Hypertension kc006 gdg

“Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata

(Hypertension)”

Thesis submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

In partial fulfillment of regulations for the Award of the degree of

DOCTOR OF MEDICINE

(AYURVEDA VACHASPATHI)

By Shivakumarayya .S. Hiremath

Guide

Dr. Ch. Ranga Rao. M.D. (Ayu)

Professor and Head of the Department Post Graduate and Research Center

D. G. M. Ayurvedic Medical College, Gadag.

Co-Guide Dr. Siva Rama Prasad Ketamakka.

M.D. (Ayu) Reader in Kayachikitsa

Post Graduate and Research Center D.G.M. Ayurvedic Medical College, Gadag.

POST GRADUATE AND RESEARCH CENTRE (KAYACHIKITSA)

D.G.M.AYURVEDIC MEDICAL COLLEGE, GADAG.

1997-2001

Ayurmitra

TAyComprehended

This is to certify that Shivakumarayya .S. Hiremath (M.D. (Ayurveda) Kayachikitsa), has worked for his thesis on the topic entitled

“Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)”.

Cl inical tr ials are done under my supervision and guidance.

This thesis makes a dist inct advance on scient i f ic l ines in the above

subject and the f indings are highly signif icant at the stat ist ical

evaluation and have considerably contributed to the present

knowledge of the subject.

I am ful ly satisf ied with his or iginal work and hereby forward the

thesis for the evaluat ion of adjudicators.

Co-Guide

Dr. Siva Rama Prasad Kethamakka M.D. (Ayu) (Osm)

Reader in Kayachikitsa

Head of the Department

Postgraduate and Research Center (Kayachikitsa)

D.G.M. Ayurvedic Medical College, Gadag.

This is to certify that the contents of this thesis entitled “Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)” has been worked out by Shivakumarayya .S. Hiremath,

under my supervision and close guidance and co guidance of Dr. Siva Rama

Prasad Kethamakka, M.D. (Ayu) (Osm).

Even though this disease, Hypertension has not been mentioned in

Ayurvedic texts, the etiology, pathogenesis etc., as developed and explained by

Shivakumarayya .S. Hiremath is unique and scientific and will definitely help in

explaining the disease in Ayurvedic parlance and further planning the

management.

This work is applied, scientific and an original contribution in the field of

research in Ayurveda.

I am fully satisfied with the work and recommend the thesis to be put

before the adjudication.

Guide

Dr.Ch.Ranga Rao M.D. (Ayu) (Osm)

Professor and head of the department Post graduation and research center

Kayachikitsa D.G.M. Ayurvedic Medical College, Gadag.

Acknowledgement

I am highly indebted to my guide Dr. Ch. Ranga Rao H.O.D. post graduate and

research center in Kayachikitsa, shri D.G.M Ayurvedic Medical College, Gadag for his

valuable suggestions and guidance in completing this work successfully.

I have my hearty acknowledgement to my co guide Dr. K.Siva Rama Prasad, for

his guidance, supervision and suggestions for the early completion of this research work.

I am thankful to Dr. G.B. Patil principal shri D.G.M Ayurvedic College Gadag for

his help during my study.

I am also indebted to Dr. Ashok kumar panda and Dr. M.C patil, lecturers P.G

Department of Kayachikitsa for their suggestions and comments in this study.

I wish to convey thanks to my teachers Dr. G.S Juktihiremath, Dr. C.M

Sarangamath, Dr. S.A patil, Dr. G.S Hiremath, Dr. C.S Hiremath, Dr. U.V Purad, Dr. V.M

Malagoudar, Dr. R.K Gacchinamath, Dr.B.G Swamy, Dr. S.S Avvani and all other U.G

lecturers for their help and suggestions during my post graduation studies.

I wish to thank Dr. V.S Hosamath, physician in Gadag for his help during my

study.

I sincerely thank my beloved classmates Dr. V.B Kotturshetter, Dr. A.S Patil,

Dr.(Smt) Yashoda Mudigoudar, Dr. S.T Hombal, for their deep co operation and

involvement in the P.G study.

I am also thankful to all my post graduate colleagues Dr. B.M Mulkipatil, Dr.

R.Y.Shettar, Dr. J.I Hiremath, Dr. Suresh R.D, Dr. S.K Tiwari, Dr. C.V. Rajashekar,

Dr.Shyal kumar, Dr. Jayaprakash, Dr. Anil Kumar Bacha, Dr. V.N. Kulkarni and Dr. D.

Sitarama prasad, for their constant cooperation and help.

I am highly indebted to my beloved parents Mr. and Mrs. Shankarayya, T.

Hiremath and to my Uncle Dr. S.T Hiremath, my brother Totayya, Chandru and sisters

Dr. Vijjaya lakshmi, Mangala, Geeta and Shaila, for their love and affection rendered

throughout my career.

I wish to convey my thanks to beloved shri V.M Mundinamani and Mr.S.B.

Sureban for supplying me essential references in the study.

I wish to thank the physicians nursing of the hospital and their co-operation.

I thanks to Mr. P.M. Nanda kumar for his help in the statistical evaluate.

I wish to convey my thanks to beloved Dr. S.H. Doddamani, K.B.Stavaramath,

J.V. Aravanashi, Veeresh Kumbar and K.H.Surakoda for their encouragement and help.

I thanks to my beloved patients who are involved constantly in this clinical study

and obliged my advise by which this study able to get finished in stipulated time. I

express my thanks to the persons who directly or indirectly helped me in the study.

Lastly I pay my deep homage and tribute to my former teacher late Prof. Dr.

V.V.S. Sastri for his selection of this valuable project.

Shivakumarayya .S. Hiremath

“Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)”

By Shivakumarayya .S. Hiremath Under the guidance of Dr.Ch.Ranga Rao

And Co-Guidance of Dr.K.Siva Rama Prasad Section - I Introduction Definition

Physiological out look of “Blood pressure”

Hypertension in Ayurveda

Proposal

Historical review

Pages: 1 to 10 Ama in hypertension

Srotas in hypertension

Focus on the title

Contents of the thesis

Influence of neurosis (Vata) in hypertension

Section - II Literary review

Shareera

Introduction

Dosha and Dooshya

Concept of dosha in relation to

Hypertension

Dushya and srotas

Agnimandya

Dietetic causes

Behavioral causes

Other causes

Hridaya (heart)

Nirukti of hridaya

Embryological development

Surface anatomy

Inner view of the heart

Spandana of Hridaya

Interference of Pleeha with hridaya

Pages: 11 to 31 Circulation of the blood

Internal transport system of

the body

Pranavata

Location of pranavata

Functions of pranavata

Sirasthita pranavata

Urahsthita pranavata

Vyanavata

Location of vyanavata

Functions of the Vyanavata

Functions of the heart

Rasavahasrotas

Rakta peedana

Srotavaigunya

Contents

Nidana

Definition of Hypertension

Raktagavata

Raktavrita vata

Siragata vata

Bhrama

Roudhira Mada

Raktapradoshaja vikaras

Avruta Vata

pittavrutha prana vayu

Pittavruta udana vata

Murcha

sanyasa ( coma)

Dhamani pratichaya

Classification of hypertension

Symptomatic classification of hypertension

Labile hypertension

Stable hypertension

Classification by blood pressure (level)

readings

Mild hypertension

Moderate hypertension

Severe hypertension

Classification by severity of vascular lesions

Stage I

Stage II

Stage III

Classification by etiology

Essential hypertension

Secondary hypertension

Classification by age groups

Juvenile hypertension

Hypertension in the elderly

Pages: 33 to 62

Epidemiology of hypertension Prevalence

Level of pressure

Genetic Influences

Environmental Influences

Geographical aspects

Age and Sex in Hypertension

Hypertension and body weight

Pathophysiology

Primary hypertension

Primary (essential) hypertension

Genetic factors

Dietary influences

Sodium chloride intake

Protein intake

Alcohol

Soft water

Psychological factors

Haemo dynamic changes

Neural changes

Secondary hypertension

(Hypertension with identifiable cause)

Hormonal contraceptives

Hypertension due to organic

disease

Clinical features of hypertension

Differential diagnosis of hypertension

Renal hypertension

Primary aldosteronism

conn’s disease

Cushing’s syndrome

Contents

Chikitsa

Management of hypertension General stagetegy

Weight reduction

Salt restriction

Smoking

Relaxation techniques

Chikitsa in Ayurveda

Management with drugs

Steps care treatment of hypertension

Mild hypertension Vasodilators

Diuretics

Beta-blockers

Calcium antagonists

Angiotensin convertor enzyme

Inhibitors

Antiadrenergic drugs

Pages: 63 to 82

Reserpine

Alpha methyldope

Guanethidine

Clonidine

Labetolol

Choice of anti hypertensive drugs (in special situations)

Hypertension in children

in the elderly

in pregnancy

in ischaemic heart disease

in cardiac failure

in renal insufficiency

Pathya and Apathya

Section - III Material and methods Pages: 83 to 114 Drug review

Composition of vachamamsyadi yoga

Punarnava (Boerhavia diffuse Linn.)

Gokshura(Tribulas terrestris Linn.)

Jatamamsi (Nordostachys jatamansi DC.)

Vacha (Acorus calamus Linn.)

Drug preparation

Storage of vachamamsyadi yoga

Posology

Review of methodology Observations

Section - IV Discussion and conclusion Pages: 115 to 134

Summary

Section - V Present trends and Bibliography

Contents

List of Charts Chart number – 1

Demographic data for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Chart number – 2

Complaints for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Chart number – 3 Diet and drug history in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Chart number – 4

Emotional status and Family history in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Chart number – 5

Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Systolic hypertension

Chart number – 6

Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Diastolic hypertension

Chart number – 7

Statistical Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Chart number – 8

Significance table of “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Contents

List of Figures

Figure no 1:

Graphical demonstration of Decreased systolic Hypertension in regular intervals In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure no 2:

Graphical demonstration of Decreased diastolic Hypertension in regular intervals In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure no 3:

Showing sex ratio In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure no 4:

Religion distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 5: Occupation distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 6:

Economical status distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 7:

Diet distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 8:

Group study In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Contents

Figure number 9: Chief complaints In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 10:

Associated features In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 11:

Diet and drug history In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 12:

Emotional status In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 13:

Family history In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Figure number 14:

Result In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

List of Photographs Photograph-1

Punarnava (Boerhavia diffuse Linn.) Photograph-2

Gokshura (Tribulas terrestris Linn.) Photograph-3

Jatamamsi (Nordostachys jatamansi DC.) Photograph-4


Contents

Hypertension most commonly heard clinical state in the older age groups of

patients. They suffer with the risen arterial blood pressure giving rise the signs and

symptoms such as giddiness or dizziness (Bhrama), headache (Sirahsoola), fatigue

(Angasada), insomnia (Nidranasha) and palpitation (Hritdrava). An Ayurvedic

practitioner get confused as the nomenclature of Hypertension was not included in

classical texts and neither of Acharyas has affirmed such a condition elaborately.

The Hypertension, called as “Salient Killer”, drawn the attention of W.H.O. in

1978 and declared that year as “Hypertension year”. This disorder definitely has its

action over decreasing the life span by 10 to 20 years causing cardiac and renal

troubles. Further it can be said it is an important factor in increasing the morbidity and

mortality due to the cardiovascular pathology.

DEFINITION:

The definition of Hypertension is as follows. “Abnormally high tension,

especially a state of abnormally increased blood pressure with Electro cardiograph

evidence of cardio arterial derangement (left ventricular preponderance)”1 and

vernacularly “abnormally high blood pressure” and “great emotional tension”2. Other

wise it is as abnormally increased blood pressure exerting on the arterial and

arterioles more then 120mm Hg systolic and 80-mm Hg diastolic pressures. The

WHO has recommended that blood pressure of 160/95 mm Hg or above in adults

should be considered as Hypertension.

Introduction 1

As there is no definitive definition universally accepted, the joint National

committee (JNC-4) of United states on detection, evaluation and treatment of high

blood pressure defines Hypertension as systolic blood pressure (SBP) of 140 mm Hg

or more and diastolic blood pressure (DBP) of 90 mm Hg or more.

Table 1

Classification of BP in Adults aged 18 years or older 3

Diastolic Blood pressure

BP range Category #

< 85 Normal Blood pressure

85 to 89 High normal Blood Pressure

90 to 104 Mild Hypertension

105 to 114 Moderate Hypertension

> 115 Severe Hypertension

Systolic Blood pressure when DBP< 90

BP range Category

< 140 Normal Blood pressure

140 to 159 Borderline systolic Hypertension

> 160 Isolated Systolic Hypertension

# A Classification of borderline is isolated systolic hypertension (SBP 140-159 mm Hg) or Isolated hypertension (SBP>160 mm Hg ) takes precedence over high normal BP (DBP 85-89 mm Hg ) when both occur in the same patient. High normal BP (DBP 85-89 mm Hg) takes precedence over a classification of normal BP (SBP 140 mm Hg) when both occur in the same patient.

Introduction 2

Blood pressure is a continuous physical variable and is complex, being

influential by many factors. An individual can show variations through out the day

depending on physical activity, body posture, mental activity, emotional status, the

environment and consumption of drugs, alcohol and tobacco. Dynamic or isometric

exercise can also risk blood pressure in normal subjects.4

Physiological out look of Definition “Blood pressure”:

Blood pressure is generated by cardiac out put which is determined by the

rate and force of heartbeat and the resistance to the flow of blood through vessels5 in

the arterial system and the viscosity of blood6. Apart from it is the resultant of a

number of forces, among the chief of which are the contractions of the heart and the

peripheral resistance provided by the arterioles, although the elastic recoil of the

large arteries and the state of capillary bed are also of importance7.

Hypertension in Ayurveda:

Ayurveda is based on the humoral theory and establishes that the Tridoshas

have its effect over the body. These humors move all over the body. The Vata, Pitta

and Kapha rule the ages of child, youth and old age8. It also has its effect on the

divisions of the day and night, and also to the food; where dosha vitiation is seen

naturally contributed by the external factors.

While describing the diseases developed by the doshas exclusively in

Charaka samhita Sutra stana under the heading of Nanatmaja vyadhi, explained

Introduction 3

eighty varieties of vataja, forty varieties of Pittaja and twenty varieties of Kaphaja

vyadhis9.

As there is no specific nomenclature available in relation to Hypertension from

classical textbooks, we have to see the corresponding Disease State from various

Ayurvedic textbooks. Charaka has very clearly expressed all the disease and

disorders or states of illness, may not be known with specific nomenclature, but

grouped under particular modalities of classification. There by no definitive and

permanent name can be attributed to a particular condition as it is expected to

change with time to time according to its presentation. Thus by understanding the

dosha state, site of appearance and its signs and symptoms, we have to come for

conclusion and treat the state of disease or illness on the basis of vikalpa i.e.

combinations and permutations of doshas10.

Different names are recommended for the Hypertension or the Hypertensive

States are as follows –

1. Bhrama

2. Dhamani pratichaya

3. Mada

4. Moorcha

5. Pittavrita udanavata

6. Rakta gata vata

7. Raktachapadhikyata

8. Raktapradoshaja vikara

9. Raktavriddha pittavrita vata

10. Roudhiryamada

Introduction 4

11. Sanyasa

12. Siragata vata

13. Ucha rakta bhara

14. Ucha rakta chapa

Proposal:

But when the lakshanas of Hypertension are observed with its

pathophysiology, the present proposed name “Raktapeedanadhikyata” will be

relatively clear to explain state of Hypertension.

As Charaka explained, there may be only one cause for one disease or same

cause may give rise many diseases. Some times we may find so many causes gives

rise or develops one disease or many causes develops many diseases11. Thus, the

present selected disease has many synonyms, according to the state of development

of the disease or with respect to that of the disease development.

The Vata nanatmaja vyadhi consists of three conditions that appear in the

process of Hypertension pathogenesis. They are Hritdrava (palpitation), Bhrama

(Dizziness) and Aswapna (sleeplessness)12. The appearance of the above said in

Vata age and rutukala is of physiological and if it appears with Pitta and Kapha

association or age and rutukala, it becomes pathological. If Dhamani pratichaya

(atherosclerosis)13, one out of twenty Kaphaja diseases appears or associates with

the aging factor have more responsibility to give rise Hypertension or

Raktabharadhikyata.

Introduction 5

Historical review:

In ancient days the Hypertension was not described as an individual disorder.

It may be because of less prevalence as they followed strict daily and seasonal

regimens and also not much psychological interference in daily routine. But they

were not ignorant of the conditions developed by the psychological pressure

disturbances. There by they placed them under the nanatmaja vyadhis, related to

their cause and mode of development. Much more such symptoms are explained and

tagged with Vata, which can be said as that to be under neural control impairment

and very few conditions are with Pitta and Kapha.

Until 1920’s, Hypertension was considered that as beneficial, even through in

1733 Stephen Hales measured first time Atrial blood pressure. He demonstrated in a

dramatic fashion, that the blood in arteries is under a great deal of pressure. His work

was published by Royal society in 1733 as two volumes.

The instrument developed by Stephen Hales14 was improved by Karl Ludwig

(1816-1895) improved the Instrument developed by Stephen Hales by adding a float

in the measuring cylinder. Karl Vierodt (1818-1884) constructed a sphegmograph

tracking the human pulse, which estimates the blood pressure by puncturing the

vessel. It was difficult and also painful for the patient. This method was greeted by

British medical journal and followed by Samual Von Bach (1880) and later developed

by Scipione Riya Rocci in 1896.

Introduction 6

In 1905, Karokoff a Russian, introduced the auscaltatory method of estimating

blood pressure. With in few years Sphegmamanometer took place with the

stethoscope. The mercury column and spring dial sphegmamanometers were

introduced in 20th century. Late 20th century with advancements in electronics has

presented digital sphegmamanometer to the medical community apart from ECG and

Doplar studies, which will provide scope to measure, blood pressure15.

Influence of Neurosis (Vata) in Hypertension:

In 1965, Myas Nikov contended that the under lying factor of Hypertensive

disease is neurosis, as the term is interpreted by Pavlov. According to this

hypothesis, the principle etiological factor of hypertensive disease is psychological

over strain leading to impaired regulation of the vascular tone. This hypothesis is at

the support of Ayurvedic dosha, Vata interference in producing

Raktapeedanadhikyata. But at present it lost its popularity as contemporary clinicians

regard essential hypertension as a disease of uncertain origin16.

Ama in Hypertension:

Ayurveda speaks about dhamanipratichaya (arteriosclerosis) as an

associated condition with hypertension responsible for 30% of population suffering

from hypertension. The rest of 70% are solemnly under the neurotic control or may

be associated with Pitta other wises the Agni17, which is the most common cause of

initiating a pathological state by diminishing. Diminished Agni causes Ama18, and that

Ama, an endotoxin equaling to that of poison causes the pathology either localized or

generalized.

Introduction 7

Srotas in Hypertension:

Out of the samprapti ghatakas, the srotas is very important. Here in

hypertension the Raktapeedanidhikyata, the hridaya as organ and corresponding

rasvahasrotas as the srotas involved has been expressed the hridaya corresponds to

thoracic heart along with arteries attached with hridayam and dasha dhamani). With

the above Myasnilkov’s statement even sirohridaya i.e. brain (neural control) with

cranial nerves and its involvement can be thoroughly discussed. But as hridaya

(thoracic), especially the left ventricle of the heart counters the increased resistance

in areterial blood pressure and also leads to its hypertrophy which is manifested at

first by intensified apex beat, rounded left ventricular apex and characteristic ECG

changes19. We can more precisely think of the Urohridaya instead of sirohridaya, as

the Urohridaya is under the control of sirohridaya, that the consideration of

sirohridaya is stand still.

Along with the rasavaha srotas, the annavaha srotas is also to be considered

as a srotas, which permits the intake of aetiological factors in the form of vijateeya

dravyas converted in to sajateeya dravyas by the presence of Agni. At last the

mootravaha srotas which regulates the pressure of liquid part circulated in the body

i.e. rasa – rakta complex is also to be drawn attention.

Focus on the title:

Present study as a part and parcel of fulfillment of “Ayurveda Vachaspathi”

(Doctor of medicine), M.D. Ayurveda under Rajeev Gandhi University of heath

sciences, Bangalore was titled as “Evaluation of the effect of

Vachamamsyadi yoga in Raktapeedanidhikyata (Hypertension)”.

Introduction 8

There are few established anti hypertensive drugs with the combination of

sarpagandha (Rauwalfia serpentina) used in India because of its sedative and anti

hypertensive property. Reserpine, the main alkaloid of Sarpagandha was isolated

and practiced as anti hypertensive medicine.

Present study under the Ayurvedic principles suggests only regulating and

eliminating the waste byproducts from the body, which are over loaded in the body.

These toxins can be eliminated through either gastrointestinal tract or through urinary

tract. As it is found that the thickened vessels of renal interrupt formation of urination,

two herbs which support urination has been selected in the composition. They are

Punarnava (Boerhavia diffuse Linn.) and Gokshura (Tribulas terrestris Linn.). Another

perennial herb Jatamamsi (Nordostachys jatamansi DC.) also called Spiknard

possesses an important action on central nervous system. This herb also has diuretic

effect along with nerve sedative action. The fourth herb included in the study is

Vacha (Acorus calamus Linn.) is nervine and rejuvenator along with its action over

circulatory system. It has been successfully used by Dr.B.R.K.R.Ayurvedic college

postgraduate and research center and found having efficacy over hypertension along

with tranquilizer effect.

With preset inclusive and exclusive criteria the selection of patient is selected

from Postgraduate and research center, D.G.M.Ayurvedic medical college, Gadag,

and medicine was administrated under the supervision. The literary and part,

observations and results are expressed in stipulated chapters as under –

Introduction 9

“Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)”

by Shivakumarayya .S. Hiremath

1. Introduction

Historical review

Focus on title

2. Literary review

Shareera (Physiology and Anatomy)

Nidana (etiology)

Samprapti (Pathophysiology)

Chikitsa (Classical treatment)

3. Material and methods

Drug review


Gokshura (Tribulas terrestris Linn.)



Drug preparation

Review of methodology

Observations

4. Discussion and conclusion

Summary

Present trends

Bibliography

Special case sheet of Raktapeedanadhikyata

Introduction 10

References: 1 Dorland’s Pocket medical dictionary ,pp310 2 The pocket Oxford dictionary of current English, pp432 3 ****, based on the average of two or more readings on two or more occasions, pp480 4 Ibid, pp480 5 Shareera kriya vijnan, pp425 6 Text book of medicine, R.J.Vakil, pp772 7 Text book of pathology, W.Boyd, pp586 8 A.H.Sareera,1/8 9 Charaka Sutra 20/10 10 Charaka Sutra 18/46 11 Charaka Nidana, 8/28 12 Charaka sutra 20/12 13 Ibid 20/15 14 A literary search on Raktachapadhikyata, S.H.Doddamani, pp1-2 15 Ibid, pp5 16 Differential diagnosis of internal disease, A.V.Vinogradov, pp88 17 Susruta Sutra, 21/9 18 A.Hridaya Sutra, 13/25 & Arunadutta on it Bhavaprakasha Madhyama Khanda 1/59 Vijaya Rakshita on Madhava Nidana 25/2 19 Differential diagnosis of internal disease ,pp89

Introduction 11

INTRODUCTION

For any research the collection of available source of hypothesis’s and its

emphasis is necessary. At present study “ Evaluation of the effect of vachamamsyadi

yoga in Raktapeedanadhikyata “ (Hypertension), it has clear interventions with that of

Vata and avritavata. In Charaka Samhita, while describing the complication of avrita

Vata in vatavyadhi Chikitsa Charaka affirms due to neglect of Avaritavatas, cardiac

disorder, abscess, spleen enlargement, Gulma and diarrhea appear as

complications1.

At the above reference we can draw a conclusion that in case of

Hypertension as Raktapeedanadhikyata. The involvement of Vata with its

characteristic feature “ Gati 2“ is known to ancient Acharyas; the influence of Gati with

its momentum and pressure exertion over Srotases especially to Dhamanis where

the Rasa Rakta complex flow is witnessed. This Rasa Rakta complex is propelled or

ejected into conduits of its attachment3. Thus a detailed study of Hridaya – Thoracic

heart with its attachments are necessary to be studied in detail or part from the

Srotases involved viz. Rakta and Mootravaha Srotases in the study.

As the clear description is available about the involvement of hridaya (thoracic

heart) along with Pleeha, a moola stana of Rakta vaha srotas; even though not

directly concern with Raktapeedana in Dhamanis and Siras, its involvement can not

be ruled out.

At this juncture a detailed anatomical and physiological study is necessary

apart from pathophysiology of Raktapeedanadhikyata i.e., Hypertension.

Literary review - Shareera 11

Dosha and Dooshya

Present day scholars of Ayurveda Dr. P.D. Joshi, Dr Gurudeep singh and Dr

Shukla done the research on dosha pattern in essential hypertension and decided it

as Vata pradhana Vyadhi with Pitta and Kapha association.

At the observation of the disease, hypertension we found that the involvement

of Dhamani pratichaya, a Kapha nanatmaja vikara is associated with hypertension.

Not only Dhamani pratichaya even nidranasha a condition with Pitta vitiation is also

found. We can not be certain that the nidranasha as exclusively of Pitta vikara and it

may appear with Vata vitiation also. But the observations are more suggestive with

above referred scholars in Ayurveda in comparison to Acharya shri vishwanath

dwivedi who has correlated hypertension to roudhir mada and raktaja vikara. Here in

this concern Rakta can be one out of these Dooshya as it is flowing in the vessels of

blood along with Rasa and ejected out through hridaya for its “Jeevana “ function.

Dosha Vata

Anubandha dosha Pitta – nidranasha

Kapha – Angasada

Dooshaya Rasa

Rakta

Adhistana

Hridaya; thoracic heart with its connections

Brain with cranial nerves especially Vegas

Dhamani

Sira


Concept of dosha in relation to Hypertension

The vitiated doshas are the prime important factors for a disease, they are

capable of the vitiating the other body elements like dhatus, malas and srotases46.

Doshas in kshaya (decreased state) are not capable of progressing through the

stages of kriyakalas to produce samprapti47. Doshas in vriddhi (increased state)

manifest different specific symptoms and effects of the vitiation of particular doshas.

Dushya and srotas :

Next to doshas the most important contributing factors of disease are dushya

and srotas. Among the body substance dosha, Dhatu and Mala, the latter two are

considered as dushyas. Doshas travel in the body through the channels (Srotases)

and these are formed of different Dhatus. Therefore greater importance should be

given to Dhatus.

The deformity of Srotases is called khavaigunya. "kha" means akasa or

cavity. Srotas being a channel, it necessarily consists hallow portion inside with a

covering wall around it48. Sthana samsraya is the stage of samprapti where doshas

get lodged in Srotases and start the process of amalgamation with them (dosha

dooshya sammurehana In short all the bodily activities are entirely dependent on

Srotases. All the doshas, Dhatus and Mala are dependent on Srotases for their

formation, conduction and destruction49. Hence, when Srotases get deformed, the

activities of dosha, Dhatu and Mala also become favorable for the genesis of a

disease. This state of dosha - dushya sammoorchana corresponds to the phase of

the manifestation of prodromal symptoms or poorvaroopa.


It is therefore evident that in the event of the impairment of the integrity of a

srotas, a Dhatu either located in its own place or circulating through its srotas

definitely becomes morbid. In the present context the Rasa is the substance

conveyed by the 10 Dhamanis and it is the Rasa that has the altered physico-

chemical properties, which can change the physiology of the Dhamanis.

Agnimandya;

Charaka has clearly explained the importance of Agni; "When the Agni is

extinguished, man dies; when a man is endowed with its adequately, he lives long in

good health. When it is deranged he falls sick. Therefore the function of the Agni is

said to be the main stay of life"50.

In the present context, Agni may be disturbed under the following aspects;

1. Dietetic causes :

1. Irregular diet habits.

2. Over-eating

3. Ingestion of the following types of food:

a) Heavy and indigestible

b) Raw and uncooked

c) Fried foods

d) Which are rooksha and sita (cold)

e) Which can cause irritation and inflammation of the stomach.


f) Unclean and contaminated foods

g) Soaked in too much of water and also for long duration.

h) Food containing articles which are incompatible to one

another.

i) Ingestion of food before the previous meal is completely

digested.

j) Ingested foods disgusting or for which one has an aversion.

2. Behavioral causes :

1. Intense emotional stresses such as grief, raga, worry, fear etc.

2. Irregulars sleep habits.

3. Lack of physical exercises

4. Suppression of natural urges.

5. Use of defective and faulty methods of vamana, vireka and sneha karmas.

3) Other causes :

1. Emaciation due to any disease.

2. Faults or changes in desha, kala and ritu.

Because of this impairment, the functions of jatharagni viz., sanghatabheda,

dahana, tapana, parinamana and paravritti of the food are not effected properly. By

virtue of asrayasrayee bhave, the impaired function of jatharagni leads to the

defective functioning of the pittadharakala (grahani). Therefore the functions of the


samanavata are also disturbed, leading to the erratic motility of the gastrointestinal

tract. Two kinds of effects are envisaged: -

1. The grahani holds the food for longer duration leading to its fermentation

resulting in the release of the toxic substances collectively known as Ama.

2. The grahani does not hold the food ill it is digested but pushes the partly

digested food downward into the pakvasaya and sthulantra, effecting a

rapid evacuation.

The kayagni being located in its own place, not only takes part in the

digestion of the food, but also contributes to and augments the functions of other

Pitta51. Therefore it is clearly evident that on the event of the impairment of the

function of the jathargni the functions of the other Pitta are also impaired52. So the

cause and/or conditions which contribute to the impairment of the jatharagni can also

disturb the functional activity of the other Agni.

HRIDAYA (heart)

The heart (cardiac) is an important visceral organ made of Mamsa Dhatu

situated in thorax apparently in between two nipples3a. It is particularly muscular and

contractile tubular segment interposed between the veins and arteries; situated in

middle mediastinum covered by fibrous pericardium4.


NIRUKTI OF HRIDAYA:

The term “hridaya” consists of three roots; ‘hri’, ‘da’ and ‘in’ and they

respectively mean, harana, dana and ayana (gati) which indicates three important

functions meaning the receipt, giving away and moving on continuously activity of the

two earlier functions. Therefore the word hridaya explains and signifies the functional

aspect of an organ and its identification depends on the substance, which is being

“received”, “given away” and the organ thus functioning continuously for the

purpose4a.

In the light of the above definition, there are certain organs in the body which

can qualify to be called as “Hridaya” like the thoracic heart, the lungs and the central

nervous system etc. In view of the water freely moving in and out, even every jiva

paramanu or cell can be designated as “Hridaya”. In the present context of

hypertension, Hridaya clearly indicates the thoracic heart only.

Embryological development5

Hridaya is said in Astanga sangraha as developed from Sleshma and Rakta6.

It is one out of the Matru janita avayava along with Pleeha7 in third month foetus

develops heart which has attached to the mother and mother called as “Dwohridi”:

The heart which is developed by mother is attached with Rasa vahaka nadi of

mother. The desires of foetus is thus expressed by the mother8 according to

kritaveerya hridaya develops first as it is the seat of the Buddhi and manas and

vetoed by Dhanvantari as all the anga pratyangas are going to be developed at

once9. It is explained in Sustruta Samhita the hridaya develops in 4th month.


Rather it can be said in between the 3rd and 4th months of pregnancy the

hridaya is going to be developed which is chetanastana10, 11.

Surface anatomy

Aorta and the pulmonary trunk mainly hide the superior border of the heart,

formed by the upper margins of the atria. The right border of the heart formed by the

right atrium extends from the right end of the superior border to a point on the right

sixth costal cartilage 1-2 from the margin of the sternum. This border is slightly

convex to the right. The inferior border of the heart, formed mainly by the right

ventricle. It extends from the inferior extremity of the right border to a point (apex of

the heart) in the fifth left inter costal space immediately medial to a vertical line

dropped through the mid-point of the clavicle (midclavicular line). Normally this

border is slightly concave to inferior and becomes convex and gives the globular

shape incase of hypertrophy. A convex line to the left joining the left ends of the

superior and interior borders marks the left border. It is formed by mainly the left

ventricle and the left auricle and forms a small part of this border at superior

surface12. From the Ayurvedic classics it has been said hridaya is a Sira marma

situated in between the two breasts in the chest, looks like as that of the opening of

the Amashahya13. It has on its left side Pleeha and Puppusa and to the right Yakrit

and Kloma14. Its shape resembles the inverted long bud having chambers in it15. In

taittariyoparishat, relative placement has explained with Nabhi- the neval region it

was said Nisti above to the umbilicus the Nisti means 9 inches approximately. In

further at the same context it was explain heart look like an inverted lotus bud having


down with its muscular pouch attached to the veins and arteries, 9 inches above to

the umbilicus16. Such hridaya is said as the placement for Ojas, Pranavahasrotas,

Rasavahasrotas, Buddhi, and Manas of so many important factors dealt in Ayurveda.

Inner view of the heart 17

The heart in adults completely divided into right and left sides and look like a

double barreled tube, receiving blood at one end (the atria) from veins and pumping it

out at the other end (the ventricles) into the arteries. Since the heart must pump

blood in only one direction it is provided values to insure against back flow from a

reason higher to one of lower pressure.

The inner lining of the heart continues with the intima of the vessels

connecting to it, is known as the endocardiaum; and does not differ especially from

the intima of the blood vessels. It also forms valves that lie between the atria and

ventricles and at the bases of the two great arterial tunnels living the heart.

The muscular part equaling to the media of blood vessels, is a special type of

muscle (cardiac muscle) found only in the heart and great vessels as the attach to it

although it is striated like voluntary muscle, it differs from in all other respects.

The cardiac muscle fibers so branching and anastamos that it is impossible to

determine to limits of a fiber. Indeed, the myocardium of both ventricles is actually

one continues muscle mass, and the myocardium of the both atria is another

continuos mass. Because of the continuity an impulse for contraction originating in an

atrium can spread through out the arterial musculature; similarly, an impulse

originating in a ventricle can spread throughout the ventricular musculature with all or


none law. It is built in such a way rhythmical transmission initiated by the nerve

impulses keeps the heart contracting and relaxing in regular intervals. In comparison

atria musculature is thin as the work at low pressure. Ventricular musculature thicker

especially of left ventricular as it has to pump the blood for the entire the body, where

as right pumps blood only to the lungs.

No much reference is available about the heart description at the

microstructure level in Ayurveda except it has “Agarakarnika” i.e., chambers, from

Charaka Samhita18. According to Susruta it is made up of two mamsa peshis18a and

example by Dalhana with reference to its channels have their origin in khadantarm

i.e., the organ cavity the hridaya18b. Hridaya is the source of the ten Dhamanis, which

spread throughout the body, giving of even small branches during their course

ultimately end as Srotamsi which are perforce extremely fine tubules with

innumerable openings or pores in their walls, through which Rasa sravana takes

place18c.

Spandana of Hridaya

Hridaya is chetana sthana sthana35 i.e., the seat of chetana. The term

“Chetana” is being understood as animated, alive, living etc, The life of Hridaya is

expressed in the form of akunchana and prasanana (contraction and relaxation)

together termed as spandana. The spandana is characterized by the akunchana and

prasarana of the hritpeshi is maintained by the chetana or swayam prerana shakti i.e.

the auto stimulating quality. Due to its spandana, the hridaya is able to spread Rasa

and Rakta through the body for the Preenana and Jeevana kriyas.


Interference of Pleeha with hridaya

While discussing the complications of avrita Vata Charaka has placed Pleeha

along with hridaya to get the complications. Light has to focus how and why the

Pleeha (spleen) appears here in the context.

Pleeha is placed left in the abdomen left side to that of heart, little down to it.

It is described as the mula for Raktavahasrotas19and Rakta20. Chakrapani in further

added the Rasavahasrotomula viz. hridaya and 10 Dhamanis are to be considered

as Rakta stanas21. Thus the importance and interference with the Rasavahasrotas to

Raktavahasrotas is explainable. At present we have to eliminate the interference of

Pleeha to give rise a disease state in Rasavahasrotomula i.e., hridaya, as

hypertension in association with Rakta.

The spleen is includes in a part of the mesentery of the stomach, and its

parenchyma resembles that of lymph nodes, yet it is a part of the blood vascular

system. Lymphatic within the spleen are confined to its capsule and to large

trabeculae, so that the lymphatic nodules of the spleen add lymph directly to the

blood stream instead of delivering them first into lymphatic vessels, as lymph nodes

do. Phagocytic walls of the sinusoids, a part of the reticuloendothelial system, are the

chief elements concerned with the destruction of the red blood cells and the removal

of the iron component from them in order that this can be used again in forming new

cells. The spleen filters the blood and participates with other parts of the

reticuloendothelial system in the formation of antibodies22. The processes of filtration

of crystalloid and waste recyclable product of the blood it helps to maintain the


viscosity and specific gravity of the blood. There by blood will not be flooded with

unnecessary colloids and crystalloid to maintain normal blood pressure. Otherwise it

will be resulted into blood pressure rise.

Circulation of the blood

The circular movement of the blood (Dhatu) in the body has been mentioned

while describing the Dhatu parinama or the transformation of one Dhatu into another.

The movement of the Dhatus (which nourish the body) goes on eternally like (the

motion of) a wheel23. Chakrapani has pinpointed the Dhatus as the Rasa Dhatu etc.

The simile of the wheel is significant here. This indicates not only the circular

movement, which is continuous, without any rest is dependent upon the ejecting

force of the hridaya i.e., the stimulus of the vyanavata to the Hritpeshi.

Internal transport system of the body:

Srotamsi (conduits) represents the internal transport system of the body. The

term Srotas means a channel - it is derived from the Sanskrit root "sru sravana"

meaning to exude, to ooze, and to permeate. Charaka has defined it is "sravahat

srotamsi" meaning, the structure through which "sravanam" takes place24. According

to Charaka, no structure in the body can grow and develop or waste and atrophy,

independent of Srotamsi that transport Dhatus, which later, are constantly subjected

to (metabolic) transformations. And the Srotamsi supplies the needs of

transportation25. The Srotamsi of the body comprise of channels of different kinds

and they are separately named according to the site and functions. At the present


context, the names Dhamani and Sira are relevant to the circulation of the blood.

Says Charaka; they are spoken of as Dhamanis because they pulsate, as Srotamsi

because they permit oozing and Siras because they maintain a continuous flow of

blood (Rasa - Rakta)"26. The Dhamanis are stated to have their origin in the heart27.

In view of the arrangement made by Charaka, specially when studied

together with the description of characteristic features of different parts of the

vascular system, it is clear that the Dhamanis end in the Srotamsi (capillaries) which

in turn unite to form Siras (veins). Thus hridaya, Dhamanis, Srotamsi and Siras

constitute a single circulatory unit, which regulate the proper flow of blood and

nutritional supply to the body.

The hridaya occupies a central place in the circulatory system as the organ

supplying the motive force for the movement of the Rasa - Rakta combination and

also as a source of Dhamanis.

There are two subdivisions of Vata, namely Pranavata and Vyanavata which

are stated to be concerned with the function of the hridaya. In brief the action of

Pranavata is hridaya Dharana and that of Vyanavata is to eject the Rasa-Rakta

combination for circulation throughout the body.

PRANAVATA

The word "prana" is composed of the root "an" with a prefix "pra" "na" means

to breath, to live. In view of this definition, the Pranavata should be responsible for all

vital functions, which are essential for human existence. The definition "pranayatiti

prana" also indicates the relationship of Pranavata with respiratory act.


Location of Pranavata:

Charaka and Vagbhata28 state Shiras (head or mastishka) to be the seat of

Pranavata. Pranavata is sated to traverse in the regions of oral cavity, ears neck and

chest for the proper control and discharge of its functions.

Functions of Pranavata:

According to Charaka, the functions of Pranavata are the following;

1. Respiration (swasakriya)

2. Deglutition

3. Spitting out (stheevanam)

4. Sneezing (kshavadhu)

5. Belching (udgaram)

Susruta states that Pranavata assists the different vitalizing principles of the

body in discharging their functions in life, deglutition and contribution to the general

sustenance of the body29.

In addition, Vagbhata states that Pranavata maintains the actions of hridaya

(heart), Manas, Buddhi, Indriya (sensory organ) and supports the Dhamanis

(probably the vasomotor functions i.e., circulatory system)30. One of the functions of

prana vata is hridaya dharana31. The word dharana is derived from the Sanskrit root

"dhri". Which means to hold in check, to restrain and "charana" indicates the

preserving, sustaining, protecting etc. Therefore the function of Pranavata, is to be

understood as a check or restraint on Hridaya Spandana, for the preservation or

protection of the organ.


The functions are to be considered as those of an organ/region or part of an

organ, having a shape of Nabhi and situated in the brain. The functions like

respiration, maintenance or the actions of the heart and circulatory system,

deglutition, spitting out, sneezing, bleaching and the functional maintenance of the

sensory organs are peripheral in nature and so the impulses have to leave the

central nervous system for their proper execution. On the other hand the functions

like the regulation of the sensory input, and consciousness which belong to the

Manas and Buddhi are central in character and the impulses have to reach the

respective higher centers.

Therefore some scholars, based on the regions of actions, have further

subdivided the Pranavata as: -

1) Sirasthita Pranavata which is located in the head and

2) Urahsthita Pranavata which is located in the cheat. The sirasthita Pranavata

may regularly move down into the chest through the neck, to join the urahsthita

Pranavata that goes to the oro-nasal region, ears and eyes through the throat. It

carryout the acts of sneezing, belching etc; it is clearly stated that Pranavata is

controlling the hridaya and also the Dhamanis (hridaya dharana and Dhamani

dharana). Hridaya is located in Uras and the Dhamanis are spread throughout

the body. Since the hridaya has to conduct the "vikshepa karma" for the blood to

circulate throughout the body, the conditions of the Dhamanis are particularly

relevant and associated with the function of the hridaya.


Dhamani dharana kendras is also located in the area of Pranavata and is an

important center in that area. Its effect on Dhamanis is of two types:

1) Sankochana (contraction)

2) Vikasana (dilatation)

These two functions are possible only due to the presence of mamsa peshis

in the Dhamanis. The contraction of these peshis causes the decrease in the caliber

of the vessels (vaso - constriction) and the relaxation causes the dilatation. These

are two separate areas in the Dhamani dharana kendra, the stimulation of one cause

contraction and the stimulation of the other dilatation.

The main function of Rakta is Jeevana kriya to all the tissues of the body.

Therefore Rakta is kept in circulation by the spandana of the hridaya. The decrease

in the caliber of the Dhamanis produces a decrease in the supply of the "prana" vayu

and therefore the hridaya is stimulated for increased and forceful spandana, thereby

increasing the Raktapeedana. The decrease in the caliber of Dhamanis also causes

increased peripheral resistance. Thus the Dhamani dharana kendra can either

increase or decrease of the activity of hridaya.

VYANAVATA

Location of vyanavata : Charaka and Susruta have not mentioned any specific

place regarding the location of the Vyanavata, except that it pervades swiftly

throughout the body32. According to Vagbhata, the Vyanavata is located in 'Hridaya '

but traverses throughout the body swiftly33.


Vagbhata states that the Vyanavata is located in "Hridaya" needs some

elucidation in view of the fact that location and function of the nervous system relates

to Vata. And the phenomenon of Vata is the phenomenon of nerve impulses. The

word 'Hridaya' signification is of an anatomical organ that depends on the dravya or

substance, with the functions "receiving" and "give away" and the organ thus

functioning continuously for this purpose. This can be better appreciated with the

understanding of the functions of Vyanavata.

Functions of the Vyanavata

The important functions of the Vyanavata can be two in the present context:

• Function of the Rasa is the nourishment of the body i.e., the dhatus34

• Effecting the outflow of the blood

The circulation of Rasa (Rakta is also included) is due to the vikshepa karma

of the heart, caused by the contraction of the musculature of the organ, due to the

stimulation by the Vyanavata.

Effecting the outflow of the blood depends not only on the effective ejecting

capacity of the heart but also the caliber of the blood vessels. An increase in the

quantity of the circulating blood causes an increased outflow. Therefore function of

Vyanavata is to be understood as to increase the caliber of the blood vessels.

It may be noticed from the above details that the Pranavata and Vyanavata

act in opposite directions with reference to the heart and blood vessels. Pranavata

not only checks or restrict the hridaya spandana but also constricts the blood


vessels. The Vyanavata increases the hridaya spandana with forceful contraction of

the heart musculature and increases the caliber of the blood vessels.

Functions of the heart

Many functions have been mentioned in relation to Hridaya. The whole body

including viscera, consciousness, sense faculties, five objects of senses, Atma

together with its qualities like happiness etc; mind and its objects are all located in

the hridaya36. The heart represents the entire sense perception, animation and

moreover the heart is the substratum of the Ojas and it controls the mind37. As the

entire girder supports bamboo framework of the thatch, so the heart represents the

substratum of all the entities38.

The circulation of Rasa-Rakta is maintained by three factors: -

1) The muscular structure of the heart through its contractions and relaxation. The

heart is made up of two muscles. The main characteristic of the muscle in the

body is its contraction and relaxation.

2) The heart working as a pump i.e., the heart through its working takes in the blood

during relaxation and gives out the same during contraction. The definition of the

word Hridaya explains its functional nature. Since hridaya is seat of Rasa and

Rakta, Hridaya takes in and gives out the Rasa Rakta combination by

continuously functioning for the maintenance of the circulation.The actual

reference regarding the contraction and relaxation of the heart is found in Yoga-

vasistha as “Whenever expansion (relaxation) and contraction in the duct

situated in the heart occurs ….”. This statement clearly explains that the heart


contracts and relaxes regularly. That the heart works continuously for Charaka

implicitly explains the maintenance of the circulation while dealing with the

functions of Vyanavata. "The Rasa Dhatu (the Rakta is also included) is

circulated continuously through every part of the body simultaneously by the

Vyanavata, by virtue of its physiological function of projection"39. Vyanavata is

stated to be located in hridaya. The two words used regarding the continuity of

this function are "Ajasram" is Avisratam i.e., without any rest and of the word

'sada' is "sarvakalam i.e., at all times.

This function of the heart, which is chetana stahana explained as the self

stimulating nature, to take in and give out blood continuously without any rest

resembles the action of a pump which supplies a liquid material.

3) The circular movement of the blood in the body is done by Rasavahasrotas.

Rasavahasrotas:

Rasa is the important adya Dhatu, because it has dhatu poshak dravyas

(nutrient substances) for all Dhatus in it. And also the nourishment to other Dhatus is

through it. This Rasa Dhatu is capable of spreading all over the body. Ahara Rasa

pertains to the prasada bhaga of ahara, which has been treated as 'Rasa'40. The

function of Rasa Dhatu is preenana41. It indicates the function of satisfying or

gratifying. The Rasa is produced in koshta (annavahasrotas) from food after

completion of the pakvavastha (digestion) to be absorbed through the walls of the

koshta. The circulation of Rasa by hridaya is to maintain the life by proper

nourishment to the body.


Hridaya is the Rasa sthana, it is also the moolastana of Rasavahasrotas42.

According to Susruta, hridaya and rasa-vahini Dhamanis are the moolas of

Rasavahasrotas43. Hridaya is also the seat of Rakta and other fluids which are

capable of circulating in the body44. Therefore the hridaya is not to be considered as

the seat of Rasa only and similarly are the dasa (ten) dhamanis. Since Rakta is also

a (partially) fluid Dhatu, with its main function as jeevana kriya, to be continuously

maintained and also circulated by the hridaya. It is clear that the Rasa and Rakta

move together for the maintenance of these functions. Rakta Dhatu contains the cells

with raktamsha, which are not capable of entering most microscopic srotas. But due

to its quality of sukshma, Rasa penetrates into all Srotases. The Rasa - Rakta is

circulating in a combined state. Because of the inability of the cellular components of

the Rakta to enter all Srotases; the Rakta with its raktamsha ceases to move further

while the Rasa proceeds carrying the nutrients. Therefore hridaya and Rasavahini

dhamanis should be considered as the moolas of Rasavahasrotas.

Rasa is ejected by the hridaya into circulation and moves in the dasa

dhamanis and their branches. The Dhamanis are stated to have khani (pores ) in

their walls through which Rasa passes through to all parts of the body very much like

the minute passages present in a lotus stem45. Therefore these pores present in the

walls of the Dhamanis are also considered rasavahinisrotas.

Because of the ashrayashrya bhava (interdependence) between the srotas

and the substance conveyed through it, any change in the composition of Rasa can

vitiate the Rasavahasrotas and also its moola i.e., hridaya.


Rakta peedana

There is no definite information regarding the normal or abnormal states of

raktapeedana (blood pressure) in Ayurvedic classics. The word "peedana" indicates

pressure and its adhikyata is an increase in the pressure in line with the action

noticed in the arteries (Dhamanis). But Rakta peedana or blood pressure is defined

as the lateral pressure exerted by blood on the vessels walls while flowing through it.

Since the rasa-rakta combination is forcefully ejected by hridaya for the maintenance

of preenana and jeevana kriyas, into the Dhamanis, some pressure is exerted by

rasa-rakta on the Dhamanis. Therefore two issues are taking part here;

• blood with its flow, (here blood is a combination rasa and rakta)

• the blood vessels (or) artery (Dhamani)

This indicates that any change in these two is likely to effect a change in the

raktapeedana. The flow of blood is dependent on the vikshepa karma of the hridaya.

Therefore provided the dhamanis are in a healthy state; the vikdhepa karma of the

hridaya and the raktapeedana are maintained by the akunchna of the hritpeshis

through the action of Vyanavata. So the maintenance of normal raktapeedana is due

to an equilibrium state between the actions of Vyanavata and Pranavata, which has

the function of "Dhamani dharana" also. Rakta adhika peedana indicates a sustained

increase in the raktapeedana and it is a feature of several distinct diseases.

1. Reduction in the caliber due to a vitiated state of Pranavata or a disturbance in

the equilibrium in functions of Pranavata and Vyanavata.


2. Srotavaigunya of the Dhamani caused by a change in the structure. This is

mainly due to dhamaniprtichaya; which is caused by a change in the composition

of the rasa-rakta. These two sates cause a reduction in the essential kriyas of

Preenana and Jeevana to the tissues of the body. Therefore in order to keep the

tissues alive, the hridaya is forced to increase the ejecting power with a

consequent increase in raktapeedana.


1 Charaka Chikitsa, 28/236,237 2 Susruta Sutra, 21/5 3 Bhela Sutra, 20/3 46 Madhava nidana 1/25 Madhukosha on it 47 Charaka Sutra 17/62 48 Susruta Sutra 24/10 49 Charaka Vimana 5/3 50 Charaka Chikitsa 15/4 51 Astanga Hridaya Sutra 12/12 52 Charaka Chikitsa 15/19 3a Su.Sareera. 6/25 4 Text book of Anatomy, Henry Hollinshed, pp78 4a satapatha brahamana, brihadaranya kand, 14, cha. 18. Brahamana 4-1. 5 Grays Anatomy, 6 Astanga Sangraha Sarira, 5-49 ; Su.Sa.3/12 ; A.san.sa. 5-14 7 Charaka Sarira, 3/13 8 Charaka Sarira, 3/16 9 Susruta Sarira, 3/18 10 Bhela Sarira, 7/ 12 Cunnighams manual of practical anatomy, vol-2, pp45 13 Susruta Sarira, 6/40 14 Susruta Sarira, 4/31 15 Astanga Sangraha Sarira, 5 16 Taittariyopanishat 17 API text book of medicine 18 Charaka Sutra, 30/5 18a Susruta Sarira 5/37 18b Susruta Sarira 9/13 Dalhana on it. 18c Charaka Sutra 30/3, Astanga Hridaya Sarira 6/46 35 susruta sarira 19 Charaka Vimana, 5/8 20 Susruta Sarira,9/12 21 Charaka Chikitsa,24/35 Chakrapani 22 Text book of Anatomy, Henry Hollinshed, pp80 23 Charaka Chikitsa 15/21 24 Charaka Sutra 30/12 25 Charaka Vimana 5/3 26 Charaka Sutra 30/12 27 Charaka Sutra 30/3 28 Charaka Chikitsa 28/6 Astanga Hridaya Sutra 12/4 29 Susruta Nidana 1/13). 30 Astanga Sangraha Sutra 20/4 ; Astanga Hridaya Sutra 12/4,5 31 Astanga Sangraha Sutra 20/4 indu on it 32 Charaka Chikitsa 28-9 Susruta Nidana 1-17) 33 Astanga Sangraha Sutra 20-4 Astanga Hridaya Sutra 12-6) 34 Susruta Sutra 15/5 36 Charaka Sutra 30/4 37 Charaka Sutra 30/6,7 38 Charaka Sutra 30/5 39 Charaka Chikitsa 15/36 40 Charaka sutra 24/ Chakrapani 41 Susruta Sutra 15/5 42 Charaka Vimana 5/8 43 Susruta Sutra 19/12 44 Charaka Chikitsa 24/35 Chakrapani 45 Susruta Sarira 9/10


Definition of Hypertension: -

In the adult, rise of systolic pressure above to 140mm Hg. and of diastolic

pressure higher then 90mmHg, are usually considered as hypertensive levels,

although such a sharp distinction is not reliable unless considered in relation to age.

The blood pressure may be persistently above or below the normal range.

The high range then the normal is termed as Hypertension and low as Hypotension.

Hypertension is defined arbitrarily, at level above generally accepted normal values.

High blood pressure (hypertension) is the condition in which occurs abnormal

sustained increase of the pressure exerted by the arterial wall to flowing blood.

The clinical syndrome of hypertension appears to be a result of the elevated

diastolic pressure; usually the systolic pressure is also raised, but it need not be. Also

some times systolic hypertension may occur without a diastolic pressure elevation.

Systolic hypertension alone is not believed to be clinically important, unless very high

levels threatened integrity of the blood vessels.

Disease considered as hypertension in 20th century authors is as follows.

1. RAKTAGAVATA:

The disease Raktagata Vata, which is mentioned under the context of

Vatavyadhi, can be correlated with essential hypertension. Separate nidana have not

been mentioned far Raktagavata, so samanya nidana mentioned for Vatavyadhi can

Literary review - Nidana 33

be considered as etiology for the Raktagata Vata. Some Ayurvedic scholars have

mentioned that Raktagata Vata as Raktavata.

Charaka broached lakshanas as -

Teevraruja

Santapa

Vaivarnya

Krishatha

Aruchi

Stambata soon after having food (charaka chikitsa 28/31)

Vagbhata also mentions almost all the symptoms, which are mentioned by

Charaka, in addition with -

Swapam

Raga and

Bhrama ( AH.NI.15/10)

Shri sudarshan shastri and shri yandunandanopadhya while writing vyakhya

of Raktagata Vata says that the word Raktachapa has to consider as hypertension.

Acording to Kaviraj Gananathsen, the conditions Raktagata Vata and Vata Rakta are

one and the same. But Sri Sudarshan Shastri and Sri Yandunandanopadhya

conferred opinion, as Raktagata Vata is nothing but hypertension.

2. Raktavrita vata:

Charaka has described the disease Raktavrita vata under the context of

Vatavyadhi but no other Acharyas have mentioned regarding this disease. Raktavrita


vata resembles to that of Raktagata vata. They are Daha in between twak, mamsa

and Vedana saragayukta shota and mandala.

3. Siragata vata:

Siragatavata is described under Vatavyadhi. Charaka, Susrutha and

Vagbhata describe it. When there is vata prakopa in siras, it causes many diseases

such as vata sambava vyadhies. Lakshanas mentioned under siragata vata are -

mandaruja,

shopha,

kampa

no spandana in siras but there will be akunchana in them. ( CHA.

CHI.28/36)

Susrutha and Yogaratnakar supported Charaka in all aspects.

4. Bhrama:

The literal meaning of Bhrama is rotation. As a disease, it has been explained as

a feeling that a person experiences the fast rotation in the shiras similar to that of fast

rotating wheel. Charaka has considered the Bhrama as one out of the vataja

nanatmaja vyadhi. Here Bhrama corresponds to Giddiness and Vertigo. Bhrama is a

disease not only concerned to the shiras but also considered as Raktapradoshaja

Vyadhi. Chakrapani dutta, has explained Bhrama as a smruthi mohaha that means

hallucination in his commentary. (CHA.SU.20/11)


Vagbhata has mentioned that this is because of vata dosha (AH.SU.11/61) where

as Charaka affirmed it as sanchaya of vata dosha blocked by vitiated pitta dosha.

(CHA.CHI.28/31). Bhrama explained as a prodromal symptom of some diseases.

It is also said as symptom and complication of many diseases.

5. Roudhira Mada:

Mada is, mado Harshaglanopanay (BH.Part 1) it means, Harsha and glani of

Rakta takes place. I.e; increased gati and matra of rakta takes place or other wise

utkarsha or aakarsha of rakta is called mada. In charaka samhita 43 types of raktaja

vydhies are mentioned and mada is one among them. (CHA.CHI.28/31)

On the other hand there are seven types of madas explained. Vataja, pittaja,

kaphaja, sannipataja, vishaja and roudhiramada. (BH.P.part1). Roudhira mada is

considered as hypertension by Acharya shree Vishwanath Dwivedi and clarified

dushya involved in this disease is as Rakta.

In Roudhira mada, initially the vitiation of blood results into increased Rakta,

and there by altered Akunchana and Purana of Raktavaha and siras takes place.

Then it confers to Roudhira mada.

6. Raktapradoshaja vikaras :

In charaka samhita totally 43 diseases are mentioned in vidhishonita adhyaya

all these diseases come under the rakta pradoshaja vikara. In this group mada,

raktapitta etc., diseases are considered. (SUS.SU.24/9, CHA.SU.24/11-16)

(AS.SU.36/7) Hypertension is considered under the Raktapradoshaja vikara, due to

the involvement of Rakta Dhatu.


7. Avruta Vata

Some of the avrutha vata are also considered under the heading of

hypertension. They are Pittavruta pranavata and Pittavruta udanavata.

pittavrutha prana vayu: The lakshanas mentioned are

• murcha,

• daha,

• bhrama,

• soola,

• vidaha,

• chardi and

• sheeta kamatwa.(CHA.CHI.28/218)

Pittavruta udana vata : The pittavruta udanavata lakshana are

• murcha,

• daha,

• shoola,

• daha in the nabhi and urah region,

• ojobransha,

• shwasa, and

• klama. (CHA.CHI.25/220)


8. Murcha and sanyasa :

Murcha is disease of raktavaha srothas which is due to vikrutha pitta and

tamo guna i.e, both sharirika and manasika vyadhi. Murcha can be considered as

syncope, which is mentioned, in modern science. A simple faint or temporary loss of

consciousness due to cerebral and it is important to note that giddiness, faintness or

actual syncope is much more frequently due to peripheral circulatory failure.

According to Astanga hridaya mada, murcha and sanyasa are the diseases of

rasa, rakta and samjnavaha sroto dusti. Acharya Susruta explained 6 types of

murcha vataja, pittaja, kaphaja, raktaja, madyaja and vishaja. While explaining about

the raktaja murcha, it is due to smell of blood or by seeing the blood it occurs. Sri

sudarshan shastri and sri yadundana upadhyaya opined that murcha occurring in

rakta vata or high blood pressure can be raktaja murcha.

9. sanyasa ( coma):

sanyasa is disease of samajnavaha srotas and also called as gambhira

murcha. If murcha is not treated properly it leads to Sanyasa. According to modern

science coma is a state of unnatural heavy deep and prolonged sleep often

accompanied by slow irregular breathing and consequently ending in to death. (index

of different diagonisis by herbet french).

10. Dhamani pratichaya:

According to Charaka Dhamani pratichaya is one of the kaphaja nanatmaja

vyadhi. The description of dhamai prathichaya as available in Nidhana Chikitsa


hastamalaka is ati poornata of dhamani. This atipoornata of dhamani is because of

adhika poshana or excess nourishment.

Due to adhika poshna specially Rasa and Rakta increases and interrupts the

movements in Dhamanis there by they get stretched under the influence of fullness

of the Rasa, Rakta (vriddhi) Dhatu. With this the Gati becomes manda and guru. The

manda is the counter guna of Vata, thus it infers the Vata vitiation. The Vata vitiation

aggravates the Vata, and there by it increases Vata gunas such as chalatva.

Chakrapani, Gangadhara and Yogendrenath annotated on the word dhamani

pratichaya, dhamaniupalepa to denote atherosclerosis.

Brief description and opinion of Brihatrayee about different conditions

resembles Hypertension is as follows:

S.No Diseases Charaka Susruta Vagbhata

1 Raktagaa vata + + +

2 Raktapradoshaja vikara + + +

3 Raktavrita vata + + +

4 Raktavata +

5 Pittavruta Pranavata +

6 Pittavruta Vyanavata +

7 Bhrama + + +

8 Mada + + +

9 Murcha + + +

10 Sanyasa + + +

11 Dhamani pratichaya +

12 Siragata vata + + +

13 Roudhira mada +


Classification

The purpose of a classification of hypertension is

1. To provide an easy and reliable method for the personification of each

patient.

2. To assess the severity of disease by reference to epidemiological data so that

risk can be restricted and appropriate treatment can be instituted.

Classification of hypertension

1. Symptomatic classification of hypertension;

a) Labile (Borderline or Transitory) hypertension.

b) Stable hypertension.

• Moderate

• Severe

2. Classification by blood pressure (level) readings;

a) Mild hypertension

b) Moderate hypertension

c) Severe hypertension

3. Classification by severity of vascular reasons;

a) stage I

b) stage II

c) stage III

4. Classification by cause;

a) Hypertension due to administration of drugs. (Iatrogenic

hypertension)

b) Hypertension disease of pregnancy

c) Other disease (renal hypertension)

5. Classification by age groups;

a) Juvenile hypertension

b) Hypertension in the elderly


1. Symptomatic classification of hypertension:-

The determination of arterial pressure permits the classification into “Labile and

permanent hypertension”. The later may be either moderate or severe. Such a

classification is purely symptomatic and gives no information concerning the etiology

of the disease.

a) Labile hypertension:-

Labile hypertension has many synonyms: -

• Borderline or Transitory hypertension.

• The pre-hypertensive state

• Hyper dynamic circulatory syndrome and

• Hyperkinetic heart.

The term ”Labile” means little. The term labile (or borderline) hypertension is used

to describe subjects in whom arterial pressure is above to arbitrarily selected thresh-

hold or the values between the normal and hypertensive range. Labile hypertension

patients have no constant haemo dynamic or biological characteristics. The

prognosis for their hypertension is highly variable, and the value of treatment has not

been demonstrated.

b) Stable hypertension: -

The stable hypertension may be divided into two groups, according to gravity:

i) Moderate or Benign and

ii) Severe or malignant (some times also termed accelerated)


Classification by stages of development introduces as authority element for

assessing disease severity. The rate of progression of hypertension varies from one

individual to another depending on the environmental and genetic backgrounds.

Arterial hypertension may be classified in three separate ways:-

1) By the blood pressure level

2) By the extent of damage to organs and

3) By the etiology

2) Classification by blood pressure (level)readings:-

a) Mild hypertension: -

Diastolic pressure is between 90 to 140mm Hg is said as mild hypertension.

Regular medical surveillance is advisable and the value of anti-hypertensive

drugs is being evaluated.

b) Moderate hypertension :-

Diastolic pressure is between 105 and 114mm Hg is said as moderate

hypertension. Benefit has been demonstrated from the use of anti-hypertensive

drugs at these blood pressure levels.

c) Severe hypertension :-

Diastolic pressures are 114mm Hg or above, at these blood pressure reading

carries a distinctly high risk to the patient. Prompt anti-hypertensive treatment is

always advisable.


3) Classification by severity of vascular lesions:-

(Classification according to extent of organ damage; stages of hypertension)

Classification of this kind indicates the extent of the disease, the rate of

progression of hypertension highly varies depending on many influences from one

individual to another, but the extent of organ involvement corresponds most closely

to the level of pressure. However both blood pressure and organ impairment should

be evaluated separately. Since markedly high pressures, carrying a high risk, organ

damage has to be evaluated with reference to the rise of blood pressure.

a) Stage I: -

No objective signs of organic involvement are evident. This is defined by the

absence of signs of vascular disease. There are normal retinal vessels, renal

function, and electrocardiogram and cardiac radiography. Functional disorders; such

as headache, should always be considered with caution before being attributed to the

rise in blood pressure.

b) Stage II: -

At least one of the following signs of organ involvement is present.

- Left ventricular hypertrophy on physical examination, chest x-ray,

Electro cardiograph, echo-cardio graph etc.,

- Generalized and local narrowing of the retinal arteries.

- Protenuria and/or slight elevation of plasma creatinine

concentration.

d) Stage III:-

• Both symptoms and signs have appeared as a result of damage to various

organs from hypertensive disease.

These include:


• Heart - left ventricular failure or congestive heart failure, ischaemia; stroke;

angina; myocardial infarction

• Optic Fundi - retinal hemorrhages and exudates with or without papilloedema.

• Kidneys - renal failure, Renal insufficiency.

• Brain - cerebral, cerebellar, or brain stem hemorrhage, cerebral or coronary

thrombosis and hypertensive encephalopathy, ,

• Vessels: dissecting aneurysm arterial occlusive disease.

4) Classification by etiology:

a) Essential hypertension: -

The great majority of patients with elevated blood pressure have no

identifiable cause for this. These subjects are defined as essential

hypertensives. The research is carried out on the haemodynamics and

endocrinology of essential hypertension to characterize it.

b) Secondary hypertension: -

Secondary hypertension in contrast to essential hypertension must be

classified precisely and definitively. Diagnosis can permit specific treatment;

which is usually more effective and less expensive than that of drug treatment.

This is defined as hypertension with identifiable cause. The possible causes are

classified below.

• Hypertension due to the administration of drugs (iatrogenic hypertension)


Iatrogenic hypertensive forms of hypertension are easily discovered by

questioning and also can be cured by withdrawing the hypertensive agents. They

include:

1) Use of estrogen - Progesterone derivatives as contraceptives or estrogen

treatment for other reasons. Withdrawal of therapy often but not always,

returns the blood pressure readings to normal.

2) Abuse of compounds containing glycyrrhetive acid- (liquorice biogastrone)

3) Abuse of vaso-constrictive nasal drops.

4) Abuse of analgesics, which may lead to renal lesions.

- Hormonal contraceptives.

- Liquorice and carbenoxolone

- ACTH and cortico steroids

• Hypertension disease of pregnancy :-

This is a form of hypertension specific to pregnancy, and which occurs after 24th

week and more often after the 30th week of gestation. There may be accompanying

edema and proteinuria. Eclampsia is defined by the onset of convulsions.

• Renal disease :-

Renal hypertension frequently accompanies a wide variety of renal arterial

abnormalities. These include the various conditions.

1. Glomerulopathies

2. Renal involvement in collagenoses

3. Tuber lesions

4. Infections

5. Interstitial nephropathies and

6. Tumors


Renovascular hypertension results from narrowing or occlusion of one or both

renal arteries, which alters the excretory and endocrine function of the kidneys.

Renal diseases, (renal artery stenosis; glomerulonephritis; pyelonephritis;

radiation nephritis; renal tuberculosis, renal cysts; hydronephrosis; renal tumor

including renin secreting tumors and renal failure) and diseases of the adrenal cortex

(primary hyperaldosteronism, cushing’s syndrome, tumors producing excess of other

corticosterioids e.g. corticosterone and desoxycortone and inborn errors of

corticosteriod biosynthesis) along with the diseases of the adrenal medulla

(pheochromocytoma) are included in this category.

5) Classification by age groups: -

a) Juvenile hypertension :

Hypertension in young people (juvenile hypertension) is now the subject of

very much more research at present which has to be considered from two points

of view, clinical and epidemiological.

b) Hypertension in the elderly :-

65 years and over groups however should not looked at in isolation from the

younger members and blood pressure trends, weight trends, coronary risk factors

and other cardio-vascular aspects are to be regularly monitored. The systolic

verses diastolic pressure and the risk of coronary heart verses diastolic pressures

are relevant to the questions of hypertension in the elderly. There are few

assumptions regarding hypertension is -


• Systolic pressure elevation is unimportant and it is only diastolic pressure

elevation that contributes to morbidity and mortality.

• Women tolerate hypertension well.

• An elevated level of hypertension is often a ‘normal’ concomitant of aging.

Epidemiology of hypertension

1) Prevalence: - It has been repeatedly emphasized that in Europe and U.S.A

high blood pressure is very prevalent. The systolic pressure increases with

age and the diastolic pressure increases up to age 55-60 when it tends to

level off. The types of hypertension have also been studied in various

population groups to identify those believed to be primary as contrasted with

those of secondary origin. Primary hypertension is responsible for about 93%

of hypertensive adults.

2) Level of pressure :-

The mortality ratio was seen to rise above the standard risk when diastolic

pressure exceeded 83mm Hg and when the systolic pressure exceeded 127mm

Hg. The risk is doubled with systolic values above 158 mm Hg and diastolic

above 97mm Hg. Studies have confirmed that the mortality rises in proportion to

the height of the systolic and diastolic blood pressures.

3) Genetic and Environmental Influences: -

Population studies of varying size have been used to assess the continuation

of genetic factors in hypertension. The monozygous twins have a higher


correlation of systolic and diastolic blood pressures than diazygous twins, and the

first degree relatives of hypertensive persons have higher pressure at all ages

than first degree relatives of individuals not having hypertension. It has been

reported that husbands and wives have a tendency to similarity of blood

pressures, but it has been shown that this is attributable to a shared environment.

Most investigators subscribe to the view that both genetic and environmental

influences contribute to what is called primary or essential hypertension.

• Geographical aspects: -

People living in the alpine regions have low blood pressure, but levels

increase and show a normal rise with age when high attitude residents migrate to

less primitive lowland regions.

4) Age and Sex: -

Virtually all surveys, shown a rise of blood pressure with age in both men and

women. This phenomenon brings more marked in women after the age of 50.

The increase in systolic pressure appears to continue throughout life, whereas

there is a tendency for diastolic pressure. Longitudinal studies have indicated that

the increase of blood pressure with age is more marked the higher blood

pressure initially at any age. The off spring of hypertensive parents tend to have

high blood pressure in childhood and early adult life than the off spring of

normotensive parents and over weight children are especially prone to severe

high blood pressure.


4) Hypertension and body weight: -

A distinct and significant association has been found in young individuals

between elevated blood pressure and over weight. The some has also been seen

in adults. Among adults, the association is observed in both sexes (but somewhat

more in women than men) and related to both systolic and diastolic values. It has

also been reported that over weight adults are especially prone to develop high

blood pressure and that weight loss facilitates the successful management of

hypertension.

Pathophysiology of primary hypertension

It is of two varieties i.e., primary and secondary and they are relevant in the

discussion of its pathophysiology.

A) Primary (essential) hypertension: -

The development of high blood pressure depends on the interaction of

several genetic and environmental influences.

1) Genetic factors :-

Although the precise mode of inheritance of arterial hypertension has not yet

been demonstrated in man, it appears most likely to be polygenic. The evidence

supporting this connection is as follows –

a) Familial aggregation of blood pressure is significantly correlated among

first degree relatives (parents, siblings, and children) at all ages.

b) The similarities between both systolic and diastolic blood pressures in

mono- zygotic twins are significantly closer than in di-zygotic twins.


2) Dietary influences :-

There is a close relationship between blood pressure and weight. This applies

to all ages and groups. Studies have established that individuals who gain more

weight show more increase in blood pressure. Moreover, weight reductions have

been accompanied by a fall in arterial pressure. This is not exclusively a dietary

consideration, subsequently heredity and exercise are also the influencing factors.

Lows fiber and high fat, high calorie diet, Glucose intolerance

Stress

High fat, High calorie diet

Cardiovascular Diseases

Diabetes Obesity

Hypertension Hyperlipidemia

High intake of saturated fat and animal foods

Stress, high fat, high calorie diet, high salt intake, Alcohol consumption and smoking

Smoking

Diagrammatic expression showing dietary intake and CVD

c) Sodium chloride intake :-

Several communities whose daily intake of sodium chloride is 3 gm (or less)

have low average blood pressure. When people migrate from such areas to

where the daily salt intake is around 7-8 gm; blood pressure increases

proportionately. It remains unclear whether the change in salt intake is solely

or partially responsible. It has been suggested that not only sodium but also

the proportions of sodium to potassium, sodium to calcium, and sodium to


magnesium may be important pathogenically. In general however, less salt

intake and its implications for prevention remain unresolved.

d) Protein intake :-

A protein intake may be useful in alternating the adverse effects of high salt

intake on blood pressure.

e) Alcohol :-

An association between hypertension and high alcohol intake has been

indicated; but further elucidation is needed to confirm it.

f) Soft water :-

There is some evidence of an association between high blood pressure and

the use of soft water. Soft water may have a high content of sodium, as well as of

calcium, which are partially responsible for rising blood pressure..

3) Psychological factors: -

The role of psychological factors is the subject of considerable debate. Studies

on migrant populations have lent some support to this hypothesis, although

movement from a primitive culture to a more advanced one will obviously involve

change in dietary habits, nutrition, socio-economic status, and other environmental

factors. This entire area remains obscure and merits continued and extensive

investigations.

Elevated arterial pressure is associated with patho physiological alterations

involving the sympathetic (adrenergic) nervous system, the kidneys, the renin-

angiotensin system, and various haemo dynamic and humoural mechanisms.


i) Haemo dynamic changes :-

An increased heart rate is a fairly consistent feature of hypertension, and is

observed with different levels of arterial pressure. Early in the course of essential

hypertension cardiac output is elevated while total peripheral resistance may be

within the normal range or only slightly raised. Together with mild arteriolar

constriction in early hypertension, there may be peripheral vasoconstriction, which

serves to redistribute the circulating blood from the peripheral to the cardiac-

pulmonary area. As constrictor influences on the capacitance and resistance, vessels

persist and arterial pressure is progressed. As vascular resistance increases further,

ultimately, the heart shows evidence of adaptive hyper function and left ventricular

hypertrophy; and with advancing hypertension and further increase in total peripheral

resistance and cardiac output, together with stroke volume, gradually falls until

cardiac failure supervenes.

With progressive hypertension, there is a corresponding increase in vascular

resistance in the kidneys and a fall in renal blood flow, although the glomerular

filtration rate and overall renal function are initially well preserved. Eventually,

however, as total peripheral resistance increases more steeply, there is a further rise

in renal vascular resistance accompanied how by a fall in glomerular filtration rate

and adeteriortion in overall renal function.

The blood pressure limits between cerebral flow is maintained which have been

described as being shifted upwards in established hypertension. This as an important

consideration in therapy, since if blood pressure is lowered too rapidly, there is a


danger that cerebral flow will fall and that cerebrum is clinically will be enraged.

Plasma volume tends to decline slowly with the progression of hypertension as a

total peripheral resistance increases. Eventually, if renal function becomes impaired

and intra vascular volume may be expanded.

ii) Neural changes :-

Hypertension may be caused by primary sympathetic hyperactivity. This

hyperactivity might result from two factors;

a) Centrally by frequent repetition of environmental and psychic stimuli.

b) Derangement of reflex cardio vascular control, psychic and

environmental factors in human essential hypertension leads to lack of

self-assertion and displaying scarcely suppressed hostility,

aggressiveness and anxiety.

The possible relationships of essential hypertension to the hypothalamic

defense reaction are showing the close similarities between the haemo dynamic

pattern of defense. As exemplified in man by mental arithmetic and the haemo

dynamic pattern of labile or borderline hypertension, in both conditions there are

some increases in cardiac output and heart rate, renal and cutaneous

vasoconstriction and a decreased vascular resistance in the skeletal muscles. Even

in established essential hypertension, the muscle bed remains relatively vasodilated..

However, it has recently been shown that the increased cardiac output and heart rate

found in young subjects with borderline hypertension is neurologically maintained.


• Central mechanisms: -

Decreases in blood pressures are also observed during human sleep. However,

sleep has not provided such clear information about the extent of the neurogenic

component of hypertension in man. Substantial decreases in blood pressure during

sleep in hypertensives have been described.

• Humoral changes :-

The renin-angiotensin system has been extensively studied since the introduction

of practicable essay methods for plasma renin and angiotensin patients with

essential hypertension have been subdivided into subgroups with low, normal and

high plasma renin on the grounds of the elevated pressure. The different

mechanisms and in particular those patients with low plasma renin might have

excess, mineralocorticoid activity. Plasma renin and angiotensin ii values are

continuously distributed in the hypertensive population. Further peripheral levels of

plasma renin and angiotensin ii have been found to be related inversely to age in

essential hypertension. Peripheral levels of anti diuretic hormone have been reported

as being slightly suppressed in uncomplicated essential hypertension.

B) Secondary hypertension (hypertension with identifiable cause)

1) Hormonal contraceptives :-

Prospective controlled studies have shown that estrogen progesterone oral

contraceptives cause a distinct increase in systolic and to a lesser extent diastolic

pressure in virtually all women. In some individuals marked elevation of pressure can


occur, but the mechanism of the rise in blood pressure is imperfectly understood.

Almost invariably the pressure falls when the oral contraceptive is withdrawn.

a) liquorice/carbenoxolone :-

Liquorice or carbenoxolone administration may elevate blood pressure, which is

attributable to the mineralocorticoid activities.

b) ACTH Cortico steroids :-

An increase in blood pressure may follow administration of ACTH or

corticosteroids. With ACTH it seems likely that this blood pressure rise is due mainly

to adrenal release of ACTH, sensitive minor alocortiicoics, although other classes of

corticosteroids may be involved. Therapeutic administration of cortico steroids also

produces a rise in blood pressure.

2) Hypertension due to organic disease: -

1) Ductus arteriosus :-

Ductus arteriosus, a congenital abnormality, gives rise a characteristic form of

hypertension in which the femoral pulses are diminished or absent and delayed in

comparison with the radial pulses.

2) Renal diseases :-

The various changes in renal function that accompany the progression of

essential hypertension and the renal complications of hypertension and in addition, a


wide variety of renal diseases can cause or aggravate hypertension. Parenchyma

renal lesions typically affect both kidneys, distinct impairment of renal function usually

accompanies blood pressure elevation.

Diseases of the adrenal cortex:

Primary hyper aldosteronism :-

This can be due to a single adrenocortical adenoma or to bilateral

adrenocortical hyperplasia. Aldosterone excessive secretion associates with an

increase in body sodium and a decrease in potassium. The plasma potassium level

is typically low and plasma renin is suppressed.

Cushing’s syndrome: -

About 80% of patients with cushing’s syndrome have hypertension, and this

has been attributed to sodium retention and an excess of extra cellular fluid due

mainly to the mineralo corticoid effects of excess cortisol.

Humoral factors

Blood volume Sodium

Mineralocorticoids atriopeptin

Constrictors

Angiotensin II Catecholamines Thromboxane Leukotrienes Endothelin

Local factors Autoregulation

Ionic (pH, hypoxia)

Neural factorsConstrictors α -adrenergic

Dilators β -adrenergic

Cardiac factors Heart rate Contractility

PERIPHERAL RESISTANCE XCARDIAC OUTPUT =BLOOD

PRESSURE

Dilators

Prostaglandins Kinins NO/EDRF

BLOOD PRESSURE REGULATION NO/EDRF = Nitric oxide – endothelium – derived relaxing factor


Clinical features of hypertension

Hypertension is a condition with at first no symptoms. The condition rarely

causes symptoms and is usually discovered when the patient is examined for other

reasons. High blood pressure is often found on routine examination e.g. for life

insurance or accidentally. Basing on that a patient complaining of headache or

giddiness is more likely to have the blood pressure measured. Only one symptom

was more common among hypertensive subjects i.e., dyspnoea. It was anticipated

due to a combination of higher pulmonary venous pressure secondary to left

ventricular stiffness; with some true cases of left ventricular failure as a result of

hypertensive left ventricular disease. This is characteristically worse in the morning

and may be present on working. Once the degenerative consequences of

hypertension have established then the symptoms may be due to the failure of heart,

frank left ventricular and congestive heart failure.

Usually there are no relevant symptoms although symptoms may be due to

anxiety. The clinical features are very variable. Early symptoms which are frequently

attributed to hypertension are difficult to differentiate from those associated with

psychological factors, e.g. nervousness, irritability loss of energy, easy fatigue, and

insomnia. Headache dizziness and impairment of memory and concentration are

latter features, which may be troubles come.


Key items of the base line history in patients with mild or moderate Hypertension Symptoms

Blurred vision Brochospasm Chest pain Claudication Cold extremities Cough Depression Dizziness Dyspnoea Fatigue Flushing Headache Hematuria

Impotence Joint pains Muscle cramps Nocturia Palpitation Polyuria Skin rash Sweating Unsteadiness Weakness Weight loss or gain

Past disease History

Angina Asthma Diabetes Congestive heart attack Glomerulonephiritis Gout Heart block Hepatitis Hypertension Lupus erythematosus Myocardial infraction Peptic ulcer Pyelonephritis Toxemia Transient ischemic attacks

Diet and Drug History

Alcohol Aspirin Blood pressure medications Cigarettes Cocaine Cold remedies Chewing tobacco Cyclosporine Licorice Nasal sprays Nonsteroidal anti inflammatory agents Oral contraceptives Potassium (dietary) Salt (dietary) Tricyclic antidepressants

Family History

Coronary heart disease Diabetes Hereditary nephritis Hyper lipidemia Hyperparathyrodism Hypertension Phechromocytoma Polycystic kidney disease Renovascular hypertension Thyroid disorders

In the early stages, hypertension is intermittent. The blood pressure is usually

labile, rising to an abnormal degree under the influence of such stimuli as emotion,

exercise and cold. Later the resting blood pressure becomes permanently elevated

only in the late stages there is evidence of impaired renal function, and most patients’

now-a-days die from the effects of atherosclerosis in heart or brain while still


maintaining adequate renal function. The approximate incidence of the three major

causes of death in hypertensive disease is used to be given as cardiac failure 60%,

cerebro vascular accidents 35% and renal failure 5%. Few patients die from cardiac

or renal failure. The principal causes now are myocardial or cerebral infarction due to

associated atherosclerosis.

Differential diagnosis of hypertension

1. Renal hypertension: - (vascular and parenchymal).

A cost effective searching in a case of suspected renal hypertension should include: -

1. Urine analysis

2. Renal ultrasound

3. Intravenous pyelogram

4. Isotopic scanning

5. Angiograms including digital substation

6. Renin assays

1. Urine analysis :

Parenchyma renal disease is suspected when albumin casts, and Red Blood

Corpuscles are present.

2. Abdominal ultrasound :

Will help to describe such conditions as small shrunken kidney, Polycystic

kidneys, hydro nephrosis, renal mass and other congenital anomalies. Intravenous

pyelogram (IVP) is a very useful and simple test in delineating the role of the kidney

in hypertension.


Small shrunken kidneys with clubbed calyces a joint to a chronic pyelonephritis,

while those with a normal pelvic calyceal system point towards chronic

glomerulonephritis or nephrosclerosis.enlarged kidneys with a spider leg

appearance of calyces indicate polycystic disease. IVP also helps to raise

suspicions of obstructive uropathy and renal carcinoma.

3. Renal isotope studies :-

Radioactive renogram is quite widely used. It provides a measure of renal

function, compares the function of the two kidneys and shows the presence of acute

obstruction in the/ or both kidneys.

4. Renal angiography :- (renal aortography)

It helps to identify vascular lesions. During angiography the pressure gradient

across the stenosis in the renal artery can be measured, and if it is 10mm Hg

(higher), the chances of successful intervention are high. Angiography also helps in

detecting other abnormalities in the renal vessels. Depending on the renal functional

impairment, intravenous pyelogram (IVP) and isotope study and digital subtraction

angiography (DSA) if available, would help to diagnose functional impairment of the

effected kidney, while an aortagram will help to establish the site of the stenosis.

• Digital substraction angiography (DSA);-

A new modality of vascular imaging what can be done with a simple

peripheral injection of contrast media. This investigation is first choice in the

diagnosis of renal vascular disease.


5. Renin assay :_

Peripheral renin assay if done randomly is very unreliable.

• Renal parenchymal disease :-

• A slightly different approach is necessary. After history, clinical

examination and urine and blood studies, an abdominal ultra-sound study,

an IVP and a retrograde pyelogram are done. Occasionally one may have

to do kidney biopsy. After these investigation, a defencitive diagnosis is

made and appropriate therapy can then be initiated.

Plasma catecholomine estimation - if inconclusive, this could be repeated after

giving 0.3mg of clonidine orally. Cloniding suppresses the levels in normal patients

but not in-patients with phecohromocytoma. ACT scan will localize a tumor even less

than 1cm in size.

Primary aldosteronism/conn’s disease: This is suspected when there is hypo

kalaemia in the absence of the use of diuretics. When 24 hour urinary potassium is

more than 20mg. Plasma estimation is done, if plasma renin is low plasma

aldosterone estimation is done. Very high values indicate primary aldosteronism. CT

scanning helps to tumor identification and localization.

Cushing’s syndrome: When this syndrome is suspected on clinical evidence, the

following investigations are done to clinch the diagnosis. Dexamethosone text – 1mg.

Of dexamethosone is given at bedtime. Next morning, at 8a.m plasma cortisol is

estimated. If cortisol is less than 7 micrograms/100ml or if a 24 Hours urine for free

cortisol is more than 100 micrograms/100ml then cushing’s syndrome becomes a


strong possibility. To confirm the diagnosis, a prolonged dexamethasone test is done.

ACT.scan can localize Adrenal/pituitary tumor, and appropriate management steps

can then be taken.

The search for the etiology of hypertension requires an in-depth knowledge of the

condition, coupled with a common sense approach. In each case the necessary

investigations should be precisely determined and carried out. A chance of finding a

curable cause should not be missed.

Key items of the baseline physical and laboratory examinations in patients with mild or moderate hypertension

Physical examination General Appearance Blood pressure (supine or siting; standing; both arms) heart rate (supine or sitting; standing)

Heent #

Carotid bruit Fundi Neck veins Temporal arteries Thyroid gland

Chest

Aortic regurgitation Apex impulse Breast Rales S3, S4Systolic murmur Wheezes

Abdomen

Bruit Palpable kidneys

Extremities

Edema Peripheral pulses Peripheral bruits

Neurologic Focal signs Proximal muscle strength

Laboratory examination General

Hemoglobin Hematocrit White blood cell count

Kidneys

Blood urea nitrogen Creatinine Urine dipstick Urine sediment

Metabolic

Calcium Cholesterol * Glucose (fasting) Potassium Uric acid

Miscellaneous

Chest x ray ECG Echocadiogram

* Also obtain fasting triglyceride and high density lipoproteine cholestrol levels if the serum cholestrol level is 200mg/dl or more in patients with other cardiovascular risk factor or 240 mg/dl or more in patients with out other cardivascular risk factors. # HEENT = head, eyes, ears, nose, and throat.



MANAGEMENT OF HYPERTENSION

In general, most patients with chronic arterial hypertension have no

identifiable cause for the disease. Treatment usually involves drug therapy; and this

commits the patient and the physician to a long-term association. Prior to the

institution of an anti hypertensive regimen, however, general therapeutic measures

are necessary.

GENERAL STAGETEGY

Attention to the patient’s life style may be important in a few cases but in

general it is difficult to change. Nevertheless it is wise to dissuade people from

smoking and simultaneously to face the difficult task of losing weight, if obese, or of

not gaining if normal. The patient should be impressed with the importance of future

surveillance. Mental relaxation can be urged more easily than achieved. Sometimes

regular graded exercise will cause a simultaneous feeling of well being. Several

studies have shown the value of regular exercise in lowering arterial pressure, but

the exact mechanism of this effect eludes.

The following modes of treatment for hypertension are available: -

1. Non-pharmacological treatment

2. Pharmacological treatment

Drug treatment should always be accompanied by general measures such as ;

1. Weight reduction

2. Salt restriction

3. Moderate physical exercise

4. Moderation in alcohol ingestion

5. Cessation of smoking

6. Relaxation techniques.

Literary review - Chikitsa 63

1. Weight reduction :-

Weight loss by itself helps to lower blood pressure in obese patients. Weight loss

probably causes reduced activity by the sympathetic nervous systems. And decrease

in plasma epinephrine, non-epinephrine and renin activity. A reduction of 8-10dg if

weight reduces blood pressure by about 25mm Hg Systolic and 20mm Hg diastolic.

2. Salt restriction

It is well known that salt restriction helps to lower blood pressure. If the salt intake

is reduced from 150-200mEg/day to 50-90mEg/day, usually a reduction in the blood

pressure of 10mm Hg is achieved. The other advantage of salt reduction is that,

when diuretics are given to these patients, less sodium is available at the distal renal

tubules for exchange with potassium. Hence, there is less potassium loss. It is best

to advise patients on the following lines;

1. Avoid processed food, which usually contain more salt this

includes pickles etc;

2. Do not add salt while cooking and/or at the table.

3. If salt is still desired, use potassium salts (salt substitute)

4. Moderate physical exercise: - Regular isotonic aerobic exercise

may bring about a fall in blood pressure besides aiding weight

loss. The increased sense of relaxation and well being that

accompanies and follows exercise also helps in lowering blood

pressure. Regular exercise improves physical fitness and is to be

encouraged.


5. Smoking :- Smoking enhances atherosclerosis and hypertension.

Smokers have an overall mortality 7 times higher than that of non-

smokers. Tobacco smoke contains nicotine and carbonmonoxide;

Nicotine causes endothelial injury and release cathecholamines,

which may have a vasotoxic effect or arterial endothelium. Carbon

monoxide causes perivascular edema of the blood vessels and

hypoxia. This alters the permeability of the endothelium and

increases the deposition of lipids in the vessel wall. Reduction or

stoppage of smoking helps to reduce blood pressure.

6. Relaxation techniques: - It is necessary to advise patients to ‘avoid

stress’. Formal relaxation classes, transcendental meditation and

bio-feed back have all been shown to reduce blood pressure.

Yoga also helps in relaxation.

Chikitsa (line of management) in Ayurveda:

The patient oriented approach of treatment as described in Ayurvedic classics

is more suitable especially in dealing with the Hypertensive patients. Accurate

assessment of various etiological factors, constitution of the patient and the stage of

vitiated dosas and dooshya in each patient is essentially needed for the proper

planning of therapy.

In hypertension, the main pathogenesis occurs in Rakta Dhatu and blood

vessels. The ideal therapy for raktaja roga is Rakta mokshana. Exact site of Rakta


mokshana in hypertension has to be decided by Ayurvedic scholars and research

workers.

The Ayurvedic line of management of hypertension can be finalized on the

following principles.

1. Nidana parivarjana

2. Langhana

3. Deepana-paachana

4. Lekhana

5. Sroto shodhana

6. Avarana bhedana

7. Rakta shodhana

8. Tridosa shamana

9. Virechana

10. Shirodhaara

11. Rasayana (medhya)

12. Mootrala drugs

13. Hridya drugs

14. Yoga Chikitsa

15. Satvaavajaya Chikitsa

Nidana parivarjana: the factors, which are known to produce hypertension they

should be avoided.

Langhana: it is considered as Ama pachana, Sroto shodhaka and removes Agni

maandya.


Deepana pachana: these drugs help in improvement of status of Agni and prevent

formation of Ama dosa eg. Guduchi, chitraka, ativisa etc.

Lekhana: they clear the obstruction of fat like substances in blood vessels eg.

Guggulu, shilaajeeta, triphala, etc.

Srotoshodhana: these drugs reduce obstruction in the path of flowing blood.

Avarana bhedana: it can be performed by two methods.

a) by increasing Aavrita dosha in quantum

b) by inducing paaka of Aavrita dosha

If patient is healthy we must use drugs which have same properties as having

Avrita dosha. Aavrita dosha increases in quantum and by these process Avarana

bhedana occurs. Doshas are propelled into kostha and these are eliminated from the

kostha by vamana and virechana.

In week child and old people pachana drugs are advises for the pachana of

Avarana. They clear the obstruction in microcirculatory channels by pachana of the

Avarana (obstruction).

Rakta sodhana :

Most of tikta drugs act as rakta shodhaka for example and these drugs are

saarivaa, simba, guduchee, manjisthaa etc.

Tridosha shamana :

Hypertension is a tridosaja vyaadhi the drugs, which have Tridosha

shaamaka properies, will help in treating hypertensive subject.


Virechana:

Hypertension is a pittolvana tridoshaja disease and Virechana is best known

treatment for the removal of Pitta dosha.

Shirodhara:

It is more effective in mild type of hypertension.

Rasayana:

These drugs may strengthen all the systems of the body, protect Ojas,

improve Agni, cleanse the microcirculatory channels etc. medhya Rasayana drugs

like shankhapushpi, vachaa and brahmi etc. are especially indicated for it.

Mootral drugs:

This group of drugs may reduce the vascular volume by diuresis eg.

Trinapanchamoola, punarnava etc.

Hridya drugs :

The drugs, which are beneficial for, heart area known as hridya eg. Arjuna,

svarna etc.

Yoga chikitsaa :

Yogaasana such as makaraasana, vajraasana, pranaayaama etc. are

beneficial for treatment of hypertension.

Satvaavajaya :

This is a therapeutic for emotional stress.


Single drugs used in treatment of hypertension:

Sarpagandhaa, punarnavaa, balaa, puskara moola, eranda moola,

shankhapuspee, guggulu, haritaki, gomootra, braahmi, mandookaparni, gokshura,

jataamaansi, vachaa, shigru, rasona etc.

Compound drugs used in treatment of hypertension:

Rasaraaja rasa, hridayeshvara rasa, pravaalapisti, chintaamani chaturmukha

rasa, brihata vata chintaamanirasa, amara sundari vati, yogendra rasa, brahma

rasaayana, brahmi vati, choona saarvasvataarista etc.

3. MANAGEMENT WITH DRUGS

There are numerous anti hypertensive drugs. According to their mode of action,

the blood pressure lowering drugs may be broadly classified into five major groups;

1. Diuretics (drugs that effect the electrolyte and water balance and

secondarily, the total peripheral resistance)

2. Betablockers and other adrenergic receptor blockers; (drugs that

interfere with the activity of the sympathetic system, including the a-b

adrenoreceptors)

3. Calcium antagonises

4. Vasodilators (acting directly on smooth muscle of arterioles)

5. A.C.E.Inhibitors (angiotensin convertor enzyme) (Drugs that interfere

with the renin angiotensin system)


STEP CARE TREATMENT OF HYPERTENSION

Step 4 others, betablockers and diuretics

Step 3 Methyldopa ACE inhibitors and Diuretics

Step2 Betablockers Calcium antagonists

Step 1 vasodilators

A step care approach has been devised to use these drugs in a rational

manner, taking into account the characteristics of the patient and the degree of

elevation of blood pressure.

The simplest and most effective drugs are used first, in step 1. If they don’t

control blood pressure, step 2 drugs are used, and then those of step 3 and 4. In

most patients, it will not be necessary to reduce blood pressure rapidly. Indeed a

gradual lowering of blood pressure may be preferable, and a “stepped care” program

may simplify therapy and reduce side effects.

Economic considerations, especially the cost of drugs, are also important.

The general principle of such as stepped-care program is to begin treatment with an

anti-hypertensive agent that may achieve only a modest reduction in pressure but

which has relatively minor side effects. The regimen progresses only to combinations

of drugs if the simpler methods fail.

The various drugs or classes of drugs differ in their Pharmacodynamic

profiles and their mode of action, which makes it possible to influence different


mechanisms involved in the relation of blood pressure. Hence, the combined use of

two or even three types of anti hypertensive agents may result in an additive or

synergistic effect on high blood pressure.

MILD HYPERTENSION: -

Mild hypertension patients can be satisfactorily treated with a single anti-

hypertensive drugs, which will be determined by safety, convenience and free from

side effects spouses should be disgusted from perceptually, reminding parents to

their hypertension. Rigid salt restriction has been demonstrated to be effective in

lowering blood pressure, but it is not practicable in every day life. Several studies

have shown blood pressure reduction in mild hypertension by modest dietary salt

restriction to 4-6gms daily.

As single drugs for the treatment of mild high blood pressure, most specialists

recommend B-adrenoceptor blockers or diuretics. Both kinds of drugs have a slow

onset of action, and the maximum effect may be achieved only after several weeks

and after a gradual increase in dosage. For both types of drug, a single application

per day, preferably in morning is advisable to improve patient’s compliance. The

principal agents used in single drug treatment of hypertension are thiazide diuretics,

beta adrenoceptor antagonizes and methyldopa.


VASODILATORS :-

(Drugs acting on the vascular smooth muscle)

These drugs exert their effect principally by producing peripheral arteriolar

vasodilatation, by acting on the arteriolar smooth muscles. Drugs that reduce the

arteriolar smooth muscle tone directly are also called vasodilators, though this term

refers to drugs with a different mechanism of action. Numerous attempts have been

made to lower the blood pressure by drugs that relax arteriolar smooth muscle

directly and in this way refuse the total peripheral resistance, but in most cases the

results were disappointing. The first effective vasodilators in the treatment of high

blood pressure were hydrolyzing and dihydralazine. Both these drugs produce a

long lasting fall in blood pressure and an increase in heart rate.

Recently it has been found to be useful in lower doses, especially when used

with betablockers and diuretics. Hydralazinex lower blood pressure but reflex

sympathetic activity and sodium retention blunts this effect. Part of the blood

pressure lowering effect is counteracted by the increase in heart rate, which may be

abolished by the simultaneous administration of a B-adrenoceptor blocking drug. This

can be countered by adding a diuretic and beta-blocker to the regimen. Besides

acute side reactions (flushing, headache, nausea, vomiting) which in most cases

diminish during the first week of treatment. It is recommended not to exceed doses of

100-150mg. Daily. Since hydralazine is mostly used together with other

antihypertensive drugs, the dosage may be kept within this range or below it.


Prazosin is the other vasodilator, which is also a postsynaptic alpha-receptor

blocker. It may cause severe postural Hypotension, especially with the first dose, due

to abrupt loss of sympathetic venous tone and venous pooling. It should be given at

night. The initial dose should be very small (0.25mg) and should gradually be

increased up to 20 mg.

Minoxidil, another vasodilaor, causes focial hirsuitism, and this discourages

women from taking it. It is given in doses of 2.5 - 20mg twice a day.

Sodium nitroprusside and diazoxide are two other vasodilators, which are

mainly used in hypertensive emergencies.

VASODILATORS IN TREATMENT OF HYPERTENSION.

Minimum dose Maximum dose 1. Hydralizine 50 mg 300 mg 2. Prazosin 2 mg 20 mg 3. Minoxidil 2.5 mg 80 mg 4. Sodium nitroprusside - - 5. Diazoxide - -

3. Diuretics :- (drugs effecting salt and water balance )

4. Diuretics have over the years, been the mainstay in the treatment of

hypertension. They are most common drugs used in the initial phase. They

reduce blood pressure by 15/10mmhg in about 66% of patients. In addition they

potentate the anti-hypertensive effects of other drugs. Thiazides are most popular

diuretics. The diuretics of the thiazide type have a mild anti-hypertensive effect

which reduce intra vascular volume and cardiac output. Xipanide and indapamide

have been used for several years and found useful in small doses. Loop diuretics


are used mainly in renal hypertension. Potassium sparing diuretics by themselves

are very weak anti-hypertensive agents. They are always used with thiazides, not

only to potentate the action of thiazides, but also to reduce potassium loss.

In treatment of hypertension, the diuretics are generally given in lower doses than

in the control of edema. In rare cases diuretics may be associated with side effects,

especially due to electrolyte imbalance. A drastic diuretic effect should be avoided

except in-patients with acute left ventricular failure, chronic use of the thiazide

diuretics may impair glucose-tolerence and the excretion of uricacid giving rise to

hyperglycaemia and hyperuricaemia.

Diuretics in treatment of hypertension:

Minimum dose Maximum dose Thiazides Hydrochlorthiazides, Chlorthalideone 12.5mg 50mg Thiazide related sulfones : Xipamide, indapamide 2.5mg 5mg Loop diuretics : Frusemide, 40mg 320mg Bumetanide, 0.5mg 5mg Ethacrynic acid 25mg 100mg Potassium spring : Spironolactone 25mg 100mg Amiloride hydrochloride 5mg 10mg Triamtrene 50mg 150mg

4. beta-blockers :- (drug acting on the sympathetic nervous system)

in the last few years beta-blockers have been increasingly used and have become

the most popular form of antihypertensive therapy, after diuretics. Various beta-

blockers exert their antihypertensive effect by:


1. Reducing the cardiac output by 15-20%

2. Reducing the renin release by about 60%. They also reduce the renin

stimulation caused by salt restriction and by the hypotensive effect of most

other antihypertensive drugs.

3. Reducing the post-excersise or stress induced in tachycardia and

hypertension.

In principle, the following sites of action can be distinguished;

a) Central sympathetic areas in the hypothalamus and in the region of the nucleus

solitarii; where – adrenoceptors are located further more, central stores of

catecholamines, such as nor- adrenaline, adrenaline, and dopamine may be effected.

b) Sympathetic ganglia, where impulses are transmitted from the preganlionic to the

postganglionic fibers.

c) Post-ganglionic adrenergic nerve endings, where impulses are transmitted from

the posganglionic fibers to the smooth muscle effector cells (neuro effector junction).

d) a and b adrenoceptors in the smooth muscle cells of the vasculature are located

presynaptically.

However, betablockers may cause side effects. They aggravate and some

times induce broncho-spasm, cardiac failure, a-v conduction defects, and intermittent

claudication; and cause cold limbs. Hence they are contraindicated in bronchial

asthma, cardiac failure, heart blocks and raynaud’s phenonmenon. They are to be

used with extreme caution in diabetics, as they may not only precipitate

hypoglycaemia but also mask the sympathomimatic signs and symptoms of

hypoglycaemia. Most of these side effects are less pronounced with cardio selective

agents like atenolol and metaprolol.


Beta –blockers have been found to be useful in the treatment in the following

patients:

1. High renin hypertensives

2. Young patients

3. Patients with ischaemic heart disease

4. Patients with associated states of marked anxiety

5. Patients taking tricyclic antidepressents.

The anti-hypertensive effect of the B-adrenoreceptor blocker, is moderate, but

it may be sufficient in a certain percentage of patients with high blood pressure. The

reduction in blood pressure rarely exceeds 30mmHg systolic and 20mmHg diastolic.

One of the main advantages of B-blocker treatment is that the blood pressure is

similarly reduced both in the standing and in the recumbent positions and that no

orthostatic reactions occur. If beta-blockers and diuretics alone don’t control

hypertension, a combination of the two may be tried, and is often effective.

BETA BLOCKERS IN THE TREATMENT OF HYPERTENSION

Minimum dose Maximum dose Non-selective beta blockers a. without ISA* actovotu : Propranolol 40mg 120mg

b. with ISA* activity pindolol cardio-selective beta blockers

10mg 60mg

a. metoprolol 50mg 200mg b. atenolol 25mg 150mg Non-selective alpha and beta blockers Labetolol 200mg 1800mg ISA* = Intrinsic sympathomimetic activity.


4. CALCIUM ANTAGONISTS :-

Of late, it has been found that calcium antgonists (especially nifedipine) are also

excellent step 1 drugs. Calcium antigonists, specifically influence the calcium

dependent cellular vasoconstrictor mechanism in hypertension. They not only reduce

the peripheral resistance and after load, but also reduce the pre-load by reducing the

smooth muscle contractility in the veins, causing venous dilatation.

Calcium antagonists are relatively safe drugs. They may cause minor side effects like

light-headedness, headache, flushing, palpitation, oedema and A.V.block (especially

when verapamil is used).

Calcium antagonists are useful especially in the treatment of the elderly, and

obese. They are also useful in pregnancy, systolic hypertension and hypertension

associated with ischaemic heart disease, cardiac failure, arrhythmia, broncho-spastic

disease and peripheral vascular disease.

CALCIUM CHANNEL BLOCKERS: -

Minimum dose Maximum dose

1. Diltazem 60mg 360mg

2. Nifedipine 30mg 180mg

5. A.C.E. Inhibitors :- (angiotensin convertor enzyme (drugs interfering with the

renin-angiotensin system)

In some forms of renal hypertension, renin may be responsible for the maintenance

of high blood pressure, and in malignant hypertension as a consequence of severe

renal damages.


In addition to the three major groups of antihypertensive agents, the blood

pressure can be lowered in selected cases by drugs that act on components of be

renin-antiotensive system.

Angiotensin converting enzyme (ACE) inbihitors reversibly bind to the active

centre of the converting enzyme. This leads to a decrease in angiotensin 2.

Aldosterone and sodium and an accumulation of vasodilating substances like

bradykinin and postaglandins. The various useful ACE inhibitors are; captoprill;

enalepril; lisnopril; a) captopril is useful in essential and renovascular hypertension. It

is useually combined with a diureteic. It may cause elevation of serum potassium and

creatinine, loss of sensation of taste, skin rash, and bone marrow depression. It is

given in doses of 25 mg B.D. for mild hypertension and upto 150 mg/day for severe

hypertension.

c) Enalepril is similar to captopril but without the sulfhydryl group, hence it cause

less side effects. It is given in the doses of 2.5 –20 mg/day.

ANTIADRENERGIC DRUGS

1. Reserpine :-

Reserpine is the oldest of these drugs. It has both peripheral and central actions,

it is given in doses of 0.25mg/day. The side effects include parkinsonism, depression,

nasal block, suicidal tendencies, pepticulcer and impotence.


2. Alpha methyldope :

Alpha c-methldopa has been a popular drug for moderate and severe

hypertension. It is given in doses of 0.5 – 3.0mg/day. It may cause hepatitis and

haemolytic anemia due to drug sensitivity.

3. Guanethidine :

Guanethidins is a potent hypotensive agent, which reduces cardiac output and

peripheral resistance. Guanethidine acts at the adrenergic nerve endings, where it

interferes with the release and storage of noredrenaline.

The duration of action of guanathidine is lone, the drug can be administered once

daily, preferably in the morning. Guanethedine is one of the most powerful blood

pressures lowering drugs and is usually kept in reserve for severe cases of

hypertension, which are not well controlled with other antihypertensive drugs. It

causes severe postural hypotension, failure of ejaculation and diarrhea.

4. Clonidine :

Clonidine acts as an alpha adrenegic blocker which maintain renal blood flow and

does not cause postural hypotension. However, sudden withdrawal of the drug can

result in a life threatening hypertensive crisis. It causes fluid retention and must be

used with a diuretic.


5. labetolol :

It is a non-selective, lipid soluble agent with both beta and alpha adrenergic

blocking features. It produces marked vasodilation and decreased after lead. It

maintains cardiac output despite the usual negative ionotropic effect. Sever brady

cardia, peripheral vascular symptoms; postural hypotension, paraesthesias, and

cholestatic and hepatic jaundice may limit its use, it may also aggravate

bronchospasm in asthmatics.

CHOICE OF ANTI HYPERTENSIVE DRUGS IN SPECIAL SITUATIONS:

Though stepped-care approach gives useful guidelines to the choice of drugs, the

approach may have to be altered under certain conditions.

1. Hypertension in children.

In children, the same step-care approach may be followed, except that the

dosage has to be reduced.

2. Hypertension in the elderly :

In elderly patients there is a reduced effectiveness of the baro-receptor reflex.

Hence, all drugs that can cause postural hypotension, such as guanethidene, should

be avoided. Again, all drugs must be given gradually increasing doses to prevent

excessive lowering of blood pressures. The goal of therapy should be to reduce the

systolic blood pressure to 160mmhg in people over 60 –years of age.

3. hypertension in pregnancy :

Anti hypertensive drugs for maintenance and control of blood pressure can given

in pregnancy.


4. Hypertension with ischaemic heart disease :

Beta-blockers and calcium antagonists are useful if there is angina and

arrhythemia. Beta-blockers also protect against initial and recurrent myocardial

infarction.

5. Hypertension with cardiac failure :

In cardiac failure diuretics like frusemide should be given with digitalis. Beta

blockers can be dangerous and must be avoided.

ACE inhibitors when combined with diuretics and digitalis have been shown to

improve hypertension, as well as congestive cardiac failure. ACE inhibitors may

possess a specific advantage in decreasing protenuria and showing the proteinuria

and showing theprogresion of renal failure. However, serum potassium levels and

serum creatinine levels have to be monitored.

6. Hypertension with renal insufficiency :

When serum creatinine is more than 2.5mg/dl, thiazides are usually ineffective.

Frusemide and gunethamide may be more useful. Beta blockers are usually quite

effective.hydralazine and clonidine can be used as they increase renal blood flow.


Pathya

1. Ahara:

Moonga, masoora, patola, medthee, vaastuka, papeetaa, rasona, hingu, jeeraka,

gomotra etc.

2. vihaara :

Samyaka vishraama, upavaasa, shavaasana, samyaka vyaayaama, sadavitta

paalana, etc.

Apathya

1. Ahara:

Anoopa mamsa, imali, achaara, dughavikaara, and tobacco, egg. Alcohol, opium

etc.

2. Vihara:

Divaasvapna, ativyaayaama, avyaayaama, vega vidhaarana, adhyashana,

atichintana, atikrodha, atishrama, atisukhaasana, raatri jaagarana, etc.


SUBJECT:

The hypertensive (Raktapeedanadhikyata) patient is selected with

preset criteria from OPD/IPD of Postgraduate and Research Center, D.G.M.

Ayurvedic medical college, Gadag. He is given the trial drug. The details of

trial drug as follows.

COMPOSITION OF VACHAMAMSYADI YOGA:

Punarnava (Boerhavia diffuse Linn.)1

Gokshura (Tribulas terrestris Linn.)2

Jatamamsi (Nordostachys jatamansi DC.)3

Vacha (Acorus calamus Linn.)4

PREPARATION AND STORAGE OF VACHAMAMSYADI YOGA:

The above said four herbs are well identified and collected fresh in

equal quantities. They are powered in to fine form and filled into 500-mg

capsules. They are stored in air tight glass containers and distributed in seven

days interval. The patients are collected with in six moths from the date of

manufacturing the medicine.

POSOLOGY OF VACHAMAMSYADI YOGA:

The trial dose prescribed for the Patient is 3 gm in divided dose per

day i.e. 24 Hrs. Therapeutic dose may be increased or potenciated according

to the studies.

Material and Methods – Drug review 83


Latin name Boerhavia diffuse Linn

Natural Order Nyctagineae

Sanskrit Name Shotaghni

English Name Spreading hog-weed

Kannada Name Sanadika

Synonyms5

Punarnava, Swetamoola, Prudhivika, Deergha

patraka, Vishari, Derghavarsha, Bhoo, Punarbhu,

Mandalachada

Parts Used Herb and root

Habitat

Found all over India, especially abundant during the

rainy season. It is of two kinds one with white flowers

(sweta punarnava) and second with red flowers (rakta

punarnava). Sweta punarnava is vividly used in

medicine preparation. In Tibbi literature a third variety

with blue flowers has also mentioned.


Pharmacological properties6,6a

Rasa Madhura, Tikta, Kashaya, Katu

Guna Laghu, Rooksha, Ushna

Veerya Ushna

Vipaka Madhura

Prabhava

Hridya, lekhana, Tridosha hara, Kasahara,

Swedopaga, Anuvasanopaga,

Constituents

The air-dried plant was found to contain unusually large

quantities of potassium nitrate. As presence of this salt may partly

account for the diuretic action of the drug, the total content of

potassium present in the plant was estimated. Taking the whole of

potassium as potassium nitrate, its quantity in the powered drug

amounted to about 6.41 percent. This is, however unlikely and it is

probable that other salts of potassium are present. Besides these

salts, there is an active principle – an alkaloid, present in very small

quantities, about 0.01% of the weight of dry plant. The alkaloid was

isolated in just sufficient quantity for pharmacological experiments. It

had a bitter taste and the hydrochloride was obtained in crystalline

form. It has been named “punarnavine”. It contains a sulfate of a body

alkaloidal in nature (punarnavine) 0.01p.c., potassium nitrate 6.41%;

an oily amorphous mass of the nature of a fat; sulfates and chlorides

and traces of nitrates and chlorates from the ash. The sulfate of the


alkaloid is described as small needle shaped crystals brownish white

in appearance, when in mass. Its taste is nearly bland or very faintly

bitter and resembles that of impure quinine sulfate. The yield of the

alkaloid as sulfate was 300 mgm from 20 oz. of the original plant, i.e.

0.053 per cent7.

Action

Bitter, stomachic, laxative, diuretic, expectorant, diaphoretic

and emetic. Root is purgative, antihelmenthic and febrifuge.

Dhanvantari Nighantu described the white variety as possessing

laxative and diaphoretic properties, and the red variety is bitter. Its

active principle is a diuretic chiefly on the glomeruli of the kidneys

through the heart, increasing the beats and strength, and rising the

peripheral blood pressure in consequence. On the cells of tubules it

exerts little or no action. In Raja Nighantu, white variety is

recommended in diseases of the nervous system and in

Bhavaprakasha in heart disease and piles. Chakradutta used it in the

treatment of chronic alcoholism, mada and various other writers used

in the treatment of phthisis, insomnia, rheumatism, jaundice, ascites,

asthma and mention its diuretic properties.

Distribution8

Through out India, Baluchistan, Ceylon, Tropical and sub

tropical Asia, Africa and America.



Latin name Tribulas terrestris Linn

Natural Order Zygophyllaceae

Sanskrit Name Ikshugandha, Gokshura, Trikanta

English Name Small caltrops

Kannada Name Negil-mullu

Synonyms

Goshura, goshuraka, bhashaka, swadukantaka,

trikantaka, shadanga, kshuraka, kshura, gokantaka,

goshuraka, sharanya, trikantaka, trikantika, kantaphala,

swadamstra, vyaladanstraka, phalanshalka,

vanasrigataka, and stala srinagataka.9

Parts Used Fruit and root, especially entire plant

Habitat

This trailing plant is common in sandy soil through

out India and Ceylon, plentiful in the united provinces

and in Madras. The carpels or cocci of the fruit

resemble a cloven hoof of the cow. This variety is

known as Mitta (sweet) Gokuru as distinguished from

Kudwa or moto gokuru.


Pharmacological properties

Rasa Madhura

Guna Guru, Snigdha

Veerya Seeta

Vipaka Madhura

Prabhava Hridya, Mootrala

Brimhana, Vrishya, Tridoshashamaka, Hridrogahara,

Pramehahara, mootrakrichahara, soolaghna and Agni

vardhaka10.

Distribution

Through out India up to 11,000 ft in Kashmir,

Ceylon; all warm regions of both hemispheres12.

Constituents

Extract of the powered fruit was found to contain an alkaloid, a

resin, fat and mineral matter 14%. The fruit is said to contain a

substance having an aromatic smell and it gives off a fragnent odour

when it is burnt. The fruit contains an alkaloid in traces (0.001%), a

fixed oil (3.5%) consisting mainly of unsaturated acids, an essential oil

in very small quantities, resins and fair amounts of nitrates. An

aqueous solution of the tartrate of the alkaloid, after removal of the

alkaloid was found to contain sugars, etc., but no physiologically

active substance.


Action

Plant and dried spiny fruits are esteemed as cooling, demulcent,

diuretic, tonic and aphrodisiac. The diuretic properties of the plant, no

doubt, are due to the large quantities of the nitrates present as well as

the essential oil, which occurs in the seeds. Stems are considered as

astringent. This plant was also known to old Greek physicians, is used

in south Europe as an apparent and diuretic. In china it is used as a

powerful hemostat and also for edema.

The fruit is sour, with bad taste diuretic remove gravel from urine

and stone in the bladder. Especially the leaves are diuretic thus the

total plant when it is taken it gives immense cooling effect along with

its action over the apanavata as controlling urinary troubles along with

menstrual problems11.



Latin name Nordostachys jatamansi DC

Natural Order Valerianaceae

Sanskrit Name Tapaswini, Bhytajata, Jatamansi

English Name Musk root, Indian Spikenard

Kannada Name Jatamavshi

Synonyms

Mamsi, krishna jata, himsa, nalada, jatala, amisha,

jata, pisita, peshi, kravyada, tapaswini, maata, romasha

and mishi13.

Parts Used Rhizome and oil from rhizome

Habitat

The herb is growing at great elevations up to

17,000 feet on the Alpine Himalayas, in Nepal, Bhutan

and Sikkim.

Pharmacological properties

Rasa Tikta, Kashaya, Madhura

Guna Laghu, Snigdha

Veerya Seeta

Vipaka Katu

Prabhava Bhutaghna, Manasa doshahara


Constituents

A volatile essential oil 0.5%, resin, sugar, starch, bitter

principle extractive matter and gum.

Action

Root is some what bitter taste, aromatic, anti spasmodic,

diuretic, emmenagogue, nerve sedative, nerve stimulant, tonic,

carminative, deobstruent and sedative in spinal cord. It

promotes appetite and digestion.

Jatamamsi roots should also be fresh as an aromatic

adjunct in the preparation of medicinal oils and in perfumery.

Jatamamsi is a good substitute for the official valerian. Infusion

prepared from fresh roots is employed in the treatment of

spasmodic hysterical affections, especially palpitation of the

heart, nervous system headache, chorea, flatulence, etc. in

doses 1-2 Ozs. TDS.



Latin name14 Acorus calamus Linn

Rootstocks of Vacha are as thick as the middle finger, creeping

and branching. Leaves are 0.9 to 1.8 meters long and by breadth 1.7

to 3.8 cm., bright green, acute thickened in the middle and margins

are waved. Spathe 15 to 75 cm. Long, pedicle 3.8 to 3.2 cm. Broad.

Spadex 5 to 10 by 1.3 to 2 cm., diameter obtuse slightly curved and

green in color. Sepals is as long as the ovary, scarious; anthers

yellow. Fruit turbinate, prismatic, top pyramidal.

Natural Order Aroidaceae

Sanskrit Name Vacha, Shadgrandha, Ugragandha

English Name Sweet flag

Kannada Name Baje

Synonyms

Vacha, Ugragandha, Golomi, Jatila Ugra, Lomasha,

Shadgrandha, Vijaya, Kshudra, Mangalya and Hymavathi.

Parts Used Dried rhizome

Habitat

A semi aquatic perennial cultivated in damp marshy places in India

and Burma. This herb exceedingly common and found in Manipur and

Naga Hills and on the edges of lakes and streams in India. It is seen in

ascending Himalayas at the height of 600 feet and also in Sikkim.


Pharmacological properties15

Rasa Katu, Tikta

Guna Ushna, Laghu, Teekshna

Veerya Ushna

Vipaka Katu

Prabhava

Vatatasleshma hara, Kantya, medhya, krimihara,

vamakam, adhmanaharam and malamootra vibandha

haram.

Varga Satapushpadivarga

Constituents

A volatile oil, acorin, a bitter principle acoretin (choline), calamine

(useful in dysentery), starch, mucilage and a little tannin. The dried

rhizome yealds 1.5% to 2.7% of a neutral yellow aromatic essential oil

having an agreeable odor. The fresh aerial parts yeald about 0.123%

of the volatile oil; the upper roots however give a much better yeald

from 1.5 to 3.5%.

Acorin, a glycoside is a honey like liquid very bitter and aromatic,

soluble in alcohol, chloroform and ether splitting into sugar and volatile

oil. Acoretin is a resin like body yealding by reduction ethereal oil and

sugar.

Calamine is a very crystalline alkaloid soluble in alcohol and

chloroform. The valuable essential oil of Acorus calamus is yellowish


brown and is found to be composed of asaryl aldehyde. It also have

free normal (C714O2) heptylic acid (C16 H 32 O2), palmitic acid,

eugenol, esters of acetic and palmitic acids, pinine, camphene, sequi-

terpene, calamene (C15H24, 2.3%); and a small quantity of phenol;

Eugenol (C10H12O2, 0.3%), methyl eugenol (C11H14O2, 1.2%),

calamenenol (C15H24O, 5.3%), and calameone (C15H26O2, 2.2%). The

crystaline body named Calameone asarone.

Action

Root and rhizome are stimulants, emetic, nauseant, stomachic,

aromatic, expectorant, carminative, antispasmodic and nervine

sedative. In large doses induces vomiting.

Useful in dyspepsia, flatulence, and loss of appetite, choleric

diarrhea of children and as anti periodic when it is given in tertian

fevers. It is also beneficial in hysteria and neuralgia.

Externally it is used in chronic rheumatism, the root being powered

and rubbed up with cashew spirits to the chest in the catarrh of

children it works as counter irritant. The powder is a very effective

insecticide.

It is used as a diuretic in calculus affections and as an anti

helmintic to expel worms.

The root is supposed by the Chinese to affect the heart and lungs

and to be beneficial for cancer. In general, it is taken as a restorative

for the body and spirits.


1 Indian Materia medica, A.K.Nadkarni, pp203-207, Indian Medicinal plants,K.R.Kitrtikar, pp2045-2048 2 Indian Materia medica, A.K.Nadkarni, pp1229, Indian Medicinal plants,K.R.Kitrtikar, pp420-423 3 Indian Materia medica, A.K.Nadkarni, pp840-842, Indian Medicinal plants,K.R.Kitrtikar, pp1307-1309 4 Indian Materia medica, A.K.Nadkarni, pp35-37, Indian Medicinal plants,K.R.Kitrtikar, pp2626-2629 5 Dhanvantari Nighantu – Guduchyadi Varga, 6 Dravyaguna Vijnan,Priyavat Sharma, pp631, 6a Dhanvantari Nighantu – Guduchyadi Varga 7 Indian Materia medica, A.K.Nadkarni, pp203, Chopra “I.D. of I” pp300 to 305 8 Indian Medicinal plants, K.R.Kirtikar, pp2045 9 Dhanvantari Nighantu – Guduchyadi Varga 10 Ibid 12 Ibid, K.R.Kirtikar, pp420 11 Indian Medicinal plants, K.R.Kirtikar, pp421 13 Dhanvantari Nighantu – Chandanadi Varga 14 Indian Materia medica, A.K.Nadkarni, pp36, Indian Medicinal plants,K.R.Kitrtikar, pp2628 15 Dhanvantari Nighantu – Satapushapadi Varga


Present study “ EVALUTION OF THE EFFECT OF VACHAMAMSYADI

YOGA IN RAKTAPEEDANADHIKYATA” (HYPERTENSION) is studied and

evaluated as below.

Introduction:

Present day living style of people making them to undergo tension which

leading to Raktapeedanadhikyata (hypertension) in the body. As a large number of

people are having this problem, it draws the attention of an Ayurvedist for a safe and

effective medication in alternative system of medicine i.e. Ayurveda.

Review of literature:

“Hypertension “ is not dealt in Ayurvedic literature by any parallel name. So

many nomenclature claimed as Hypertension are Raktabhapa, Raktabhara,

Raktavritavata etc. But as a matter of translation to the word and condition of

hypertension "Raktaoeedanadhikyata” is said to be correct because it implies to the

increase of pressure. Bhrama, moorcha are considered nearer conditions to that of

Hypertension.

The present yoga consist of VACHA ( Acorus Calamus Linn)

JATAMANSI (Nordostachys jatamansi DC) GOKSHURA ( Tribulus terrestris Linn )

and PURNARNAVA ( Boerhavia diffuse linn ).Above set of herbal origins are

effective with their diuretic, tranquilizer and Hypotensive effects. A combination of

above collectively is to be tried for the early and effectively remedy for the

hypertensive patients.

Material and Methods

95

Material and Methods:

Patients are selected from the OPD/ IPD of post Graduate and research

centerHospital, Shri D.G.M.Ayurvedic medical college, Gadag.

The trial compound ingredients are collected from the local market and the

botanist confirms the identification. The literally aspect is collected from classical

Ayurvedic texts as well as from modern literature texts as well as from modern

literature, magazines journal and meddler search.

Method of collection of data

Sample size: From OPD/IPD of PGARC hospital a sample size of minimum 30 patients are

selected irrespective of sex, in all age groups( between 35-75years) with a history of

maximum 5 years duration.

Exclusive criteria: The patients with renal complications, thyroid and adrenal diseases are

excluded from the study. Alcohol abuse and secondary hypertension patients are

also excluded.

Inclusive Criteria: All the patients are enrolled in inclusive criteria other than exclusive criteria

mentioned above. The patients are selected between the age group of 35-75 years.

Study design: Prospective, clinical trial.

Posology: 50mg/Kg. Body wt/24 hours in divided dose at the maximum of 3mg/24hrs, in

divided dose.


96

Duration: 21 days

Assessment: Results are assessed by the clinical improvement and sphygmomanometer

studies.

Investigations and study of hypertension

A patient has to be carefully examined for a possible cause for hypertension and

what investigations need to be done to determination of medical treatment choice.

The identification of the cause will help in the choice of investigation and the course

of management.

A pains-taking history will often direct us to a diagnosis e.g. in a patient with a

history of use of drugs like - contraceptive pills, nasal vasoconstrictors,

glucocarticoids, phenacetin, analgesics etc; withdrawal of the offending drug is often

sufficient. Repeated urinary infections, haematuria and abdominal trauma point to a

renal cause. A history of headache, palpitation and pallor should alert one to the

possibility of a phcochromocytoma.

A history of hypertension in parents and siblings suggests a hereditary basis,

which may be of prognostic significance. Of similar significance is a history of

smoking, sedentary habits, character traits, and diabetes.

A detail examination of patient will help to grade the severity of damage due to

hypertension, as it is the only part of the body in which the state of small arteries can

actually be visualized. The case evaluation sheet as follows –


97

CASE SHEET FOR “RAKTAPEEDANADHIKYATA” POST GRADUATE AND RESEARCH CENTERE,(KAYACHIKITSA)

SHRI. D.G.M.AYURVEDIC MEDICAL COLLEGE. GADAG. Guide : Dr.Ch.Ranga Rao Dr hivakumarayya.S.Hiremath.

M.D. (Ay) M.D.Scholar Co-guide : Dr. Sivarama Prasad Kethamakka. M.A.(Astro),M.D.(Ay) 1. Name of the Patient Sl.No. 2. Father’s/Husband’s Name OPD No 3. Age - Years IPD No 4. Sex - M F Bed No 5. Religion Hindu Muslim Christian Other Date of Schedule initiation Date of Schedule completion 6. Occupation - Sedentary Active Labour 7. Economical status Poor Middle class Higher middle class Higher class 8.Diet - Veg Mixed 9. Address Pin 10. Selection Included Excluded Group A Fresh Diagnosed

B Previous Diagnosed

11. Result Cured Palliative Responded Not responded Discontinued


98

12. Chief complaints with duration.

Before After No

Complaints Fresh <1 Yrs <5 Yrs >5 Yrs

1 Sirashoola (Headache) 2 Bhrama (Dizziness ) 3 Anga sada (Fatigue) 4 Nidranasha (Insomnia) 5 Hrit Drava (Palpitation) 13. Associated Features.

Before After No Is it associated with Fresh <1 Yrs <5 Yrs >5 Yrs

1 Angina 2 Asthma 3 Congestive cardiac failure 4 Diabetes 5 Nephritis 6 Gout 7 Toxaemia 8 Transient Ischemic attack 9 Pakshaghatha 10 Arditavata 11 Medoroga 14. Diet and Drug History. No Items Quantity Duration 1 Alcohol 2 Cigarettes 3 Chewing Tobacco 4 Oral Contraceptives 5 Salt 6 Oil / Ghee 7 Anti Hypertensive Drugs 15.Emotional Status. Before After No Mild Moderate Severe Mild Moderate Severe 1 Fear 2 Anger 3 Depression 4 Anxiety


99

15. Family History. No Disease Yes No Relation Paternal Maternal Brother Sister 1 Heart Disease 2 Diabetes 3 Obesity 4 Hypertension 5 Thyroid disorders 6 Cancer 7 Any other 16. Samanya Pareeksha.

Prakruti Vataj Pittaj Kapaj Vatapittaj Vatakapaj Pittakapaj amadhoshoj a. Pulse /min b. Temp F c. Respiration /min d. Weight Kg e. Height Cms f. Heart rate Supine B A /min

Standing g. Fundus of Eye h. Oedema Stress i. Neck vein j. Peripheral pulses k. Blood pressure

Date Position Vatakala Pittakala Kaphakala Before After Before After Before After

18. Lab - Investigations Test Before Results After

Sugar Urine Albumin Serum Creatinine Blood Serum Cholesterol

E.C.G (ST segment) Any other` 19. Assesment Chart. No Bp Right Arm / Left Arm Systolic Diastolic 1 Before Treatment mm of Hg mm of Hg 2 After 3 days - mm of Hg mm of Hg 3 After 6 days - mm of Hg mm of Hg 4 After 9 days - mm of Hg mm of Hg 5 After 12 days - mm of Hg mm of Hg 6 After 15 days - mm of Hg mm of Hg 7 After 18 days - mm of Hg mm of Hg 8 After 21 days - mm of Hg mm of Hg


100

Clinical examination: -

A detailed examination is carried out.

The following findings suggest a possible diagnosis:

Possible diagnosis Possible diagnosis

1 Facial features, obesity, hirsutism Cushing’s disease.

2 Systolic murmur, anteriorly or over the back;

Palpable branchiofemoral relay in Pulse

Coarctation of aorta

3 A laterlised abdominal bruit/murmur Renal artery stenosis

4 Palpable kidneys or pain over the kidney area Polycystic disease hydroephrosis

Investigations: -

1. Blood :-

Levels Possible diagnosis

A Potassium-low value (when not on diuretics )

associated with urine sodium of 100mmol or

more per 24 hours

Cohn’s disease

B Creatinine-raised Renal cause. Primary or secondary to pre-

existing hypertension

C Uric acid raised The hyperuricaemia diuretics are best avoided in

initiating therapy.

D Glucose-raised Diabetes in association with hypertension

increased cardio vascular risk

E Cholesterol-raised When hypertension is present adds to

cardiovascular risk


101

2. Urine analysis: -

A properly carried out urine analysis will help to find a possible renal cause. This

will include tests for

a) Specific gravity; b) Albumin; c) sugar; d) Microscopic study; for W.B.C, R.B.C and Casts.

3. Electro Cardiograph :-

It helps in assessing, left ventricular hypertrophy, and associated coronary artery

disease.

4. Echo cardiograph :-

It is more sensitive and specific in detecting left ventricular hypertrophy. It helps in

calculating L.V. mass and in assessing regression of L.V. hypertrophy in response to

therapy. The simplest and cheapest tests must always be performed before complex

and expensive ones. Resistant to medical treatment that is, a diastolic blood

pressure above 100mm Hg in a complained patient despite adequate doses of three

complimentary anti-hypertensive drugs, should warrant a reference to a specified

center for exclusion of a secondary cause and also for treatment of the more serious

complications of hypertension.

COMPLICATIONS OF HYPERTENSION

Complications associated with blood pressure elevation fall into the following

categories

1. Cardiac 2. Cerebral 3. Ocular 4. Vascular and 5. Renal


102

1. Cardiac (Heart) complications:-

There are two main cardiac complications of hypertension.

• Heart failure.

• Ischaemic heart disease.

These constitute the most common cause of death. Left ventricular hypertrophy

of varying degree may be solely the result of the increased total peripheral resistance

and left ventricular work. Ultimately congestive heart failure may supervene and this

condition may prove fatal. Ischaemic heart disease the other major cardiac

complications, is well known to be more common in hypertensive than in

normotensive individuals. Angina pectoris, myocardial infarction, Cardiac failure, and

sudden death are all manifestations of this condition.

2. Cerebral (Brain) complications :-

Stroke, which is a major complication of hypertension. Cerebral cerebellar, and

brain stem hemorrhage is more closely associated with hypertension than is cerebral

thrombosis, which is mainly caused by atherosclerotic lesions. Nevertheless, the

unfavorable influence of hypertension in accelerating cerebral atnerosclerosis has

been indicated by extensive clinico pathological observations. Transient cerebral

ischaemic attacks are episodes of focal reversible neaulogical deficit of sudden on

set and of less than 24-hour duration. As these may be one of the earliest

manifestations of cerebral vascular disease, early detection and treatment is

important for the prevention of stroke. Hypertensive encephalopathy is often

associated with an extreme elevation of arterial pressure and is characterized by

variable disturbance of consciousness ranging from transient confusion to coma;


103

often with convulsions. Severe headache, nausea, and vomiting are common

accompaniments. The syndrome may be promptly reversed by anti hypertensive

therapy.

3. Renal (Kidney) complications;-

The renal complications of hypertension include premature or accelerated

atherosclerosis of the renal arteries, Nephrosclerosis, and with the development of

the malignant phase, necrotising arteriolar fibroid changes.

• The first may also occur in the absence of hypertension, but is probably

accelerated by an elevated pressure.

• The second produces slowly progressive renal impairment and only rarely renal

failure, and is associated with progressive uremia and tetinal hemorrhages

exudates, and papilloedema.

The accelerated phase the intense renal ischemia may result in elevated

circulating levels of renin and angiotension, hence secondary hyperaldosteronism is

witnessed.

4. Vascular (blood vessels) complications ;-

Dissecting aortic aneurysm and uncommon but frequent fatal condition is

associated with degenerative disease in the aortic media. It is encountered more

often in persons with hypertension. Peripheral arterial disease also is accentuated by

high blood pressure.

5. Accelerated-malignant phase complications:-

The essential pathological feature of this complication is fibrinoid arterial necrosis.

The diagnostic features are the presence of bilateral papilloedema as well as retinal


104

hemorrhages and exudates. Renal biopsies have shown that renal fibrinoid arterial

necrosis are common in severe hypertension in association with retinal hemorrhages

and exudates, but without papilloedema. With effective lowering of arterial pressure,

these gross retinal lesions may resolve.

PROGNOSIS OF HYPERTENSION

Essential hypertension is a disease with extremely variable promises. Some

of the reasons for this are understood to be that the inter play of the actual levels of

arterial pressure and the duration for which it is raised, causing ear and tear on

vessels which re variable resistant to this stress.

Prognosis depends on the height of the arterial pressure. There is a clear

linear correlation between arterial pressure and risk of death. Thus a subject with the

systolic arterial pressure of 10 mm Hg will be less at risk than one with 120 mm Hg. A

man with a systolic arterial pressure of 170 mm Hg will have about twice the mortality

risk of the man whose pressure is 120 mm Hg.

Consideration of the family history, the age of the patient, the information

obtained by the plan of assessment suggested about and an estimation of the rate of

progression of the various manifestations will give the necessary data on which to

judge the probable course of the disease. The condition is mild if the heart is not

enlarged, the fundi show on abnormalities and there is no albuminuria or evidence of

renal function. On the hand patients with untreated hypertension rarely live for more

than a year. On the whole, women appear to withstand hypertension better than

men. In general expectation of life is considerably reduced in these who have high

blood pressure with those in whom the pressure is within the normal range. However,


105

it does not follow that all who had high blood pressure necessarily have a bad

prognosis. When properly administered to a suitable patient modern treatment is

effective in relieving symptoms, preventing or postponing-omplications and in

prolonging life, but treatment of hypertension to be difficult and necessitates much

attention to detail and considerable patience on the part of both patient and doctor.

There is, as yet, no entirely satisfactory preparation for lowering the blood pressure,

that is to say one, which does not produce in some patient’s tolerance, undesirable

side effects or occasional unpredictable Hypotension. In addition, it should be

remembered that, once begun, treatment would probably have to be continued for life

long.


106

Chart number – 1 Demographic data for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Sex Religion Occupation Economical Status Food Group S .no OPD Age

M F H M C O S A L 1 2 3 4 V Mx A BResult

1 19947 32 + + + + + + Cured2 20100 51 + + + + + + Cured3 17446 54 + + + + + + Cured4 22057 64 + + + + + + Cured5 20152 60 + + + + + + + Cured6 22056 65 + + + + + + Cured7 22154 37 + + + + + + Cured8 21209 47 + + + + + + Relieved9 21491 30 + + + + + + Cured 10 21479 70 + + + + + + Cured11 21561 65 + + + + + + Relieved12 21592 30 + + + + + + Cured13 21851 54 + + + + + + Relieved14 21875 55 + + + + + + Cured 15 21454 67 + + + + + + Cured16 21740 72 + + + + + + Cured17 21919 29 + + + + + + Cured18 21922 54 + + + + + + Relieved19 21924 40 + + + + + + Cured20 21927 45 + + + + + Cured21 21878 55 + + + + + + Cured22 57 60 + + + + + + Cured23 22055 56 + + + + + + Relieved24 80 60 + + + + + + Cured 25 96 60 + + + + + + Cured26 22054 35 + + + + + + Relieved27 143 35 + + + + + + Relieved28 149 65 + + + + + + Cured 29 117 71 + + + + + + Cured30 234 60 + + + + + + Cured

M= male, F= female, H= Hindu, M= Muslim, C= Christian, O= Others, S= Sedentary, A= Active, L= Labor, 1= Poor, 2= Middle class, 3= Higher middle class, 4= higher class, V= Vegetarian, Mx= Mixed diet.

Group A= Fresh diagnosed, Group B= Previously diagnosed.

Observations 107

Chart number – 2 Complaints for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

S.no 1 2 3 4 5 A1

A2 A3 A4 A5 A6 A7 A8 A9 A10 A11

B A B A B A B A B A B A B A B A B A B A B A B A B A B A B A B A

1 + + + + + 2 + + + + 3 + + + 4 + + + + + 5 + + + + + + 6 + + + + + + + 7 + 8 + + + + + 9 + + + + 10 + + + 11 + + + + 12 + + + 13 + + + + 14 + + + + + 15 + + + + + 16 + + + + + 17 + + + + 18 + + + + + 19 + + + + 20 21 22 + + + + 23 + + + + + + 24 + + + 25 + + + + + 26 + + + + + + 27 + + + + + + 28 + + + + + 29 + + + 30 + +

S.No is in corresponding patient as in table1,

1= Sirah soola, 2= Bhrama, 3= Anga soola, 4= Nidranasha, 5= Hridrava A1= angina, A2= Asthma, A3= Congestive cardiac failure, A4= Diabetes, A5= Nephritis, A6= Gout, A7= Toxemia,

A8= Tranciant ischiemic attack, A9= Pakshaghata, A10= Ardhita Vata, A11= Medoroga.

Observations 108

Chart number – 3 Diet and drug history in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

S.no Alcohol Cigarettes Chewing

tobacco Oral

contraceptive Salt Oil / Ghee Anti

hypertensive drugs

Result

1 Cured 2 + + + Cured3 + Cured4 + + + Cured5 + + Cured6 + + Cured7 Cured 8 + Relieved9 + + + + Cured

10 + + Cured11 + + Relieved12 + + Cured13 + + + + Relieved14 + Cured15 Cured16 + + + Cured17 + + Cured18 + + + Relieved19 Cured20 + + Cured21 + Cured22 + + + Cured23 + + + + Relieved24 Cured25 + Cured26 + + + Relieved27 Relieved28 + + + Cured29 + + Cured30 + + + + Cured

Observations 109

Chart number – 4 Emotional status and Family history in “Evaluation of the effect of Vachamamsyadi yoga in

Rakta peedanadhikyata (Hypertension)” Emotional status Family history

S.No Fear Anger Depression Anxiety

B A B A B A B A

Heart disease

Diabetis Obesity Hypertension Thyroid Cancer Other

1 ++ ++ 2 ++ +++ M P3 ++ ++ ++ BP P4 ++ +++ ++ ++5 + P M Br S 6 Br S7 + + + B8 P P9 +++ +++ P M10 + + P11 P12 13 +++ +++ +++14 +++ +++ +++ +++15 + +++ 16 + 17 ++ P M M18 + Br19 + + S20 21 22 Br23 24 25 + P26 ++ M27 + + + 28 + 29 + + 30 + + M Br

B= Before, A= After, + = Mild, ++ + Moderate, +++ severe, P= Paternal, M= Maternal, Br = Brother, S= Sister

Observations 110

Chart number – 5 Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Systolic hypertension

s.no Before 3rd day 6th day 9th day 12th day 15th day 18th day After Difference Result 1 150 160 160 148 140 140 130 120 30 Cured2 160 150 140 136 136 130 128 126 34 Cured3 140 110 140 130 140 130 130 120 20 Cured4 220 190 210 188 160 150 130 120 100 Cured5 178 172 168 164 160 130 124 120 58 Cured6 180 180 170 168 164 160 138 122 58 Cured7 150 140 120 120 120 120 120 120 30 Cured8 180 180 180 170 160 140 138 124 56 Relieved9 190 188 190 170 160 150 138 122 68 Cured10 210 190 180 180 150 142 130 120 90 Cured11 180 182 170 162 158 150 140 130 50 Relieved12 150 130 130 130 128 126 126 120 30 Cured13 180 170 170 166 160 140 130 130 50 Relieved14 190 180 170 164 160 140 130 126 64 Cured15 170 170 168 168 160 150 130 130 40 Cured16 180 180 180 160 150 140 130 122 58 Cured17 170 168 164 160 150 142 132 122 48 Cured18 190 184 180 168 160 150 140 122 68 Relieved19 190 180 178 160 154 140 128 126 64 Cured20 170 168 160 152 142 130 130 124 46 Cured21 180 180 180 162 158 152 142 130 50 Cured22 170 158 152 142 138 130 128 122 48 Cured23 180 170 158 150 142 136 130 122 58 Relieved24 190 188 180 170 158 140 130 120 70 Cured25 160 160 152 148 142 136 130 120 40 Cured26 170 168 160 188 170 154 140 128 42 Relieved27 160 160 152 148 140 132 130 130 30 Relieved28 180 178 178 166 158 152 140 128 52 Cured29 170 168 162 160 150 142 138 130 40 Cured30 180 180 170 164 158 140 128 124 56 Cured

Total 5268 5082 4972 4762 4526 4214 3958 3720 1548

Observations 111

Chart number – 6 Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Diastolic hypertension

s.no Before 3rd day 6th day 9th day 12th day 15th day 18th day After Difference Result 1 100 100 100 98 96 98 90 80 20 Cured2 100 90 80 80 82 80 78 76 26 Cured3 90 80 90 80 84 82 80 80 10 Cured4 100 100 100 98 92 90 86 80 20 Cured5 98 90 90 88 86 80 80 80 18 Cured6 110 110 100 108 106 100 94 80 30 Cured7 98 98 90 84 84 80 80 80 18 Cured8 108 106 104 100 100 98 96 84 24 Relieved9 130 130 120 120 110 110 98 80 50 Cured10 110 110 100 100 98 98 84 80 30 Cured11 110 110 108 104 104 98 90 82 28 Relieved12 110 100 90 90 84 80 82 80 30 Cured13 130 120 118 116 108 98 90 84 46 Relieved14 120 120 110 100 98 94 86 82 38 Cured15 100 100 98 92 90 96 82 80 20 Cured16 120 112 110 100 100 98 90 82 38 Cured17 100 98 94 90 88 82 80 80 20 Cured18 110 110 104 100 100 98 92 84 26 Relieved19 120 110 110 102 98 92 88 82 38 Cured20 108 106 100 98 96 92 88 82 26 Cured21 110 100 100 96 94 92 84 82 28 Cured22 100 98 94 90 88 84 84 80 20 Cured23 120 110 108 106 100 96 90 84 36 Relieved24 110 108 98 96 96 92 90 82 28 Cured25 120 110 108 104 100 98 88 82 38 Cured26 120 116 114 102 100 96 90 84 36 Relieved27 120 112 108 106 104 98 90 84 36 Relieved28 110 108 104 98 98 92 88 82 28 Cured29 110 110 104 98 92 88 84 80 30 Cured30 104 104 100 100 96 90 88 82 22 Cured 3296 3176 3054 2944 2872 2770 2610 2440 858

Observations 112

Chart number – 7 Statistical Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Before 3rd day 6th day 9th day 12th day 15th day 18th day After

Average Systolic hypertension

175.6 169.4 165.73 158.73 150.86 140.46 131.93 124

Standard deviation 17.14 18.1 18.19 12.22 11.63 9.43 5.44 3.85

Average Diastolic hypertension

109.86 105.86 101.8 98.13 95.733 92.333 87 81.33

Standard deviation 9.88 9.89 8.94 8.98 7.44 7.48 4.97 1.84

Chart number – 8

Significance table of “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”

Deviated mean

Standard deviation

standard error T value P value Remark

Systolic Hypertension

51.6 17.557 3.2054 16.097 <0.001 Highlysignificant

Diastolic Hypertension

28.6 8.9311 1.63 7.539 <0.001 Highlysignificant

Observations 113

0

20

40

60

80

100

120

140

160

180

200

Before 3rd day 6th day 9th day 12th day 15th day 18th day After

Figure no 1: Graphical demonstration of Decreased systolic Hypertension

in regular intervals

0

20

40

60

80

100

120

Normal 109.9 105.9 101.8 98.13 95.73 92.33 87 81.33

Diastolic 80 80 80 80 80 80 80 80

Before

3rd day

6th day

9th day

12th day

15th day

18th day

After

Figure no 2: Graphical demonstration of Decreased diastolic Hypertension

in regular intervals

Observations 115114

Observations 116

Sex ratio: -

Present study has the distribution of the sex ratio as 57:43, male and female

respectively. The data and flow diagram follows as below.

Sex Number Percentage Male 17 57 female 13 43 Total 30 100

Male57%

Female43%

Figure no 3: showing sex ratio

Discussion and conclusion 115

Religion distribution: -

At the present study it is observed more Hindu patients are reported. It

doesn't mean that Hindu patients have more incidence of Hypertension. In the

locality where study is done has more population of Hindus. This is only a segmental

study of one area in Gadag. The reported cases are grouped as under.

Religion Number Percentage Hindu 27 90 Muslim 3 10 Christian 0 0 Others 0 0 Total 30 100

Hindu90%

Muslim10%

Christian0%

Others0%

Figure no 4: Religion distribution


Occupation distribution: -

This is done under three categories. It seems that sedentary and active group

patients have high incidence of hypertension and the labor group has very less. It

may be because of sedentary lifestyle in which Kapha is predominant or obstruction

to the vessels is seen. Out of present study it is being observed that the people who

are more dynamic and active are prone to get this condition as they are over exerted.

The distribution and diagram as follows.

Occupation Distribution Sedentary 15 Active 13 Labor 2 Total 30

13

0

5

10

15

Sedentary - 15Active - 13

Labor - 2

Figure number 5: Occupation distribution


Economical status distribution: Present study is done under four categories of distribution. Much of the

patients fall under middle class, probably they undergo insecurity feeling or crave for

the higher status. For the above region they strain and stress them selves and get

captured in to the clutches of Hypertension. The data and flow-chart as follows.

Economical status Distribution Poor 10 Middle class 16 Higher middle class 3 Higher class 1 Total 30

3 11 0 1 6

0 % 2 0 % 4 0 % 6 0 % 8 0 % 1 0 0 %

P o o rM id d le c la s sH ig h e r m id d le c la s sH ig h e r c la s s

Figure number 6: Economical status distribution


Diet distribution:

Food plays an important role in disease development. Thus it is necessary to

emphasize diet regulations in the research study. Present study has the distribution

of food regulations 1:1 to that of vegetarian and mixed diet. The data as follows.

Diet Distribution Vegetarian 15 Mixed diet 15 Total 30

Vegetarian50%

Mixed diet50%

Figure number 7: Diet distribution


Group study: For the convenience and evaluation present study undertaken in two groups

"A" and "B". Group "A" was defined as fresh diagnosed cases of Hypertension and

group "B" as previously diagnosed and following the treatment for long period. As the

number of fresh diagnosed group is high, it seems that present day trends are

directing an individual to get this condition much more. The data and flow diagram as

follows.

Group Number of observance Group A 18 Group B 12 Total 30

1812

0

5

10

15

20

Group A Group B

Figure number 8: Group study


Chief complaints:

Complaints that are usually come across the examination of Hypertension

patient are collected and presented. Out of those mainly Sirah soola, Bhrama,

Angasoola (sada), Nidranasha and Hridrava are particular. The complaints of thirty

patients are summarized in the following table and flow diagram is presented.

Chief complaints Sirah soola Bhrama Anga soola Nidranasha Hridrava Present 24 23 24 14 11 Absent 6 7 6 16 19 Total 30 30 30 30 30

2423

24

14

11

67

6

16

19

0 5 10 15 20 25 30 35

Sirah soola

Bhrama

Anga soola

Nidranasha

Hridrava

Present Absent

Figure number 9: Chief complaints


Associated features:

There are 11 associated features noted in regard with study of hypertension.

Out of that Asthma, Gout and Obesity are having high incidence. Out of the trial

patients only one got the tranciant ischiemic attack and one was noticed as diabetic.

The data and diagram follows.

Associated features Present Absent Total 1 Angina 0 30 30 2 Asthma 9 21 30 3 Congestive cardiac failure 0 30 30 4 Diabetes 1 29 30 5 Nephritis 0 30 30 6 Gout 15 15 30 7 Toxemia 0 30 30 8 Tranciant ischiemic attack 1 29 30 9 Pakshaghata 0 30 30 10 Ardhita Vata 2 28 30 11 Medoroga. 6 24 30

0 10 20 30 40

Angina

Congestive cardiac failure

Nephritis

Toxemia

Pak shaghata

Medoroga.AbsentPresent

Figure number 10: Associated features


Diet and drug history

Diet and drug history has more value in the study of hypertension. Salt, Ghee

or Oil and tobacco usage increases the risk in cardiovascular disease and

hypertension is produced. Present study has shown that the diet regulations have

more value as causative and also it can be used for therapeutic purpose by

restricting it.

Diet and drug history Present Absent Alcohol 4 26 Cigarettes 5 25 Chewing tobacco 5 25 Oral contraceptive 0 30 Salt 17 13 Oil / Ghee 17 13 Anti hypertensive drugs 9 21

Cigarettes9%

Chewing tobacco

9%

Alcohol7%

Anti hypertensive drugs

16%

Oil / Ghee30%

Oral contracept

ive0%

Salt29%

Figure number 11: Diet and drug history


Emotional status

Emotional status also plays an important role in the development of

hypertension. The psyche and body together will give rise the hypertension.

Ayurveda has described many psychological interventions, out of those fear, anger,

depression and anxiety are important. Present study refers almost all the states

present. The data and flow diagram follows.

Emotional status Present Absent Total Fear 12 18 30 Anger 13 17 30 Depression 11 19 30 Anxiety 8 22 30

0

5

10

15

20

25

30

Present Absent Total

FearAngerDepressionAnxiety

Figure number 12: Emotional status


Family history

Many of the patients don't have the family history. But out of those Obesity as

family history is relatively high. Few have the diabetes and heart problems. It is

observed that 3 out of 30 patients have a family history of Cancer. This needs further

evaluation.

Family history Present Absent Total Heart disease 2 28 30 Diabetes 1 29 30 Obesity 5 25 30 Hypertension 0 30 30 Thyroid 0 30 30 Cancer 3 27 30 Other 0 30 30

0

1

2

3

4

5

Pres

ent

Hea

rt

Dia

bete

s

Obe

sity

HyT

N

Thyr

oid

Can

cer

Oth

er

Figure number 13: Family history


Result:

Present study under taken 30 patients in two groups. Group A consists of 18

patients and group B 12 patients. The result was studied under the symptomatic and

Blood pressure readings. Over all result is emphasized. Out of 30 patients all

satisfied with the treatment schedule and expressed normalcy both symptomatic and

on sphygmomanometer. The P value also shows high significance as P<0.001. The

result is as follows. 77% of patients got cured and 23% have remarkable relief thus

the present study drug Vachamamsyadi yoga is said to have efficacy in relation to

regulate Hypertension.

S.No Category Number of patents Percentage 1 Cured 23 77 2 Palliative 07 23 3 Responded 00 00 4 Not responded 00 00 5 Discontinued 00 00

Result

Cured77%

Responded0%

Palliative23%

Not responded

0%

Discontinue0%

CuredPalliativeRespondedNot respondedDiscontinued

Figure number 14: Result



Hypertension most commonly heard clinical state in the older age groups of

patients. The definition of Hypertension is as follows. “Abnormally high tension,

especially a state of abnormally increased blood pressure with Electro cardiograph

evidence of cardio arterial derangement (left ventricular preponderance)” and

vernacularly “abnormally high blood pressure” and “great emotional tension”. Other

wise it is as abnormally increased blood pressure exerting on the arterial and

arterioles more then 120mm Hg systolic and 80-mm Hg diastolic pressures. The

WHO has recommended that blood pressure of 160/95 mm Hg or above in adults

should be considered as Hypertension.

As there is no definitive definition universally accepted, the joint National

committee (JNC-4) of United states on detection, evaluation and treatment of high

blood pressure defines Hypertension as systolic blood pressure (SBP) of 140 mm Hg

or more and diastolic blood pressure (DBP) of 90 mm Hg or more.

The Vata, Pitta and Kapha rule the ages of child, youth and old age. As there

is no specific nomenclature available in relation to Hypertension from classical

textbooks, we have to see the corresponding Disease State from various Ayurvedic

textbooks.

Different names are recommended for the Hypertension or the Hypertensive

States are as follows –

Bhrama Dhamani pratichaya Rakta gata vata Raktavriddha pittavrita vata Siragata vata Ucha rakta bhara

Summary, Present trends and Bibliography 127

Until 1920’s, Hypertension was considered that as beneficial, even through in

1733 Stephen Hales measured first time Atrial blood pressure. In 1905, Karokoff a

Russian, introduced the auscaltatory method of estimating blood pressure.

The Vata nanatmaja vyadhi consists of three conditions that appear in the

process of Hypertension pathogenesis. If Dhamani pratichaya (atherosclerosis), one

out of twenty Kaphaja diseases appears or associates with the aging factor have

more responsibility to give rise Hypertension or Raktabharadhikyata. Ayurveda

speaks about dhamanipratichaya (arteriosclerosis) as an associated condition with

hypertension responsible for 30% of population suffering from hypertension. Doshas

travel in the body through the channels (Srotases) and these are formed of different

Dhatus. By virtue of asrayasrayee bhave, the impaired function of jatharagni leads to

the defective functioning of the pittadharakala (grahani).

The Vyanavata increases the hridaya spandana with forceful contraction of

the heart musculature and increases the caliber of the blood vessels.

The heart is made up of two muscles. The heart working as a pump i.e., the

heart through its working takes in the blood during relaxation and gives out the same

during contraction. The definition of the word Hridaya explains its functional nature.

Since hridaya is seat of Rasa and Rakta, Hridaya takes in and gives out the Rasa

Rakta combination by continuously functioning for the maintenance of the circulation.

This Rasa Dhatu is capable of spreading all over the body. The function of

Rasa Dhatu is preenana. It indicates the function of satisfying or gratifying. The


circulation of Rasa by hridaya is to maintain the life by proper nourishment to the

body. Hridaya is the Rasa sthana, it is also the moolastana of Rasavahasrotas.

According to Susruta, hridaya and rasa-vahini Dhamanis are the moolas of

Rasavahasrotas. Hridaya is also the seat of Rakta and other fluids which are capable

of circulating in the body. Since Rakta is also a (partially) fluid Dhatu, with its main

function as jeevana kriya, to be continuously maintained and also circulated by the

hridaya. It is clear that the Rasa and Rakta move together for the maintenance of

these functions. The Rasa - Rakta is circulating in a combined state. Rasa is ejected

by the hridaya into circulation and moves in the dasa dhamanis and their branches.

Since the rasa-rakta combination is forcefully ejected by hridaya for the maintenance

of preenana and jeevana kriyas, into the Dhamanis, some pressure is exerted by

rasa-rakta on the Dhamanis. blood with its flow, (here blood is a combination rasa

and rakta).

The flow of blood is dependent on the vikshepa karma of the hridaya.

Reduction in the caliber due to a vitiated state of Pranavata or a disturbance in the

equilibrium in functions of Pranavata and Vyanavata can give rise Hypertension.

The clinical syndrome of hypertension appears to be a result of the elevated

diastolic pressure; usually the systolic pressure is also raised, but it need not be. Also

some times systolic hypertension may occur without a diastolic pressure elevation.

Systolic hypertension alone is not believed to be clinically important, unless very high

levels threatened integrity of the blood vessels.


The determination of arterial pressure permits the classification into “Labile

and permanent hypertension”. Labile hypertension has many synonyms as

Borderline or transitory hypertension. Labile hypertension patients have no constant

haemo dynamic or biological characteristics.

However both blood pressure and organ impairment should be evaluated

separately. Since markedly high pressures, carrying a high risk, organ damage has

to be evaluated with reference to the rise of blood pressure. The great majority of

patients with elevated blood pressure have no identifiable cause for this.

Secondary hypertension in contrast to essential hypertension must be

classified precisely and definitively. Hypertension due to the administration of drugs

(iatrogenic hypertension). Withdrawal of therapy often but not always, returns the

blood pressure readings to normal. Renal hypertension frequently accompanies a

wide variety of renal arterial abnormalities. Systolic pressure elevation is unimportant

and it is only diastolic pressure elevation that contributes to morbidity and mortality.

Miraculously Women tolerate hypertension well.

An elevated level of hypertension is often a ‘normal’ concomitant of aging.

The systolic pressure increases with age and the diastolic pressure increases up to

age 55-60 when it tends to level off. Primary hypertension is responsible for about

93% of hypertensive adults. Studies have confirmed that the mortality rises in

proportion to the height of the systolic and diastolic blood pressures. The

development of high blood pressure depends on the interaction of several genetic

and environmental influences.


There is a close relationship between blood pressure and weight. Studies

have established that individuals who gain more weight show more increase in blood

pressure. A protein intake may be useful in alternating the adverse effects of high salt

intake on blood pressure. There is some evidence of an association between high

blood pressure and the use of soft water.

The various changes in renal function that accompany the progression of

essential hypertension and the renal complications of hypertension and in addition, a

wide variety of renal diseases can cause or aggravate hypertension. Parenchyma

renal lesions typically affect both kidneys, distinct impairment of renal function usually

accompanies blood pressure elevation.

Hypertension is a condition with at first no symptoms. In the early stages,

hypertension is intermittent. Few patients die from cardiac or renal failure.

Parenchyma renal disease is suspected when albumin casts, and Red Blood

Corpuscles are present.

Drug treatment should always be accompanied by general measures such as;

Weight reduction

Salt restriction

Moderate physical exercise

Relaxation techniques

STEP CARE TREATMENT OF HYPERTENSION

In most patients, it will not be necessary to reduce blood pressure rapidly.

Indeed a gradual lowering of blood pressure may be preferable, and a “stepped care”


program may simplify therapy and reduce side effects. In addition to the standard

treatments, Diuretics (drugs effecting salt and water balance) potentate the anti-

hypertensive effect of other drugs.

COMPOSITION OF VACHAMAMSYADI YOGA:





Present study “ EVALUTION OF THE EFFECT OF VACHAMAMSYADI

YOGA IN RAKTAPEEDANADHIKYATA” (HYPERTENSION) is studied and

evaluated as below.

The patients with renal complications, thyroid and adrenal diseases are

excluded from the study. Alcohol abuse and secondary hypertension patients are

also excluded. The patients are selected between the age group of 35-75 years.

Study design: Prospective, clinical trial.

Duration: 21 days

Assessment: Investigations and study of hypertension

COMPLICATIONS OF HYPERTENSION

Complications associated with blood pressure elevation fall into the following

categories.


1. Cardiac: There are two main cardiac complications of hypertension.

Heart failure.

Ischaemic heart disease.

2. Cerebral (Brain) complications: -

Stroke, which is a major complication of hypertension.

3. Renal (Kidney) complications;-

The renal complications of hypertension include premature or accelerated

atherosclerosis of the renal arteries, Nephrosclerosis, and with the development of

the malignant phase, necrotising arteriolar fibroid changes.

4. Vascular (blood vessels) complications; -

Peripheral arterial disease also is accentuated by high blood pressure.

PROGNOSIS OF HYPERTENSION

Essential hypertension is a disease with extremely variable promises.

Prognosis depends on the height of the arterial pressure. There is a clear linear

correlation between arterial pressure and risk of death. A man with a systolic arterial

pressure of 170 mm Hg will have about twice the mortality risk of the man whose

pressure is 120mmhg.

On the other hand patients with untreated hypertension rarely live for more

than a year.


Result:

Present study under taken 30 patients in two groups. Group A consists of 18

patients and group B 12 patients. The result was studied under the symptomatic and

Blood pressure readings. Over all result is emphasized. Out of 30 patients all

satisfied with the treatment schedule and expressed normalcy both symptomatic and

on sphygmomanometer. The P value also shows high significance as P<0.001. The

result is as follows. 77% of patients got cured and 23% have remarkable relief thus

the present study drug Vachamamsyadi yoga is said to have efficacy in relation to

regulate Hypertension.

S.No Category Number of patents Percentage 1 Cured 23 77 2 Palliative 07 23 3 Responded 00 00 4 Not responded 00 00 5 Discontinued 00 00

Result

Cured77%

Responded0%

Palliative23%

Not responded

0%

Discontinue0%

CuredPalliativeRespondedNot respondedDiscontinued


The following are the latest trend in Ayurveda through various

postgraduate institutions and research centers in India.

Year Title University

1961 Rakta peedana – raktavaha srotas, Dr. Sahu Gujarat Ayurvedic

University, Jamnagar

1961 Drugs acting on blood pressure, Dr. Mukherjee G.D. Gujarat Ayurvedic


1966 Studies on Hypertension in reference to Hypotensive effect of

certain indigenous drugs

BHU. Varanasi

1967 Hypertension- Rakta chapa. Dr. Ravani-A.T Gujarat Ayurvedic


1968 An experimental & clinical study on the effect of an indigenous

drug Bhringaraja (Eclipta alba in the management of arterial

hypertension. Dr. Maheswari C.M.

BHU. Varanasi

1975 Nyuna Rakta Chapa. Dr.Shah.V.Z. Gujarat Ayurvedic


1977 A study on arterial Hypertension & role Japa pushapa on its

management. Dr. Maheshwari C.M.

BHU. Varanasi

1979 Role of Dosha & Dushya in Hypertension Dr. Joshi.P.D. Gujarat Ayurvedic


1979 Therapeutic trial of caleus amboinicus on systemic

hypertension

GAC, Lucknow

1979 A preliminary clinical study of the effect of Vacha on

hypertension, Dr: Anjaneya.S.

GAC,Hyderabad

1982 Effect of sarpagandadi yoga & shavasan in Hypertension GAC,Lucknow

1983 Effect of shirodhara by Takara in-patient suffering from

hypertension. Dr.Shukla Maheshwar

Gujarat Ayurvedic


1983 Management of hypertension with jatamansi, Dr: Chenars.B. GAC,Puri

1984 Managmentof hypertension Dr: Ravindranath. M.V. GAC,Lucknow



1984 Management of hypertension with muchevata vidhan rasa, Dr:

Kulkarni.

GAC,Ahmednagar

1985 Appraisal of Dosha in Hypertension Dr. Shah. J.R Gujarat Ayurvedic University, Ahmadabad

1985 A study of the effect of jyotishmati and punamara in

hypertension, Dr: Rao.J.V.

GAC,Hyderabad

1985 Ayurvedic drishtikon se uchcha raktachapa ka nadanik evam

chikitsatmaka Adhyan. Dr: Mishra.N.

GAC,Mysore

1986 Studies on the etio pathogenesis. Of hypertension in

Ayurvedicurveda, Dr: Raut A.A.

BHU. Varanasi

1987 An effect of Virechan and shaman on essential Hypertension Gujarat Ayurvedic.

Uni. Ahmdabad

1987 A study on hypertension an Ayurvedic approch, Dr:

Mohammad Raffhullah

GAC,Mysore

1987 Comparative Therapeutic evaluation of shvasana (yogic

Therapy) & Shirodhra panchacarma Therapy in hypertension,

Dr.: Tamrakar.B.L.

GAC,Mysore

1987 Vchcha Rakta chapa men Haldi, Amla evam guduchi ras

Ayurvedicana ka prAyurvedicgatmaku evam vaigyanika

adhyana.

GAC,Mysore

1988 A comparative study on the rule of Ras Ayurvedicana drugs &

Jaladhara in the management of uchcha Raktachapa

Gujarat Ayurvedic


1988 Clinical education of sarpagandhadi compound on

Hypertension. Dr. raghuvansi. K

GAC,Lucknow

1989 Effect of sarpagandagi yoga on hypertension, Dr:Bhushan.K. GAC,Hyderabad

1989 Study on the effect of sarpagandha churna with jatamansi

kvatha on benign or terial hypertension. Dr: Sharma. G. C. D.

GAC,Puri

1990 A new care treatment of Hypertension

( sheleshmavrita vyana ) Dr. Gupta. H.C.

B.H.U. (PHD)


1990 Further observation on the effect of Akhoherlic extraction of

chleus forshcollie Brims ( chhangala jadi ) incases of

hypertension.

GAC, Lucknow


1991 Assessments of role of compound Madhujivana in the

management of Hypertension. Dr. Bhavasar

Gujarat Ayurvedic

University,

Ahmadabad

1991 Further observation on the effect of alcoholic extract of coleus

forshcolli root in cases of hypertension. Dr. kumar. Rajeer

GAC,Lucknow

1991 Management of Raktavata vis.a.vis arterial hypertension with

bramhyadi ghana vati,Dr: Reith.R.

GAC,Puri

1993 A clinical study on Ayurvedicurvedic management of

Hypertension specific reference to some non-pharmacological

measures. Dr.: Murali krishna. P.

BHU. Varanasi

1993 A clinical evaluation of an indigious compound on arterial

hypertension.

GAC,Lucknow

1993 Management of hypertension with shodashanga kashar, Dr:

JAyurvedicasinha. P.N.

GAC,Lucknow

1994 A clinico – pathogenical study of Raktagatavata ( hypertension

) & its management by Jatamanichurna Dr: Bhupendrapal

BHU. Varanasi

1995 Efficiency of hypertension with muchenvata vidhvansa

rasa,Dr:Patil.P.P.

GAC,Pune

1998 The effect of Nordostachys jatamansi on hypertension.

Dr:Shyaml Ghosh.

GAC,Culcutta

2000 The effect of virechna in raktachapadhikyta, Dr. S.H.

Doddamani

GAC,Mysore


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