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Hypertension An Overview of the Clinical Pathophysiology of Hypertension, its Interpretation According to Tibb Philosophy and its Relationship with Temperament- Investigating whether a trend exists between blood pressure readings and patient temperament and its responsive to the respective Tibb medications.
ABSTRACT • According to Tibb philosophy, hypertension results from either hot and moist or as cold and dry excess. Therefore, those with a dominant or subdominant Sanguinous or Melancholic temperament respectively are more susceptible to the development of hypertension. Sanguinous hypertension conventionally correlates with primary or essential hypertension and would present with both high systolic and diastolic blood pressure readings, whereas the melancholic hypertension which is clinically seen as secondary hypertension presents with a high systolic and a normal or slightly elevated diastolic. The aim of this research was to evaluate and interpret the clinical pathophysiology according to Tibb philosophy and to assess whether a relationship between blood pressure readings and temperament exist. Our results found that most patients who suffered with hypertension for which there was no known clinical cause had a Sanguinous Dominant or subdominant temperament, the interpreted hypothesized pathophysiology concurs with Tibb philosophy, however the blood pressure readings recorded presented with no particular trend and were across the board according to the clinical classification stages of blood pressure readings. Only a small sample of melancholic patients were assessed, where 50% presented with isolated systolic hypertension which results from excess dryness, and the other half had not known the cause of their hypertension. The interpreted pathophysiology did not support that secondary hypertension results from excess melancholic humour as there are many secondary causes with multi-factoral pathologies. The onset of raised blood pressure in secondary hypertension results either from increase cardiac output (hot and moist) or increase systemic vascular resistance (cold and dry) or both.
Definition and classification of hypertension • Hypertension is defined as an abnormal elevation in diastolic pressure and/or systolic pressure.
Hemodynamic Basis of Hypertension • Increase in arterial blood pressure is caused by either • an increase in systemic vascular resistance (SVR) • determined by the vascular tone (i.e., state of constriction) of systemic resistance vessels • an increase in cardiac output (CO) • determined by heart rate and stroke volume
Categories of Hypertension • Primary Hypertension-idiopathic • Secondary Hypertension-identifiable cause • According to Tibb • Sanguinous Hypertension = primary hypertension • Melancholic hypertension = secondary hypertension
Primary Hypertension • Pathogenesis • Early elevations of blood volume and cardiac output initiates changes in systemic vasculature (increased resistance). • Inability of the kidneys to regulate sodium • ↑Na retention = ↑ blood volume • Chronic long-standing hypertension • Blood volume and cardiac output are normal • ↑↑systemic vascular resistance ∵thickening of the walls and reduction in lumen diameter. • ↑vascular tone ∵ enhanced sympathetic activity or ↑angiotensin II • ↓nitric oxide is produced and vascular smooth muscle is less senstive to the action of this vasodilator. • ↑endothelin production- enhance vasoconstrictor tone
Interpretation According to Tibb Philosophy • Sanguinous Hypertension • Later oxidation leads to ↑ dryness • C & D Hypertension
Chronic Renal Disease • ∵ diabetic nephropathy; glomerulonephritis etc. • Damage caused to the nephrons • Impaired excretion of sodium →sodium retention and ↑blood volume → ↑ cardiac output by Frank Starling mechanism • May also result in ↑ release of renin
Stress • Activation of sympathetic nervous system → ↑norepinephrine in heart and blood vessels → ↑ cardiac output and ↑ systemic vascular resistance • Adrenal medulla secretes catecholamines (epinephrine and norepinephrine) • ↑ angiotensin II, aldosterone and vasopressin • Cardiac and vascular hypertrophy = sustained ↑ blood pressure
Sleep Apnea • Higher incidence of hypertension • The mechanism of hypertension may be related to sympathetic activation and hormonal changes associated with repeated periods of apnea-induced hypoxia and hypercapnea, and from stress associated with the loss of sleep.
Hyper- or hypothyroidism • Excessive thyroid hormone induces systemic vasoconstriction, an ↑ blood volume, and ↑ cardiac activity, all of which can lead to hypertension. • Hypothyroidism unclear • may be related to ↓ tissue metabolism reducing the release of vasodilator metabolites, thereby producing vasoconstriction and increased systemic vascular resistance.
Pheochromocytoma • ↑↑ catecholamines (both epinephrine and norepinephrine) • This leads to alpha-adrenoceptor mediated systemic vasoconstriction and beta-adrenoceptor mediated cardiac stimulation → ↑↑ arterial pressure.
Pre-eclampsia • 3rd trimester of pregnancy • ↑ blood volume and tachycardia • The former increases cardiac output by the Frank-Starling mechanism
Aortic coarctation • Elevated pressures proximal to the coarctation (i.e., elevated arterial pressures in the head and arms) • Distal pressures are not necessarily reduced • Reduced systemic blood flow and reduced renal blood flow → ↑ renin and an activation of the renin-angiotensin-aldosterone system → ↑ blood volume and arterial pressure • Baroreceptor reflex in blunted due to structural changes in the walls of vessels where the baroreceptors are located • Baroreceptors become desensitized to chronic elevation in pressure and become "reset" to the higher pressure
Isolated Systolic Hypertension • Defined as SBP ≥ 140mmHG and DBP ≤ 90mmHG • 60% of hypertensives > 80 years old • From age 35/40 many people have elevated systolic or diastolic pressure and this elevation leads to the widening and stiffening of the aorta • ↓ elasticity and ↓ compliance of the large blood vessels → ↑ SBP and ↓ DBP
Interpretation according to Tibb Philosophy • Renal Artery Stenosis- ↑cardiac output and ↑vascular resistance • Multifactoral • Pt and temperament specific • Chronic renal disease- impaired salt homeostasis • Sanguinous • Primary aldosteronism - ↑blood volume • Sanguinous
Continued… • Stress - ↑ cardiac output and ↑ systemic vascular resistance • Pt and temperament specific • Sleep apnea – more prevalent in obese pt • Phlegmatic or sanguinous • Hyperthyroidism • Bilious • Hypothyroidism • Phlegmatic
Continued… • Pheochromocytoma- ↑ systemic vascular constriction and ↑ cardiac output • Pt and temperament specific • Pre-eclampsia- ↑blood volume and tachycardia → ↑ cardiac output • Aortic coarctation • Associated with moistness • Congenital condition in children • Isolated systolic hypertension- increased resistance of large arteries • Elderly pt • melancholic
SB case studies • 21 total pt • 17 pt sanguinous dominant or subdominant • 81% • 4 pt melancholic dominant or subdominant • 19% • Sanguinous/dominant subdominant pt • 15 ↑↑SBP and ↑↑DBP • 88% • 22 -68 years old • 1 Normal BP- using synthetic medications • 1 normal SBP and ↑↑ DBP • Melancholic dominant/subdominant pt • 2 ↑↑ SBP and normal DBP • 50% • Age > 70years • 2 ↑↑ SBP and ↑↑ DBP • 30 and 65 years old
Dr. Andreas Kefaldelis Research Project • 46 total pts • 100% dominant/subdominant sanguinous temperament • 36 pts ↑↑ SBP and ↑↑ DBP • 78% • 24-75 years old • 6 pts ↑↑ DBP • 13% • 21-37 years old • 3 pts ↑↑ SBP • 7% • 35-49 years old • 1 pt had wide pulse pressure • 1 pt prehypertension
Stages of blood pressure readings on mixed BP measurements • Stage 1/Stage 2 • 12 patients • 2 hypotensive medication • 7 no medication • 3 non compliant • Stage 2/Stage 1 • 6 patients • 3 hypotensive medication • 2 no medication • 1 non compliant • Prehypertension/stage 1 or 2 • 8 patients • 7 no medication • 1 non compliant • Stage 1 or 2/prehypertension • 3 patients • 2 no medication • 1 non compliant
90-95% pts suffer with primary hypertension • 91% of total pts in this study • Sanguinous dominant/subdominant temperament • Concludes primary hypertension = sanguinous hypertension • No relationship exists between the blood pressure reading and the quality of hypertension • Synthetic medication did not affect the overall results as most patients were not using any hypotensive agents
Elderly melancholic pts are more susceptible to developing isolated systolic hypertension • Research suggests that obese pt have higher cardiac outputs BUT lower total peripheral vascular resistance compared to lean patients • More research on melancholic patients with hypertension is needed
Response to Tibb medication • Most patients responded positively when given a combination of pressure eeze and pressure eeze forte • Pathogenesis generally complex and multi-factoral • Combination therapy combats both ↑ cardiac output (pressure eeze forte) and ↑ systemic vascular resistance (pressure eeze) • 1 elderly isolated SBP pt had no response to Rx • 1 elderly isolated SBP pt responded well to pressure eeze alone • 1 sanguinous pt had ↓DBP but an ↑ SBP • 2 sanguinous pt had no response when given pressure eeze in isolation but responded positively with combination Rx • 1 sanguinous pt had no response to both pressure eeze and pressure eeze forte • 1 sanguinous pt had ↓SBP but no response in diastolic blood pressure
Considerations • Compliancy to lifestyle factors were not considered in this study • White coat hypertension- anxiety in dr’s office may ↑ BP by 26mmHg • Small sample- findings not absolute • Effects of other chronic disease on hypertension • Dyslipidaemia • Hyperinsulinaemia and hyperglycaemia (type II diabetes) • endothelial dysfunction • Free radical damage • ↓nitric oxide bioavailability
References • 1. cardiovascular physiology, www.cvphysiology.com • 2. isolated systolic hypertension: an update, www.medscape.com/viewarticle/407695 • 3. low diastolic ambulatory blood pressure is associated with greater all cause mortality in older patients with hypertension, www.medscape.com/viewarticle/587808 • 4. hypercholesterolaemia and its potential role in the presentation and exacerbation of hypertension, www.medscape.com/viewarticle/490536 • 5. white coat effect and white coat hypertension: what do they mean?, www.medscape.com/viewarticle/462098 • 6. the relationship between body weight and the prevalence of isolated systolic hypertension in older subjects, www.medscape.com/viewarticle/407698 • To assess the relationship between the qualities associated with chronic disorders and the temperament of the person affected. By Dr Andreas Kefaladelis
