In today’s life very often we hear that the so and so person is suffering from High Blood Pressure or Hypertension. In social parties or gatherings it is a usual scene that some body or the other is refusing to take certain food items or dishes and found saying No! I can’t take this because of Salt or Fat restriction on my diet by the Doctor as I have Blood Pressure.
Now this creates a lot of interest to know more about this malady called Hypertension and also known as one of The Silent Killers of today’s society, others being the Diabetes and I.H.D. or Ischaemic Heart Diseases.
What exactly is Hypertension? Before this we must understand what exactly is Blood Pressure. To explain to have proper perfusion to occur in all the tissues of the body, Heart has to pump blood with sufficient pressure. This is called the Arterial pressure or Blood Pressure. Or it is defined as a Lateral pressure exerted by blood column on the arterial wall. It is simply the pressure exerted by the blood on the vessel walls, measured in millimeters of mercury (Hg) by Sphygmomanometer. It is of two types Systolic Pressure (when the heart muscle is at the maximum contraction) is recorded first followed by the Diastolic Pressure (when the left ventricle is in a state of relaxation).
In normal circumstances it is around 120/80mm of Hg. I put it as ideal B.P. but as the ideal circumstances are not prevailing anywhere with any body so slight variation is also considered as normal that is plus minus 10mm of Hg in both systolic and diastolic pressure. But a reading of 140/90 mm of Hg, on two out of three random checks, at different times of the day is to be taken as Abnormal Arterial pressure or Hypertension and needs further follow -up and/or evaluation.
Hypertension, hyperpiesia, high blood pressure, essential hypertension, the silent killer, problem of modern civilization are the epithets used to describe but a feature of cardiovascular physiology. Interestingly without blood pressure, life would be impossible. In more than 60% of patients with “high blood pressure”, the symptoms made their appearance after they were told that they are hypertensives. It is Amazing, but rightly, a check up clinic should be defined as, a place wherein a person walks in and where from a patient totters out. In most cases, which fall into the category of Mild and Moderate Hypertension, patients have NO symptoms.
In about 40 -50% of cases it is detected on a routine check, LIC or Pre employment check or as a complication like Stroke, Infarct, Loss of vision or Renal Failure. Hence it becomes very important for a treating physician to keep a close watch. Another reason for its significance is the attitude of the patient. They always have a ready explanation for an abnormally high pressure reading like “I didn’t sleep well” or” I have so much of tension”. Also they all feel that they can MAKE OUT what their Blood Pressure is by way of getting angry etc., and since they FEEL they have normal pressure, they neither go for regular checks nor take regular treatment, once again putting the onus on doctor.
Hypertension can be classified in two different ways. One is according to severity and second according to the cause.
Mild HT- When Diastolic pressure is less than 100mm
Moderate HT – Diastolic pressure between 100 – 120mm
Severe HT – Diastolic pressure between 120 – 140 mm
Gross or Malignant HT – Diastolic pressure more than 140 mm of Hg.
Another way of classifying the HT is Causes, which can be either Primary or Secondary.
Primary Hypertension: Also known as Essential hypertension with obscure cause or where No cause can be found. Blood pressure is high without any physical complaints and has to be treated on the basis of constitution. It is the most common type and it affects both sexes.
Secondary Hypertension – Where there is a demonstrable cause for the HT and treatment of the same cures the patient of HT.
Hypertension is said to be the disease of modern urbanization and fast life. As a matter of fact hypertension itself is not a disease in itself but it is one of the indicators alarming a person to take care of probable emergency. An enzyme called RENIN in the kidneys is responsible for control of Blood Pressure. When there is a fall in volume of blood flowing through the kidneys, kidneys secrete Renin. This Renin cause formation of a substance called Angiotensin, which leads to constriction of arteries thus raising the Blood Pressure. Angiotensin also causes excess of Aldosterone, a hormone from Adrenal Glands. This Aldosterone causes sodium retention in the body, we all know that water follows sodium, hence sodium retention leads to water retention causing volume overload thereby raising the BP even further. Here I must make a mention about the stress also. HT is sad to be the outcome or a derivative of fast life, people always rushing against time, trying to realize their ambitions, setting up newer goals, intensely competitive nature all take their toll. This permanent stance of fight leads to increased secretion of Adrenaline, which causes Hypertension.
Aetiological Factors for Essential Hypertension are: –
1. Hereditary factor: Commonly seen in the children of hypertensive patients, twins. This is due to abnormality in trans-cellular sodium transport, which is one of the genetic defect.
2. Mental Stress: Stress in everyday life is one of the most common aetiological factors found in now a day’s life style.
3. Dietary factor: Excessive intake of Salt and Fats in rich diet through pickles, papads, fast foods etc. and over use of salt in daily diet.
4. Low Potassium diet:
5. Alcohol: Alcoholics often suffer from hypertension. Although alcohol does not have any direct effect on hypertension, yet it effects indirectly and is seen during the withdrawal stage which is mediated by sympathetic nervous system.
6. Obesity: Caused due to more salt, fat and carbohydrate intake and sedentary habits.
7. Smoking.
Aetiological factors for Secondary Hypertension can be: –
1. RENAL: – Hydronephrosis, Renal Artery Stenosis, Glomerulo-Nephritis Polycystic renal disease, Diabetes.
2. ENDOCRINAL: -Cushing’s syndrome, Adrenal Carcinoma, Hyperparathyroidism, Hypothyroidism, Pheochromocytoma.
3. CARDIO – VASCULAR: – Raised Systolic pressure in Aortic Regurgitation or in Complete Heart Block, Coarctation of Aorta.
4. CEREBRAL: – Cerebral Trauma, Encephalitis, Increased Intracranial Pressure due to any causes, Bulbar Poliomyelitis.
5. TOXIC: – Toxemia of Pregnancy, Intake of Oral Contraceptives Steroids or
Lead toxicity, Estrogen therapy.
6. POLYCYTHEMIA VERA: –
7. DRUGS INDUCED: –
Out of all these mentioned types, essential hypertension is commonly seen. Most of the times such causes are ignored and patient comes with the complications. Thus, knowledge about the type and its management becomes must for all of us.
Most symptoms of hypertension generally start after a patient knows that he/she has HT. Usually it is asymptomatic. In early stages the hypertension is fluctuant. It rises to abnormal levels under the influence of emotional changes etc. and later on it becomes permanently elevated even at rest. Occasionally patient may complain of vague complaints like Headache, Headache is usually occipital which starts on waking and improves with the day. Heaviness of head, Giddiness, Palpitation, Paroxysmal Nocturnal Dyspnoea.
The commonest presentation is patient says that nowadays I feel very angry or the accompanying person tells that he/she feels very angry and agitated on trivial matters, so please check my or his/her BP. Symptoms generally are of dangerous complications due to effects on Target Organs namely Brain, Heart, Kidneys and Eyes. Sudden rise in BP can cause an artery to burst in the brain causing a Stroke. Heart has to pump harder leading to either Ischemia (IHD) or Pump failure (LVF). Renal failure can occur by reduction of blood flow to the kidneys. Tiny haemorrhages occur in the Retinal vessels leading to diminution of the Vision and finally may be to total Blindness.
Complications which can arise: –
1. ARTERIOSCLEROSIS
2. ARTERIOLAR INFLAMMATION
3. HEART FAILURE
4. ANGINA PECTORIS
5. CEREBRO-VASCULAR ACCIDENT- CEREBRAL HEMORRHAGE
6. THROMBOSIS AND SUBARACHNOID HEMORRHAGE
7. HYPERTENSIVE ENCEPHALOPATHY
8. MALIGNANT HYPERTENSION
9. RENAL DAMAGE
10. HAEMORRHAGES – EPISTAXIS, HEMATEMESIS, HAEMOPTYSIS
11. REDUCED LIFE EXPECTANCY OR DEATH
On examination and Investigating a patient of HT, we must observe following: –
a) Blood Pressure level of Diastolic Pressure is important and according to its level the patient is put into the category of Mild, Moderate, Severe and Gross HT
b) Pulse – Radial pulse bounding and hard. Femoral pulse also must be palpated.
c) CVS – Heaving cardiac impulse.
d) Eye Fundus – Arteriolar narrowing, compression, hemorrhage or oedema of disc may be seen.
e) ECG – Left Ventricular enlargement with or without T wave inversion in Lead I, AVL,V5 and V6.
f) X-Ray Chest – Left Ventricle is dense, its left border is rounded. Hyperemic lung, prominent hilar shadow.
Usually the same format is useful to investigate a newly detected case or follow up of case under going treatment. A routine package is generally recommended which gives an insight into important organ systems. In case a particular organ system showing signs of damage, detailed investigations of that system becomes mandatory.
In addition to the complete Blood Count the basic investigations should be :
1)Urine routine – To look for the presence of Albumin and Casts, which indicate Renal involvement., presence of Occult Blood indicate Calculus.
2)Blood Sugar – Diabetes and HT if present together becomes all the more important for management as chances of Target Organ damage increase.
( Normal Fasting 70-100 and P/P. 100-140 mg )
3)Serum Creatinine – elevated Creatinine suggests early renal Failure, and in absence of another cause, indicates that HT may be of long standing in that patient ( Normal 0.6 – 1.4 mg/dl)
4) Serum Cholesterol – Hyperlipidemia can both be a cause and effect of HT. If present unless treated will not let BP come under control. Preferably 12hrs. fasting should be observed for this test. Lipid Profile should be carried out if Myocardial involvement is suspected, as it tells more about blood lipids i.e. HDL, the good friendly Cholesterol(Normal M 35-45,F 45-65mg/dl) and LDL, the bad and unfriendly Cholesterol(Normal upto 150mg/dl).
5)Serum Uric Acid – Hyperuricemia is one of the most common cause for HT not responding to the treatment.
6)X-Ray Chest PA view – For Cardiomegaly specially. LVH indicates that HT is chronic and has been present for some time. Since LVH is reversible with very good control of BP, X-Ray should be repeated to see the progress and control of BP.
7)E.C.G. – Tells about Myocardial involvement and Ischaemic changes in the heart.
8)Fundoscopy – To see the Retinal Hemorrhage and Papilledema which again indicates hypertensive state.
Emergencies:
– Diastolic BP more than 120mm of Hg with major organ damage i.e.
CNS/Kidney/Cardio Vascular.
– Intracranial/subarachnoid Hemorrhage.
– CVA, Hypertensive Encephalopathy.
– Acute Aortic dissection, Pulmonary Oedema.
– Myocardial Infarction, Unstable Angina.
– Eclampsia.
– Pheochromocytoma.(Tumor of Adrenal Medulla)
– Grade III or IV K.W. fundoscopic changes.
During management: Interestingly having enemized BP and linking it to the ills of the Heart, the Brain, the Kidneys and the Blood vessels- without of course reliable proof or data for anyone! Not knowing how exactly the God’s great creation of body computer controls blood pressure every second so thoughtfully and dynamically, modern medicine has chosen to control some facets of the physiology, with inevitable train of side effects ranging from increased mortality to humiliating Impotence.
In a study of celebrated multi-blind trial on antihypertensives in UK, 90% of the physicians declared that their patients were doing well, 80% of the relations of the patients said that the patients were far from happy, and 100% of the patients felt they were worse off than before. Still if HT is treated before becoming chronic, complicated and without pathological cause can be treated better and it should be patient oriented rather than disease oriented. The basic guideline remains as following ;
-Weight reduction in obese patients.
-Low Sodium diet. Salt restriction.(Sodium transport hypothesis is commonly accepted.
-Stress and strain must be avoided.
-Stop smoking and drinking if must then Moderation of Alcohol and Smoking.
-Psychological factors should be looked into and treated first.
-Avoidance of Physical Strain. Rest and Relaxation. Moderation of physical activity. Strenuous exertions, sudden and prolonged stress should be restricted or stopped.
-Change in the outlook and life style. Inclusion of Yogasnas, preferably under the guidance of an expert ( Padmasana, Dhanurasna, Matsyasana and Shavasana are supposed to be the best for the HT patients. Here one should caution the patient also regarding the Shirshasana and Sarvangasana are strictly contraindicated in which the body is held upside down.)
Homoeopathic Therapeutics for HT: As in any other case it should be Individualized and the constitutional similimum is the most appropriate, still following are the medicines which I found useful in my patients.:-
Aconite, Adrenaline, Aurum Met., Baryta Mur, Crataegus, Gelsemium, Glonoine, Natrum Mur, Rauwolfia, Viscum Album etc.