Dr Satheeshkumar P K
As the term indicates blood pressure is the pressure by which the blood is circulated in blood vessels. Heart is the muscular pump that supplies the pressure to move the blood along the blood vessels. Blood vessels have elastic walls and provide some resistance to the flow. Hence there is pressure in the system even between heartbeats.
It is necessary to keep the blood pressure at a certain level is to ensure the adequate blood supply (nutrients and oxygen) to various organs.
Prevalence in India:
Two to four percentage of rural population and ten to fifteen percentage of urban population are hypertensive. The prevalence increases with age. Above the age of 60 years, 19 % were found to be hypertensive.
“ Rule of halves ”
Hypertension is an “ice berg” disease. It became evident that only about half of the hypertensive subjects in the general population of most developed countries were aware of the condition, only about half of those aware of the problem were being treated and about half of those treated were considered adequately treated.
Systemic hypertension is the persistent rise of basal blood pressure above the arbitrary level of 140 / 90 mm of Hg recorded on three or more successive occasions.
Chronic elevation of systolic blood pressure above 140 mm of Hg and / or diastolic blood pressure above 90 mm of hg is defined as arterial hypertension
Normal Below 130 mm of hg systolic
Below 85 mm of hg diastolic
High normal 130 — 139 mm of hg systolic
85 — 89 mm of hg diastolic
Elevation of systolic blood pressure without elevation of diastolic blood pressure is called systolic hypertension.
Physiological variation: Throughout the day.
At rest / during sleep.
How is BP kept normal?
BP is controlled mainly by the brain, autonomous nervous system, kidney, some of the endocrine gland and to certain extent by the heart and arteries.
Brain is the controlling center.
Autonomous nervous system brings signals from all parts of the body to inform the brain of the status of BP, the volume of blood and specialized need of all organs. Here, blood pressure is controlled either by narrowing of blood vessels or by opening of blood vessels.
Kidney – regulator of fluid in the body. Kidney regulates the blood pressure through the rennin- angiotensin- aldosteron system. In response to anything that lowers the BP and there by threatens the normal function of the kidney, release of hormone rennin take place. Rennin converts angiotensinogen to angiotensin -1, which further converted in to angiotensin- 2. Angiotensin -2 stimulates the production of aldosteron leads to salt and water retention. Angiotensin- 2 has a vasoconstrictive effect and thereby BP is elevated.
Endocrine gland – Mainly by the adrenal and thyroid gland. Cortisone, adrenaline and aldosteron have a hypertensive action. Thyroxin has important role in BP control. Estrogen – increase BP.
Heart — Heart secrete natriuretic hormone- a substance that can rid the body of excess salt and help keep the blood vessels properly dilated. Natruretic hormone inhibits the secretion of renal rennin and aldosteron and opposing the vasoconstrictor effect of angiotensin – 2.
Artery — Can dilate to increase the blood supply to an organ. (When we exercise, the blood is shifted to the exercising muscles.)
Based on the diastolic blood pressure, hypertension can be classified in to
1. Mild — 90 to 110 (diastolic blood pressure)
2. Moderate — 110 to 130
3. Severe — above 130 mm of hg.
Based on etiology hypertension can be classified into
1. Primary or essential hypertension and
2. Secondary hypertension.
When the blood pressure is elevated with out an evident organic cause. (When the causes are generally unknown)
Most prevalent form of hypertension.
Accounting for 90– 95 % of all cases of hypertension.
When some other disease process or abnormalities are involved in its causation then it is said to be secondary hypertension.
Eg: – Kidney diseases,
Tumors of adrenal gland,
Congenital narrowing of aorta,
Toxemias of pregnancy etc.
Classified in to four stages (based on the average of two or more readings taken at each of two or more visit after initial screening)
Stage Systolic blood Pressure Diastolic blood Pressure
Stage 1 140 — 159 90 –99
Stage 2 160 –179 100 –109
Stage 3 180 — 209 110 — 119
Stage 4 Above 210 Above 120
Causes of hypertension: (in decreasing order of occurrence)
1. Essential (95 % of patients) – unknown cause.
2. Diseases of kidney
3. Decreased blood supply to the kidney. (Reno vascular)
4. Primary aldosteronism.
5. Coarctation of aorta.
6. Cushing syndrome.
7. Oral contraceptives
[Causes of hypertension can be classified in the following way
1. Vascular causes: Coarctation of aorta
Poly arthritis nodosa
2. Renal causes: Renal artery stenosis
Tuberculosis of the kidney
3. Endocrine causes: Disease of the adrenal cortex
4. Adverse reaction to drugs: Oral contraceptives
5. Toxemia of pregnancy
Risk factors for hypertension:
Two types 1. Non modifiable risk factors and 2. Modifiable risk factors
Non-modifiable risk factors:
Age – Blood pressure rises with age in both sexes and the rise is greater in those with higher initial blood pressure.
Genetic factors — Genetic and familial predisposition. Family study have shown that the children of two normotensive parents have 3 % possibility of developing hypertension, where as the possibility is 45 % in children of two hypertensive parents.
Person with diabetes mellitus and impaired glucose tolerance has a higher prevalence of hypertension – up to 50 %.
Modifiable risk factors:
Obesity – The greater the weight gain, the greater the risk of blood pressure.
Salt intake — High salt intake increase blood pressure. Increased incidence in Japan is most probably due to the high intake of salt.
It has been postulated that essential hypertensives have a genetic abnormality of the kidney, which makes salt excretion difficult except at raised level of arterial pressure.
Potassium antagonizes the biological effect of sodium and there by decrease blood pressure. Potassium supplement lower the blood pressure.
Saturated fat — Increases blood pressure as well as serum cholesterol.
Alcohol — High alcohol intake is associated with an increased risk of developing blood pressure, especially systolic. Alcohol induced elevation may not be fixed. Blood pressure returns to normal with abstinence.
Physical activity – Help in reducing body weight and there by reducing blood pressure.
Environmental factors — Tense personality. Psychosocial factors operate through mental process consciously or unconsciously to produce hypertension.
Other factors – Oral contraceptives
Main pathological changes seen in heart and parts of the arterial tree.
Left ventricular hypertrophy in 20 – 50 % of mild to moderate hypertension. Because of these left ventricular hypertrophy, diastolic dysfunction and arrhythmias results. Diastolic dysfunction accelerates coronary atheroma and left ventricular failure. Cardiac failure due to degeneration and lysis of myofibrils.
Arterial wall shows thickening – more marked in kidney. Renal vessels show medial hypertrophy and intimal fibrosis. Heart vessels show coronary atherosclerosis and atheromatous changes. Small arteries of the brain show micro aneurysm (Charcot Bouchard aneurysm). This aneurysm may rupture and may leads to cerebral hemorrhage.
Thrombotic and embolic occlusion of arteries may result in infarction in heart, brain, kidney etc
Essential hypertension-- Usually asymptomatic. 50% of the patients are unaware of the condition. Many of them develop symptoms after knowing that they are hypertensive. Patient may felt fatigue, dizziness, palpitation, anxiety and head ache. Throbbing headache felt in sub occipital region waking after sleep suggestive of hypertension.
On physical examination, there may heaving apex beat; loud aortic second sound and increase tension pulse.
Secondary hypertension -- Evidence of primary disorder present.
Eg: – Weak or delayed femoral pulse,
Hypertension in the upper limb,
Hypotension in lower limb is seen in secondary hypertension due to coarctation of aorta.
If untreated for a long period of time can cause damage to the arteries of the body and to the organs they supply. Eg: – heart, brain and kidney. [Smoking, high cholesterol and diabetes mellitus can cause similar damage.]
Heart: forced to do extra work, it become hypertrophied and dilated when it has to pump against higher pressure.
Because the heart has the difficulty in pumping blood to the muscle, when they need extra oxygen for exercise or work, a person will feel short of breath. At first only during active exercise. Later difficulty even during rest—congestive cardiac failure.
Oxygen supply for the heart to do its work will become deficient when the coronary arteries are damaged. Then there will be a sensation of pressure, tightness and heaviness in the chest and arm. Usually this sensation last for five minutes and goes away with rest. This sort of pain is called angina. At first with exercise or strenuous work. Later with very little activity or with excitement or emotional upset.
When blood supply to the part of the heart is blocked permanent damage or myocardial infarction can occur. Here chest pain is longer when compared to angina. (15 minutes and often much longer) it may be associated with nausea and sweating.
Kidney: Nephrosclerosis may leads to renal failure.
Arteries of leg: cramps of leg and intermittent claudication. Later very severe pain even at rest – may leads even to gangrene.
Severely elevated blood pressure can cause the blood vessels either to dilate (Aneurysm) or to burst (hemorrhage and stroke).
Malignant hypertension and accelerated hypertension
Complication can be classified in the following way:
Cardio vascular- Left ventricular hypertrophy. Lead to cardiac failure.
Ischemic heart diseases lead to angina, myocardial infarction and sudden death.
Atherosclerosis of aorta leads to aneurysm and occlusion of coronary, cerebral,
Renal and peripheral arteries. Arrhythmias supraventricular or ventricular.
Central nervous system: stroke. And hypertensive encephalitis.
Kidney: renal failure.
Retina: Grade one and two retinal changes in the early phase of hypertension.
Grade three in accelerated phase.
Grade four – transition to the malignant phase.
[Grade one – arteriolar narrowing/ increase in light reflux
Grade two – marked arteriolar narrowing + arterio venous nicking
Grade three -- grade two + flame shaped hemorrhage and fluffy exudates.
Grade four -- grade three + papilledema]
Renal vein rennin test
24 hour urine
Proteins, cells and glucose
Aldosterone, excess protein and salt.
As evidence of
Kidney disorder and
Overactive adrenal gland
Increased risk of heart diseases
Diabetes mellitus Over active adrenal gland
High sodium intake.
Dietary changes: Reduce the salt intake (not more than 5 gm / day)
Moderate fat intake
Avoidance of high alcohol intake
Exercise: reduction in body weight reduces the blood lipid.
Behavioral changes: Decrease stress
Hypertension leads to reduction of life span and also considerable morbidity. Death due to cardiac failure. Mortality due to its complications. Hypertension is a major risk factor for stroke, coronary heart disease, and heart or kidney failure.
Therapeutic aim is to lower the blood pressure to normal and maintain it so both day and night. Its management depends on the type, severity, etiology and state of function of target organs.
General management: weight reduction. Restriction of salt intake. Provision of adequate sleep- 6to 8 hour per day. Avoidance of smoking. Yoga/ exercise (savasana). Meditation.
- Crataegus—produces giddiness, lowered pulse, and air hunger and reduction in blood pressure. Acts on muscles of heart and is a heart tonic. No influence on the endocardium. Is a sedative in cross, irritable patient with cardiac symptoms. Arteriosclerosis. Said to have a solvent power up on crustaceous and calcareous deposits in arteries. Heart muscle seems flabby, worn out. Heart dilated. First sound weak.
- Lachesis – head ache on awaking. Vertigo on closing eyes. Palpitation with fainting spells, especially during climacteric. Constricted feeling causing palpitation, with anxiety. Irregular heart beats.
- Nat mur — prolonged taking of excessive salt causes profound changes to take places in the system. Head ache as if a thousand little hammers were knocking on the brain, in the morning on awakening. Tachycardia. Heart and chest feels constricted. Fluttering. Hearts pulsation shakes the whole body.
- Veratrum alb – Palpitation with anxiety and rapid audible respiration. Pulse irregular, feeble. Intermittent action of heart in feeble person with some hepatic problems. One of the best heart stimulants in Homoeopathic doses.
- Adrenalin — the main action of adrenalin is stimulation of the sympathetic system, ausing constriction of the peripheral arterioles, with resulting rise in blood pressure.
- Allium sativum – has vaso dilatory properties. Arterial hypotension begins usually in 30 to45 minutes after twenty-drop doses of the tincture.
- Aur met — High blood pressure- valvular lesion of arteriosclerotic nature. Sensation as if the heart stopped beating for two or three seconds, immediately followed by a tumultuous rebound with sinking at epigastrium. Palpitation. Hypertrophy. Pulse rapid, feeble irregular.
- Baryta carb-- Palpitation and distress in the region of heart. Accelerates the heart’s action first, blood pressure much increased, contraction of blood vessels. Palpitation when lying on left side, when thinking of it especially; pulse full and hard.
- Calc carb – Palpitation at night after eating. Palpitation with feeling of coldness, with restless obstruction of chest.
- Glonoine — Surging of blood in to heart and brain. Congestive head ache. Sensation of pulsation throughout the body. Vertigo on assuming upright position. Head feels enormously large, as if skull were too small for brain. Laborious action of the heart. Fluttering. Palpitation with dyspnoea. Cannot go uphill. Any exertion brings on rush of blood to heart and fainting spells. Throbbing in the whole body to finger tips
- Graphitis — suited persons of stout, of fair complexion with tendency to skin affections and constipation, fat chilly and costive with delayed menstrual history. Rush of blood to head with flushed face also with nosebleed. Head ache in morning on waking, mostly on one side with tendency to vomit.
- Nux vom – Hypertension incident to modern life. Suited to thin, spare, quick, active, nervous and irritable. Has mental strain and lead sedentary life, found in prolonged office work, overstudies, and close applications to business, with its cares and anxieties. This indoor life and mental strain seeks stimulants, coffee, and wine in excess. Head ache in occiput or over eyes, with vertigo.
- Plumbum met– Hypertension and arteriosclerosis. Cardiac weakness. Pulse soft and small, dichrotic. Wiry pulse, cramp like constriction of peripheral arteries.
- Rauwolfia – high blood pressure with out marked atheromatous changes in the vessels
- Secale cor — Pressive and congestive pain rise from back of head with pale face. Palpitation with contracted and intermittent pulse. Insomnia with restlessness.
- Strontium carb – high blood pressure with flushed face and pulsating arteries; threatened apoplexy. Vertigo with headache and nausea. Ache from nape of neck, spreading upwards.
- Sulphur – when carefully selected fails to act, especially in acute cases, it frequently arouses the reactive powers of the organism. Complaints that relapse. Often-great use in beginning of chronic cases and in finishing acute cases. Heaviness, fullness and pressure in temples. Beating headache; worse stooping and with vertigo. Sick headache recurring periodically. Flushes of heat in chest rising to head. Oppression as of a load on chest. Pulse more rapid in morning than in evening.
- Aconite – Tension of arteries. Its sphere is in the beginning of an acute disease and not to be continued after pathological change comes. Head – fullness, heavy, pulsating, hot, bursting, burning, undulating sensation. Burning headache as if boiling water moved brain. Vertigo on rising. Pulse full hard, tense and bounding. Temporal and carotid arteries felt when sitting.
- Adonis — heart medicine, after rheumatism or influenza where the muscles of heart are in stage of fatty degeneration, regulating the pulse and increasing the power of contractions of heart with increased urinary secretions. Irregular cardiac action, contraction and vertigo. Pulse rapid and irregular. Head feel light, aches across front, from occiput around temples to eyes. Vertigo on rising, turning head quickly or lying down. Tinnitus.
- Amyl nitrosum — On inhaling this drug, it rapidly dilates all arterioles and capillaries, producing flushing of face, heat and throbbing in the head. Palpitation. Surging of the blood to head and face. It is useful in all conditions where the blood vessels are spasmodically contracted.
- Argentu nitricum — Hypertension, especially when associated with unusual or long continued mental exertion. Vertigo, with buzzing in ears and with nervous affections. Aching pain frontal eminence, with enlarged feeling in corresponding eye. Better by tight bandaging and pressure. Palpitation, irregular and intermittent.
- Ars alb -– Great exhaustion after the slightest exertion. Head relieved by cold. Burning pain with restlessness. Palpitation. Pulse more rapid in morning. Hypertension due to renal affections.
- Ars iod -– Vertigo with tremulous feeling, especially in aged. Hypertension of old people.
- Aur mur — High blood pressure due to disturbed function of nervous mechanism. Arteriosclerosis.
- Baryta mur — Arteriosclerosis; where a high systolic pressure with a comparatively low diastolic tension is attended by cerebral and cardiac symptoms.
- Causticum -– hypertension from long lasting grief or sudden emotions. Sensation of empty space between forehead and brain.
- Conium mac — Vertigo when lying down, and when turning over in bed, when turning head sidewise or turning eyes. Worse shaking head, slight noise or conversations of others, especially towards the left. Headache with nausea and vomiting. Dull occipital pain on rising in morning.
- Cuprum — giddiness accompanies many ailments. Pulse hard, full an quick. Palpitation, praecordial pain.
- Digitalis — Comes into play in all diseases where the heart is primarily involved, where the pulse is weak, irregular, intermittent, abnormally slow and dropsy of external and internal parts. Its greatest indications in failure of compensation and especially when auricular fibrillation has set in. vertigo when walking and on rising, in cardiac affections. Heaviness of head with sensation as if it would fall backwards. Pulse weak and quickenened by least movement. Hypertrophy with dilatation
- Ignatia — Effects of grief and worry. Headache as if a nail were driven out through the side. It is especially adapted to the nervous temperament—woman of sensitive, easily excited nature, dark, mild disposition, quick to perceive and rapid in execution.
- Iodum — Iodum individual is exceedingly thin, dark complexioned, with enlarged lymphatic glands, has voracious appetite but gets thin.
- Kali carb – Hypertension of fleshy aged person with dropsical and paretic tendencies. Vertigo on turning head. Occipital or one-sided headache with nausea, on riding in carriage. Palpitation with burning in heart region.
- Lycopodium – Renal hypertension. Best adapted to person intellectually keen, but of weak, muscular power. Thin withered, full of gas and dry. Pressing headache on vertex worse from 4 to 8 pm. Vertigo in morning on rising. Palpitation at night.
- Naja – Pain in left temple and in left orbital region, extending to occiput, with nausea and vomiting. Dragging and anxiety in praecordia. Feeling of weight on heart. With the heart symptoms pain in forehead and temples. Pulse irregular in force. Palpitation.
- Phosphoric acid – suited to hypertension of young people who grow rapidly, and who are overtaxed, mentally or physically. Vertigo towards evening, when standing or walking. Effects of grief and mental shock.
- Phosphorus — Ill effects of excessive use of salt. Tall slender persons, with narrow chest, thin transparent skin, weakened by loss of animal fluids, with great nervous debility, emaciation and amative tendencies. Vertigo of the aged after rising. Vertigo with faintness. Violent palpitation with anxiety when lying on left side. Heart dilated especially right.
- Pulsatilla — vertigo better in open air. Head ache from overwork.
- Radium bromide — lowered blood pressure. Vertigo with pain in back of head, left when in bed. Occipital and vertex pain. Head feels heavy. Frontal headache. Hypertension secondary to renal affections.
- Rhus tox — vertigo when rising. Heaviness of head. Headache in occipit, painful to touch. Trembling and palpitation when sitting.
- Sanguinaria — Periodical sick headache. Pain begins in occiput, spreads upwards, and settles over eyes, especially right.
- Sepia – Pulsating headache in cerebellum. Vertigo with sensation of something rolling round in head. Prodromal symptoms of apoplexy. Beating in all arteries. Tremulous feeling with flushes.
- Silicea — Vertigo from looking up. Better wrapping up warmly, when lying on left side. Pain begins at occiput, and spreads overhead and settles over eyes.
- Strophanthus — Acts on the heart and increasing the systole and diminishes the rapidity. May be used with advantage to tone the heart. And run off dropsical accumulation. In small doses for weak heart; it feels enlarged. Arteriosclerosis; rigid arteries of aged.
- Thuja – Left sided head ache. Prominent action over the kidney and thus effective in renal hypertension.
- Tabacum -- The nausea, giddiness, death-like pallor, vomiting, icy coldness, and sweat with the intermittent pulse are almost characteristic. Should prove the most Homoeopathic drug for angina pectoris, with coronaritis and high tension. Vertigo on opening eyes. Sick head ache with deathly nausea. Tight feeling as from a band. Sudden pain as if struck by a hammer. Palpitation when lying on left side.
- Vanadium – Arteriosclerosis; sensation as if heart was compressed, as if blood had no room in the aorta. Anxious pressure on whole chest.
- Veratrum vird – Induces fall of both systolic and diastolic blood pressure. Especially adapted to full blooded, plethoric persons. Great prostrations. Head – congestion intense, almost apoplectic. Hot head, bloodshot eyes. Beating pulse throughout body.
- Viscum album – lowered blood pressure. Dilated blood vessels but doesn’t act on the centers in the medulla. Hypertrophy of heart with valvular insufficiency. Pulse small and weak; unable to rest in a reclining position. Palpitation during coition. Weight and oppression of heart; as if a hand were squeezing it. Tickling sensation about the heart.
Textbook of medicine – K. V. Krishna Das,
Harrison’s principles of medicines
Davidson’s principles and practice of medicines
Park’s textbook of preventive and social medicines
Pocket manual of material medica – William Boericke