Hypertension

Hypertension (increased blood pressure) is the leading cause of the global burden of disease. Approximately a 7.6 million deaths (13-15%) were attributed to high blood pressure. It is one of the major causes of Cardiovascular diseases (Heart diseases), Coronary Artery Disease, Congestive Heart Failure, Stroke, Kidney Failure, Peripheral Vascular diseases, etc. Hypertension is always associated with one of the other risk factors, and the risk of cardiovascular diseases increases with the burden of hypertension. 

The normal blood pressure of a healthy individual 120/80 mm/hg. 120 is systolic blood pressure and 80 is the diastolic blood pressure. Millimetre of Mercury is the SI unit and it is monitored with the help of a Sphygmomanometer (BP Apparatus). Blood pressure levels vary with age, it constantly increases with the first 2 decades of life from child to adolescent and young adulthood and maintains till old age. Consequently, the diastolic blood pressure increases with the age till </> 55 years and tend to decreases over 60 years onwards of age. Whereas the likelihood of hypertension increases with the age, and among >60 years, the prevalence is 65.4% but the prevalence is increasing nowadays possibly as a consequence of increasing Obesity, Stress, Sedentary lifestyle, steep advancements in industrialization, and irregular or improper dietary food habits. Environmental and genetic factors also may contribute to the increased hypertension.

Anatomy of Heart and Blood Pressure

The human heart, the size of a clenched fist, is located in the thoracic cavity in between the lungs. In other words, in the middle and front of the chest cavity, slightly towards the left side. It has 4 chambers with major arteries and veins emerging from it

The heart has to have certain pressure to pump or receive the blood. The pressure exerted on the walls of the arteries while the heart pushes the blood during each contraction is called Blood pressure. 

• Blood pressure is expressed in Nominator and denominator as Systolic and Diastolic Blood Pressure. 
• Systolic blood pressure is the pressure where the heart contracts or squeezes itself to pump the blood (120mm/hg)
• Diastolic blood pressure is the pressure inside the arteries, when the heart relaxes or expands and refills (80mm/hg).  
• Therefore, the normal blood pressure of a healthy adult is 120/80 mm/hg 

Pathophysiology. 

There are 4 different pathologies for Hypertension.

1. Blood pressure depends on 2 things, Cardiac output and peripheral resistance and Sodium – NaCl are predominantly an important ionic substance present in the cells that balances the intervascular volume. When the volume of the blood increases, due to excess sodium intake which exceeds the kidney’s capacity to excrete it out, because of the extra volume load, the heart has to pump in greater pressure, hypertension. This is the reason; oral intake of salt is restricted in patients with Hypertension.
2. Autonomic Nervous system (ANS) plays an important role in regulating blood pressure. Regulatory process includes postural difference, which is the reduction of pressure while standing. The sympathetic nervous system (SNS) mainly control the conduction activity of the heart. Whenever there is a need for increased heart rate, SNS activates and increases the heart rate for example Exercise, Stress, etc. therefore, any differences in the ANS or SNS, causes hypertension or Hypotension (Low Blood pressure)
3. Renin – Angiotensin – Aldosterone System: It is a hormonal system that regulates Blood pressure and helps in maintaining the fluid volume. It is comprised of three Hormones. Renin, Angiotensin II and Aldosterone, and the organs involved are Kidney, Lungs, Liver, Adrenal cortex, and Hypothalamus. It influences Cardiac Output, Arterial Pressure, Vasoconstriction, and maintaining the Na+ Channels and it is regulated by the Renal Blood flow. Hence, any disarrangements in these hormones or the organs that regulate these hormones increase cardiac output, leading to increased blood pressure.
4. Vascular mechanisms: Vascular dimensions (Diameter of vessels) and compliances of arterial resistances are the important determinants of arterial blood pressure. Remodelling of any geometric alteration in these vessels, alters the blood pressure.   

Stages of Hypertension

Blood pressure classification	Systolic Blood pressure(mm/hg)	Diastolic Blood pressure(mm/hg)
Normal	120	80
Pre-Hypertension	120-139	80-89
Stage 1 Hypertension	140-159	90-99
Stage 2 Hypertension	>160	>100
Malignant Hypertension	>180	>120

Types of Hypertension:

1. Primary Hypertension or Essential Hypertension – The cause is due to genetic or external environmental causes.
2. Secondary Hypertension – Cause is due to secondary diseases or Drugs
3. Gestational Hypertension – Increased Blood Pressure during the course of pregnancy
4. White-Coat Hypertension – Physiological increase of Blood Pressure as soon as the person meets the physician or the Doctor

Causes of Hypertension.

1. Primary Hypertension or Essential Hypertension.

• Familial/Genetic
• Old Age 
• Environmental factors like Stress, Obesity
• Excessive salt intake
• No regular exercise
• Excess intake of Alcohol
• Smoking
• Climate or seasonal changes
• Momentarily, Blood pressure increases during Fever, which subsides once the fever goes down.

2. Secondary Causes of Hypertension 

• Atherosclerosis (Increased fat accumulation in the vessels)
• Aortic regurgitation (reverse flow of blood to the heart)
• Renal diseases like Polycystic Kidney Diseases, Uropathy, etc
• Cushing’s Syndrome
• Increased intracranial pressure (increased pressure inside the brain)
• Hypothyroidism and Hyperthyroidism
• Hypercalcemia
• Medications like oestrogens, steroids, anti-depressants, pain killers etc. 

Symptoms of Hypertension

• Headache
• Increased perspiration or sweating
• Palpitation
• Pedal Edema (swelling of feet)
• Dizziness
• Fatigue
• Chest Pain
• Nausea/Vomiting
• Nasal Bleed
• Haematuria (Blood in the Urine)
• Vision Problems
• Irregular Heartrate

Complications

• Cerebrovascular Accidents-Stroke
• Hypertensive Cardiomyopathy
• Hypertensive Retinopathy, Hypertensive Neuropathy
• Myocardial Infarction
• Hypertensive encephalopathy 

Investigations

• Complete Blood Count (CBC)
• Urine Analysis 
• Kidney Function Test
• Serum Sodium, Potassium, Calcium, Chloride
• Fasting Blood Sugar, Postprandial Blood Sugar
• Fasting Lipid Profile
• ECG

Ayurvedic understanding of Hypertension

Ayurveda is the science of life, which is composed of Doshas – VATA, PITTA, KAPHA – which are the three bodily major components of the body. Each dosha has a specific site, location, characteristics, and functions. These Doshas nourish each and every Dhatus (Tissues and all the Organs) of the body through Sira and Dhamani (Vessels of the circulatory system). 

Hypertension is correlated to Raktachapa or Rakta Vikshepa in Ayurveda. It is caused due to aggravation of Pitta basically, along with the vitiation of Vata and Kapha affecting the Prana (Hridaya-Heart). Due to the excess intake of ‘Lavana’ (Salt), ‘Madhya’ (Alcohol), sedentary lifestyle, less physical activity, etc. causes increased Pitta, vitiates Kapha and Medha (fat), which accumulates inside the arteries causing atherosclerosis, and imbalances the Vata (Sympathetic nervous system) causing the disease. Acharyas also mentioned that Hypertension occurs due to Beeja Dosha (Familial).    

Treatment of Hypertension

Non-Pharmacological Treatment and Lifestyle modifications 

• Regular physical exercise,
• Weight management
• Stress Management
• Dietary salt restriction
• Reduced alcohol intake
• Smoking to be avoided
• Reduced fat rich food items
• Yoga/Meditation 
• MSRT-Mind Sound Resonance Technique 

Pharmacological Treatment: As prescribed by the Physician

Ayurvedic Management of Hypertension

• Vamana (Emetic therapy) and Virechana (Purgative therapy) are the major 2 treatments among Panchakarma, which are known as detoxification therapies. They target the route cause and helps in reduction of weight and removal of excess Pitta from the body, which is the root cause of hypertension.
• Basti (Enema procedure) is the 3rd procedure among Panchakarma, has also shown the results in controlling the secondary causes of Hypertension.
• Rakta Mokshana (Blood-letting procedure) is considered as one of the unique procedures in Ayurveda, where the blood is drained out to release the sudden tension inside the arteries and also reduction of the volume of blood targets the increased blood pressure. Since it is a very serious and complicated procedure, it should be performed under the presence of a trained Physician.
• Other Procedures which target the Stress: Shirodhara, Shiro-basti, Shiro-pichu, Abhyanga, Swedana, etc.
• Single drug therapies

1. Sarpagandha- Rauwolfia serpentina
2. Ashwagandha-Withania somnifera
3. Arjuna-Terminalia arjuna
4. Rasona-Allium sativum 
5. Bramhi-Bacopa monnieri
6. Jatamanmsi-Nardostachys jatamansi

Reference

1. Anthony S, Joseph B Martin et al. Harrison’s Principles of Internal Medicine. 19th ed. Vol 2.P1611-1612 
2. Anthony S, Joseph B Martin et al. Harrison’s Principles of Internal Medicine. 19th ed. Vol 2.P1614-1616
3. Anthony S, Joseph B Martin et al. Harrison’s Principles of Internal Medicine. 19th ed. Vol 2.P1622
4. Agnivesha. Charaka Samhita.Yadavji Trikamji Acharya editor. 2014. Sutra Sthana.17thChapter.
5. Agnivesha. Charaka Samhita.Yadavji Trikamji Acharya editor. 2014. Sutra Sthana.21stChapter.
6. Agnivesha. Charaka Samhita.Yadavji Trikamji Acharya editor. 2014. Sutra Sthana.24thChapter.
7. https://teachmephysiology.com/urinary-system/regulation/the-renin-angiotensin-aldosterone-system/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314241/
9. https://pubmed.ncbi.nlm.nih.gov/28356035/