the lipid profile so that statins can be withdrawn and we can replace with this kind of treatment.

My prescription for hypercholesterolemia

Chandraprabaha vati

Arogyavardhini

Kumari asava  – Significant change in the lipid profile

Virechana – Decisive and remarkable change in the lipid profile

Diet and exercise are supreme

Coronary arterial disease prevention – Needs elaborate study

 A significant number of patients of familial hypercholesterolemia, not about the dietary issues Familial hypercholesterolemia patients they can be managed with significant value with our drugs. Then the diet and exercises very supreme.  Virechana also has shown to produce a significant results.

The adverse effects of Statins

  The most important is that the muscle aches and the rhabdomyolysis is the one area.

Statin induced myopathy

 Impact of vitamin D status on statin-induced myopathy lKrista D.Riche Pharm.D.abJustin ArnallPharm. D.c KristinRieserPharm.D .aHoney E.EastM.D.dDaniel   Journal of Clinical & Translational EndocrinologyVolume 6, December 2016, Pages 56-59

  I consider statin myopathy as Amavata and my prescription would be

Kaishoraguggulu

Mrityunjaya rasa

Amritarishta

As far as I remember I have not failed in any of the prescription of that in case of statin induced myopathies. My interns or my students who are in OPD  are always fed  up with writing  the same prescription, they think of having a seal and then press it. The reason is that there’s a very frequent prescription. The reason is simple. You’ll have plenty of patients who are taking Statin. Now that one part like whether the statin needs withdrawn or not depends upon the patient’s preferring, some of the patients may not prefer. Some patients may prefer it can be withdrawn but if statin has to be continued and patient come with  statin induced myopathy then this is one of the treatment where we can have better  results than any other treatment. None of that with D3 supplement or not even any other analgesic or any other standard protocol of the treatment that doesn’t produce such a satisfactory results. So if this condition is I say with high confidence unlike our prescription for the hypertension.

Hypertension and personality traits

Personality traits and hypertension elaborate studies are done and it’s now confirmed that it’s not about the aggressive personality which is responsible for the hypertension. Rather it is the introvert personality who tends to have hypertension. Those who do not express those who keep silent, those who do not express their emotions, they tend to have more of hypertension than who tend to expose their emotions. That’s the one part which generally people perceive the other way.

 That doesn’t mean that you’re short tempers do not increase the pressure when you become angry, naturally the pressure increases. But that’s only a temporary issue. And whether that temporary issue produces the change or not is another issue. But you’ll have plenty of patients with psychiatric disturbances, particularly depressive symptoms because of the anti-hypertensive drugs. And among them calcium channel blockers drugs are known to have the maximum incidents of depression conditions. This is from the data available, the maximum number of patients with calcium channel blocker, and they are known to have for the complications of mood disorders. Many times you’ll come across such patients who will have antihypertensive drugs and the mood disorders, somewhat maybe not very objective can be correlated in that condition. In such condition, if it is needed to continue antihypertensive drug then, I will continue the same and along with it I do prescribe Medhya Aushadhies like Saraswatarishta or Smritisagar Rasa.

 Currently used  anti oxidants-Hypertension

 Another area is antioxidants which has become a craze. Lots of drugs are considered to be antioxidants. Very often are people have a general trend to recognize many of drugs as antioxidants. Researchers are being done. I’m not criticizing that part but they are not very much objective. The best of the antioxidant according to me is a piece of mind when you do not harm others, when you are in a pleasant mood, when you do not think of unnecessary issues definitely that would be the best of the antioxidant.

 As far as the diet lots of literature is available regarding antioxidant. One of the standard book which I would like to refer is Antioxidant properties of spices, herbs and other sources by Denys J. Charles.

 I consider this book as the standard book, elaborate many of the dietary substances which are used in our day to day practice and their antioxidant properties are studied in detail.

LEAVE A REPLY

Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.