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MANAGEMENT OF ESSENTIAL HYPERTENSION IN AYURVEDIC PERSPECTIVES By Dr.G.H.ANANTHASAYANA, DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA, GOVERNMENT AYURVEDA MEDICAL COLLEGE, MYSORE

MANAGEMENT OF ESSENTIAL HYPERTENSION IN AYURVEDIC PERSPECTIVES By Dr.G.H.ANANTHASAYANA, DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA, GOVERNMENT AYURVEDA MEDICAL COLLEGE, MYSORE

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  • 1. MANAGEMENT OF ESSENTIAL HYPERTENSION IN AYURVEDIC PERSPECTIVES By Dr.G.H.ANANTHASAYANA B.A.M.S., Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. In Partial Fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (AYURVEDA) IN KAYACHIKITSA Under the Guidance of Dr.ARUNA. D.Ay.M (Ayu),DNY., HOD Department of Post-Graduate Studies in Kayachikitsa, G.A.M.C., Mysore. Co-Guide Dr.K.S. SHANTARAM MD., (Ayu)DNY Asst. Professor Department of Post-Graduate Studies in Kayachikitsa, G.A.M.C., Mysore.DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA GOVERNMENT AYURVEDA MEDICAL COLLEGE, MYSORE. 2010
  • 2. Dedicated to my late fatherShri G.Hanaumnthappa M.A.,B.Ed., His words of Inspiration and encouragementIn pursuit of excellence, still linger on.
  • 3. I convey my heartfelt thanks to all my classmates Dr Samina M Sindagikar,Dr Ranjani k Rajan, Dr Pallvi.C.P Dr Perveen Sultan, Dr Kiran kumar agadi, DrVyasaraja tantri ,Dr Ramesh Kumar,Dr Bhusena Kalyani Ashok ,Dr Ranjit Kumar ,DrKavitha for their co-operation, suggestion and constant encouragement. I am happy to acknowledge my gratitudes to all my department seniorsDr Moosebyari , Dr L N Shenai , Dr Naveen , Dr Abdul Patel ,Dr pushpa , Dr Savitha, Dr Beena ,Dr Akarshini ,Dr Triveni, Dr Chitra ,Dr Siddaram Guled ,Dr ShivanandPyati ,Dr shivanand Hiremat for their undefinite support during my work. I am happy to acknowledge my gratitudes to all my department juniors DrShridhar Murthy , Dr Mahesh Sharma , Dr Aditya bhat , Dr Soumya Bhat , Dr ShubhaRani , Dr Geeta Kumari ,Dr Aravinda BS,Dr Atika Jan,Dr Pallvi,Dr Rekha ,DrPreeta,R, Dr Hari Krishna , Dr Pradeep, Dr soumya Shree, Dr Anagha , Dr HarshiyaAli. Dr Sonia I am happy to express my gratitude to Dr Radha Krishna RamRao and DrGeeta for their support. I thank Himalaya Drug Company for their kind support by sponsoringCap.Tagara for the study. At this juncture I pay my obeisance to my esteemed Father late GHanumanthappa and Mother Anjanamma for taking pain and their sacrifice to bringup me to this position. I also cannot forget the love & affection of my Yelder brotherGH Jayadeva and Yelder Sisters, GH Sulochana, GH Maitreyi, GH Geervani, whoconstantly encouraged me. The most special thanks belong to my wife MS Veena for her understanding,selfless love and support all along and encouragement and company during the thiswork, and to my little daughter Dhriti for inspiring me to complete this work. Lastly, I thank sincerely all those who helped me directly or indirectly in thesuccessful completion of this studyDate :Place : Mysore Dr. G.H.ANANTHASAYANA
  • 4. LIST OF ABBREVIATIONSA.H - Astanga HridayaA.S - Astanga SangrahaA.T - After TreatmentB.T - Before TreatmentC.D - Chakra DattaC.S - Charaka SamhitaCh - Chikitsa sthanaDBP - Diastolic Blood PresureDT - During treatmentE-HTN - Essential HypertensionHTN - HypertensionJNC - Joint National CommitteeKal - Kalpa sthanaMa - Madhyama khandaMABP - Mean Arterial Blood PressureNi - Nidana sthanaPu - PurvakhandaS.B.P. - Systoli Blood PressureS.E.D - Sanskrit English Dictionary – M.M.WilliamsS.K.D - Shabda Kalpa DrumaS.S - Sushruta SamhitaS.S.M. - Shabda sthoma MahanidhiS.Y - Sahastra YogaSh - Shareera sthanaSu - Sutra sthanaU - Uttara tantraU - UttaratantraUt - UttarardhaVch - VachaspatyamVi - VimanasthanaY.R - Yoga Ratnakara
  • 5. ACKNOWLEDGEMENT This dissertation would not have been possible without the guidance and thehelp of several individuals who in one way or another contributed and extended theirvaluable assistance in the preparation and completion of this study. I am heartily thankful to my respected Guide Dr.ARUNA, HOD, Departmentof Post Graduate Studies in Kayachikitsa, Government Ayurveda MedicalCollege,Mysore whose encouragement, supervision and support from the preliminaryto the concluding level enabled me to develop an understanding of the subject andhelping me in completing this work successfully. I express my profound gratitude to Dr.S.G.MANGALAGI our Former HOD,Department of Post Graduate Studies in Kayachikitsa, Government Ayurveda MedicalCollege, Mysore for his constant encouragement throughout my course of study. I am overwhelming thankful to my co-guide Dr.SHANTARAM Asst.professor, Government Ayurveda Medical College, Mysore for his guidance, co-operation and untiring effort to complete this work. I am thankful to Dr.Ashok d satputte, Principal, Government AyurvedaMedical College, Mysore for his support and encouragement. I acknowledge the valuable support and suggestions given by my teachers, DrGajanana hegde, Dr.Umashankar, Dr. H.M. Chandramouli, Dr.Gopinath, and DrMaithreyi ,Dr Rajendra, Dr. Uma Soudi, and all other teachers for their support inthis study. My heartfelt gratitude to the Physicians Dr Ramachandra Naik ,DrShivananda,Dr P B Hiregoudra, Dr vishwanath Reddy,Dr V M Prabhakar,DrR.S.Patil,for their help and cooperation. My heartfelt gratitude to the staff of Government Ayurvedic MedicalCollege and Hospital, Mysore for their help and cooperation. I am thankful to all my patients who followed my directions sincerely andbecame the core subjects of my study. I also thank Dr. Lancy D’ Souza for his invaluable help and guidance in thestatistical analysis and interpretations
  • 6. ABSTRACTBackground and objectives Essential Hypertension is one of the common conditions encountered inthe clinical practice. It is one of the major risk factor for thedevelopment ofcardiovascular morbidity and mortality. It is vatapradhana tridoshaja vyadhi and we can concider HTN asabnormality of rakta dhatu popularly known as shonita dushti. The objective of this study is to evaluate the combined effect ofsnehapoorvaka Virechana Karma along with Shamanaushadha in themanagement of Essential HTN.Method: 30 patienst of essential HTN were selected incidentally and assigned intosingle group, received panchakola churna for amapachana, shodhananga snehapanawith moorchita tila taila in arohana vidhi and virechana with trivruit lehya aftersarvadhhihika abhyanga and ushnajala snana. Followed by moorchita tila taila 30 ml /day and cap tagara 1 bd ,asshamanaushadha after samsarjana karma. Total duration of treatment was 48 daysResults In the management of HTN, blood pressure goal is to achieve <140/90.In patients with hypertension and diabetes or renal disease, the BP goal is<130/80 mm Hg. In this study Mean systolic and diastolic BP before treatment is159.46/90.60 mmhg, and Mean systolic and diastolic BP after treatment is130.60/80.73 mmhg.
  • 7. Interpretation and Conclusion: The disease Essential Hypertension cannot be correlated to a single disease entityexplained in Ayurveda. Sneha poorvaka virechana followed by shamanaushadha i.e. moorchita tila tailaalong with Tagara showed highly significant result. Reduction of symptoms and patients well being is also noticed during treatment.Key words • Essential Hypertension • Moorchita tila taila • Cap tagara • Sneha poorvaka virechana Chikitsa
  • 8. CONTENTSIntroduction 01Objectives 03Review of Literature Definition 04 Prevalence 06 Shareera Vivechana 07 Nidana 15 Samprapti 20 Bheda 26 Poorva Roopa 29 Roopa 30 Upashaya Anupashaya 32 Sapeksha Nidana 33 Upadrava 34 Sadyasadhyata 36 Chikitsa 38 Pathyapathya 47 Drug Review 48 Previous works 52Methodology 53Observation and Results 59Discussion 78Conclusion 87Summary 88References 96Bibliography 98Annexure 100
  • 9. LIST OF TABLESTable # Name of Table Page # 01 Some of the etiological factors of shonita dushti which 20 are similar to that of HTN 02 Some of the symptoms of shonita doshti here which are 20 similar to that of HTN 03 Dosha Dushyadi Vivechana in Raktachapadhikyata 23 04 Classification of Blood Pressure on the basis of Severity 26 05 Differentiating Essential and Secondary Hypertension 33 06 Laboratory tests 37 07 Lifestyle Modifications to prevent and manage 39 Hypertension 08 Showing the Patyaapathya 47 09 Properties of ingredients of panchakola choorna 49 10 Properties of ingredients of Morchita tila taila 50 11 Showing the incidence of Age 59 12 Showing the incidence of SEX 60 13 Showing the incidence of Occupation 60 14 Showing the incidence of Marital status 61 15 Showing the incidence of religion 61 16 Showing the incidence of Socio- Economic Status 62 17 Showing the incidence of Fresh / Treated cases 62 18 : Showing the incidence of Locality 63 19 Showing the incidence of Symptomatic / Asymptomatic 63 20 Showing the incidence of Nature of work 64 21 Showing the incidence of prakriti 64 22 Showing the incidence of Kostha 65 23 Showing the incidence of Diet 65 24 Showing the incidence of Habit 66
  • 10. 25 Showing the incidence of Family History 6726 Showing the incidence of Salt 6727 Showing the incidence of Stress 6728 Descriptive statistics of SBP 6829 Paired Samples Statistics of SBP 6930 Paired Samples Test of SBP 6931 Paired Samples Statistics SBP ( SNE TO AT) 7032 Paired Samples Test ( SNE TO AT) 7033 Descriptive Statistics of DBP 7034 Paired Samples Statistics of DBP 7135 Paired Samples Test of DBP 7136 T-Test: Paired Samples Statistics ( SNE TO AT) 7237 Paired Samples Test ( SNE TO AT) 7238 Showing Overall Assessment 7539 HT_CATBT * Treatment Cross tabulation 7540 T-Test: Paired Samples Statistics(Wt) 7641 Paired Samples Test(Wt) 76 Master Chart 91,92,93,94
  • 11. LIST OF ILLUSTRATIONSIllustration # Illustration Page # 01 Arterial pressure 4 02 Role of Renin Angiotensin System 13 03 Showing the incidence of Age 59 04 showing the incidence of SEX 60 05 Showing the incidence of Occupation 60 06 Showing the incidence of Marital status 61 07 Showing the incidence of religion 61 08 Showing the incidence of Socio- Economic Status 62 09 Showing the incidence of Fresh / Treated cases 62 10 Showing the incidence of Locality 63 11 Showing the incidence of Symptomatic / 63 Asymptomatic 12 Showing the incidence of Nature of work 64 13 Showing the incidence of prakriti 64 14 Showing the incidence of Kostha 65 15 Showing the incidence of Diet 65 16 Showing the incidence of Habit 66 17 General Linear Model for systolic Blood pressure 73 18 General Linear Model for Diastolic Blood pressure 74 19 General Linear Model for both systolic and Diastolic B P 74 20 Showing Overall Assessment 75 21 Showing mean wt before and after treatment 76
  • 12. LIST OF FIGURESFigure # Figure Page # 01 Anatomy of Heart and Blood vessels 11 02 Drugs used in the Study 86
  • 13. Dr.G.H.Ananthasayana 2010 INTRODUCTION Modern life offers many convenience and comforts not dreamed by ourgrandparents. But we have paid a price for all this in the form of increasedhazards and risks. Beginning of 21st century brings gift of anxiety and morestress for modern society. This stress and strain of day today life affects onesbodily organs through several psychological mechanism. Among the psychosomatic diseases, the cardiovascular disorder likehypertension is quite, significant disease. More ever the complications of thisdisease are more grievous than disease itself. Key messages1 of 7th report of the JNC on prevention, detection,evaluation and treatment of HTN are, In those older than 50 years SBP of >140 mm of hg is a more important cardiovascular risk factor than the diastolic blood pressure. Beginning at 115/75 mm hg CVD risk doubles for each increase of 20/10 mm of Hg. Pre HTN individuals require health promoting life style modifications to prevent progressive rise in blood pressure.Three types of treatment mentioned in Charaka samhita are – Sanshodhana ( purify) Sanshamana( pacify) Nidana parivarjana( remove the cause )BAHUDOSHANAM …TAT DOSHAVSECHANAMA2. Panchakarma therapies are applied as Sanshodhana chikitsa. Among thePanchakarma treatment Virechana is very important and effective therapy forPittaja and also for Tridosaja vyadhi. Regarding the treatment of the diseaseEssential hypertension, pliable nature of ailment indicated as shodhana sadhyavyadhi.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 1
  • 14. Dr.G.H.Ananthasayana 2010VIREKAM-------SHONITASYA3 In present study Sneha poorvakaVirechana karma has been selected asshodhana measure, to trump over offending tridosas, as Virechana has also beenequally effective in Rakta vitiation. Title of dissertation is Management of Essential HTN in ayurvedicperspectives. This dissertation is divided in to two parts. First part deals with review of literature; this includes definition,prevalence, classification, measurement of blood pressure, shareera vivechanaregulation of blood pressure, nidana panchaka, sapeksha nidana, upadrava, andsadhyasadhyata. The second part of the dissertation is dedicated to clinical trial; thisincludes material and methods, observation and results, statistical analysis of theresults, discussion and conclusion.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 2
  • 15. Dr.G.H.Ananthasayana 2010 OBJECTIVES HTN is one of the major risk factor for the development ofcardiovascular disease. But it is modifiable risk factor. Effective management of this reduces themortality caused due to its complications significantly. Hence study is undertaken with following objective, To evaluate the combined effect of snehapoorvaka Virechana Karmaalong with Shamanaushadha in the management of Essential HTN.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 3
  • 16. Dr.G.H.Ananthasayana 2010 DEFINITION Medical science defines HTN as chronic i.e. slowly progressivepersistent increase in arterial blood pressure , which can be caused by varietyof factor, but regardless of the cause fallows a typical Pattern . As bloodcirculates it exerts pressure on the walls of the arteries. This is the arterialpressure. Guyton explained this arterial blood pressure in just one equation i.e. Arterial pressure =cardiac out * total peripheral vascular resistant. Illustration 1: Arterial pressure Arterial pressure 4 Cardiac output Total peripheral vascular resistantStroke volume Heart rate vascular structure vascular function Cardiac output and peripheral resistance are the two determinants ofarterial pressure. Cardiac output is determined by stroke volume and heart rate; strokevolume is related to myocardial contractility and to the size of the vascularcompartment. Peripheral resistance is determined by functional and anatomic changesin small arteries and arterioles.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 4
  • 17. Dr.G.H.Ananthasayana 2010 A persistent increase in this arterial pressure even when a person isin rest is HBP or HTN. If we scan various recent ayurvedic books, we find various differentwords that are used for HTN. Like, Raktagata Vata Pittavruta vata Pranavruta udana Raktavega vruddi Raktachapadhikyata Uccharaktachapa Rasa bhara Dhamani prapurana Rudhir Mada Vyana balaStill a proper term is not found and it is better to use the same word HTN.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 5
  • 18. Dr.G.H.Ananthasayana 2010 PREVALENCE WHO has estimated that HBP causes 1 in every 8 deaths, making HTNthe third leading killer in the world. Globally there are one billion hypertensiveand one million people die as a direct impact of HTN. According to recent survey in the USA about 1 in 3 adults have HBP.HTN is directly responsible for 57% of all stroke deaths and 24% of all CHDdeaths. World hypertensive league recognized that more than 50% ofhypertensive populations are unaware of this condition. Epidemiological studies demonstrate that prevalence of HTN increasingrapidly among the urban Indian population. Prevalence is lower in ruralpopulation but is increasing. Increasing HTN in India is related to adiposity levels.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 6
  • 19. Dr.G.H.Ananthasayana 2010 SHAREERA VIVECHANA Before discussing the disease, it is essential to know the physiology ofthe concerned organ and organ system. Rakta is Drava Dhatu 5. Therefore it has natural property of flowing. Tomaintain the circulation up to end tissue, additional force is required which isprovided by the contraction and relaxation of the heart. In Ayurveda threedoshas Vata, Pitta and Kapha, seven Dhatus and three Malas are considered asthe root cause of all the functions of body. Hridaya: According to Sushruta formation of heart of a foetus occurs bythe essence of Kapha and Asruk 6. There fore both Kapha & Asruk should be inits normal state to maintain the normal function of heart. Muscles of heart nourished by the essence of Rakta. Kapha resemblesproperties like Oja, retain the Bala of heart, which is utilized for the Rasa RaktaSamhanana. Hridaya is considered as chetana sthana 7. This principle alsobelieved to similar with modern one. In modern science the movement of heartis considered myogenic, where as other muscles of the body only work aftergiving stimulation by nervous system. Physiology of the heart can be explained by its Vyutpatti The threeDhatus Hri, Da and Ya combinely form the word Hridaya that shows the three 8main functions of heart viz. Aharana (receives), Dana (gives) and Ayana(movement).ANATOMY OF HEART: Heart is located between lungs in the middle of chest, behind andslightly to the left of breastbone (sternum). A double-layered membrane calledthe pericardium surrounds heart like a sac. The outer layer of the pericardiumsurrounds the roots of heart’s major blood. The inner layer of the pericardium isMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 7
  • 20. Dr.G.H.Ananthasayana 2010attached to the heart muscle. A coating of fluid separates the two layers ofmembrane, letting the heart move as it beats, yet still be attached to body. Heart has 4 chambers. The upper chambers are called the left and rightatria, and the lower chambers are called the left and right ventricles. A wall ofmuscle called the septum separates the left and right atria and the left and rightventricles. The left ventricle is the largest and strongest chamber in heart. Theleft ventricles chamber walls are only about a half-inch thick, but they haveenough force to push blood through the aortic valve and into body.Coronary artery The heart muscle, like every other organ or tissue in body, needsoxygen-rich blood to survive. Blood is supplied to the heart by its own vascularsystem, called coronary circulation. The aorta branches off into two main coronary blood vessels. Thesecoronary arteries branch off into smaller arteries, which supply oxygen-richblood to the entire heart muscle. The right coronary artery supplies blood mainly to the right side of theheart. The right side of the heart is smaller because it pumps blood only to thelungs. The left coronary artery, which branches into the left anterior descendingartery and the circumflex artery, supplies blood to the left side of the heart. Theleft side of the heart is larger and more muscular because it pumps blood to therest of the body.Dhamani: In which Dhamana and spandana occurs known as Dhamani 9. Thename indicates its function. Charaka has described Dhamani as centrally 10hollow, harder than Sira and is a pitrijabhava . Acharya Charaka has 11mentioned Hridaya as the root of Dhamanis Dhamani circulates Rasa-Rakta,propels out by Hridaya and nourishes all the body tissues (Dhatus). There fore,Dhamani has called as “oja vaha” also. Bala of the body depends on it. Whilethrough Dhamanis a pressure has been exerts by the Rakta at the walls ofMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 8
  • 21. Dr.G.H.Ananthasayana 2010Dhamanis, which depends on the elasticity of the Dhamani. If any pathologyoccurs in Dhamani, the adverse effect is seen on the blood pressure.Sira: The vessels in which “Sarana” takes place known as Sira.12 LikeDhamanis, Sira also mentioned as pitrajabhava. These are the pulsation less 13vessels. It forms by the mridu Paka of Meda sneha . It also forms as anupdhatu of Rakta 14. It carries blood from the body to the Heart.Srotas: The structure in which “Sravana” occurs are known as 15.srotas Chakrapani has described srotas those in which nutrients of Dhatus aretransported from one place to another place they make to nourish each cells ofthe body16. Waste products produced by them again transported through thesrotasa.ANATOMY OF BLOOD VESSELS: The arteries and veins have the same structure with three layers, frominside to outside. Tunica intimae (the thinnest layer): a single layer of simplesquamous endothelial cells glued by a polysaccharide intercellular matrix,surrounded by a thin layer of sub endothelial connective tissue interlaced with anumber of circularly arranged elastic bands called the internal elastic lamina. Tunica media (the thickest layer): circularly arranged elastic fibre,connective tissue, polysaccharide substances, the second and third layer areseparated by another thick elastic band called external elastic lamina. The tunicamedia may (especially in arteries) be rich in vascular smooth muscle, whichcontrols the calibre of the vessel. Tunica adventitia: entirely made of connective tissue. It alsocontains nerves that supply the vessel as well as nutrient capillaries (vasavasorum) in the larger blood vessels.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 9
  • 22. Dr.G.H.Ananthasayana 2010 When blood vessels connect to form a region of diffuse vascular supplyit is called an anatomises. Anatomises provide critical alternative routes forblood to flow in case of blockages.PHYSIOLOGY Arteries and veins to a some degree - can regulate their inner diameterby contraction of the muscular layer. This changes the blood flow todownstream organs, and is determined by the autonomic. Vasodilatation and vasoconstriction are also used antagonistically asmethods of thermoregulation. Oxygen (bound to haemoglobin in red blood cells) is the most criticalnutrient carried by the blood. In all arteries apart from the pulmonary artery,haemoglobin is highly saturated (95-100%) with oxygen. In all veins apart fromthe pulmonary vein, the haemoglobin is de saturated at about 75%. The blood pressure in blood vessels is traditionally expressedin millimetres of mercury (1 mmHg = 133 Pa). In the arterial system, this isusually around 120 mmHg systolic and 80 mmHg . In contrast, pressures in the venous system are constant and rarelyexceed 10 mmHg. Vasoconstriction is the constriction of blood vessels, by contractingthe vascular smooth muscle in the vessel walls. It is regulated byvasoconstrictors .Vasodilatation is a similar process mediated byantagonistically acting mediators. The most prominent vasodilator is nitricoxide. Permeability of the endothelium is pivotal in the release of nutrients tothe tissue. It is also increased in inflammation in response to histamine,prostaglandins and interleukins, which leads to most of the symptoms ofinflammation.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 10
  • 23. Dr.G.H.Ananthasayana 2010 Figure 1: Anatomy of Heart and Blood Vessels Courtesy:med-ed.virginia.eduMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 11
  • 24. Dr.G.H.Ananthasayana 2010 REGULATION OF BLOOD PRESSURE Blood is driven through arteries at a considerable pressure. It isgenerated by contraction of the ventricles. In the aorta a resting blood pressurerises to about 120 mm.of Hg during systole and drops to about 80 mm.of Hgduring diastole in the young adult. Arterial pressure =Cardiac output x Total peripheral resistance. Where cardiac output depends on Heart rate, Contractility, Bloodvolume And TPVR depends on Humeral, Local, Nervous factors. A number of physiological mechanisms interact in a complex fashion tomaintain blood pressure and adjust it in response to changing circumstances. Control of blood pressure is achieved mainly though three mechanismneurological, hormonal and rennin angiotensin system, which are discussed hereunder as three types of pressure control mechanism-Rapid Control: Baroreceptor, CNS ischemic mechanism, Chemoreceptor’s Combine tocause vasoconstriction, increasing venous return, increase heart rate andcontractility, arteriolar constrictionIntermediate Control: During this time nervous mechanisms usually fatigue and become lessimportant.Long-Term Control: Renal-body fluid pressure control mechanism -hours to daysMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 12
  • 25. Dr.G.H.Ananthasayana 2010The Renin-Angiotensin System: Renin is an enzyme which is released by the kidneys when ABP falls toolow. Renin is synthesized and stored in an inactive form by thejuxtaglomerular cells of the kidney .Decreased BP in the afferent arterioleresults in release of renin from prorenin.Renin is an enzyme, not a vasoactivesubstance. It acts on angiotensinogen to form angiotensin I (AI).ACE convertsAI to AII. Angiotensin II is a powerful vasoconstrictor and increases ABP by increasing TPR increasing venous return to the heart (increasing cardiac output) decreasing excretion of both salt and water (long-term effect) Illustration No.2. Role of Renin Angiotensin System Juxta Glomerular appartus Renin Renin Substrate Angiotension IIVaso constriction Increased aldosterone synthesis Sodium retension Increased Blood pressureMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 13
  • 26. Dr.G.H.Ananthasayana 2010 MEASUREMENT OF BLOOD PRESSURE 17 The accurate measurement of BP is the important for successfulmanagement. The equipment—whether aneroid, mercury, or electronic—shouldbe regularly inspected and validated. The auscultator method of BP measurement should be used. Personsshould be seated quietly for at least 5 minutes in a chair, with feet on the floor,and arm supported at heart level. Caffeine, exercise, and smoking should beavoided for at least 30 minutes prior to measurement. An appropriately sized cuff (cuff bladder encircling at least 80 percent ofthe arm) should be used to ensure accuracy. At least two measurements shouldbe made and the average recorded. For manual determinations, palpated radial pulse obliteration pressureshould be used to estimate SBP—the cuff should then be inflated 20–30 mmHgabove this level for the auscultator determinations; the cuff deflation rate forauscultator readings should be 2 mmHg per second. SBP is the point at whichthe first of two or more Korotkoff sounds is heard (onset of phase 1), and thedisappearance of Korotkoff sound (onset of phase 5) is used to define DBP.Ambulatory Blood Pressure Monitoring Ambulatory blood pressure monitoring (ABPM) provides informationabout BP during daily activities and sleep. Twenty-four hour BP monitoringprovides multiple readings during all of a patient’s activities. While office BPvalues have been used in the numerous studies that have established the risksassociated with an elevated BP and the benefits of lowering BP, officemeasurements have some shortcomings. For example, a white-coat effect isnoted in as many as 20–35 percent of patients diagnosed with hypertension. Ambulatory BP values are usually lower than clinic readings. Awakehypertensive individuals have an average BP of >135/85 mmHg, and duringsleep, >120/75 mmHg.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 14
  • 27. Dr.G.H.Ananthasayana 2010 NIDANA (PROBABLE AETIOLOGY) Essential Hypertension is the name given to the type in which no exactcause can be found. But numbers of factors are related to its development i.e.genetic, dietary, stress etc. Essential HTN has not been explained as such in Ayurvedic texts so; itsNidana factors are also not incorporated. According to basic Ayurvedicfundamentals each disease is an outcome of vitiation of three somatic Dosas and 18two Mansik Dosas . After vitiation, these Dosas interact with each other andinfluence various organs of body and produce disease. This true in case ofEssential HTN also.Inheritance (Genetic Influence in EHT): The role of heredity in the aetiology of Essential HTN has long beensuspected The evidences in support are, The familial aggregation: Hypertension is more frequent in some communities and families than others. It has been estimated that if both parents have hypertension, the incidence of this disease in children is more than the others. Identification of HTN susceptibility gene: Many genes have been pinpointed during experimental studies, which are implicated in causation of Essential HTN. These are rennin gene, the ANP receptor gene, 11-B hydroxyl’s gene.Vaya (Age): - Vaya at which it usually occurs is between to 40 years and 60 years. Thepeak incidence of the disease occurs between 50 to 60 years. Acharya Susrutahas mentioned that the nutrient materials cannot nourish the body, which hasunder gone changes due to age 19. (Su.14/19).MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 15
  • 28. Dr.G.H.Ananthasayana 2010 In the context of Hypertension, it may be said that blood vessels getsthickened due to aging process and arteriosclerosis. So tendency to high bloodpressure is always above the age of 40 years.Linga (Sex): - Though Hypertension affected both sexes, the incidence is slightly lowerin the female up to 40 years. However after that females are more prone toHypertension.Samhanana (Constitution): Samhanana means Constitution of the body. They are of two types –Krisha (asthenic) and sthula (obese). In obese person blood pressure is usuallyhigh. Obesity is undoubtedly and aggravating factor in Essential Hypertensive,and blood pressure is usually observe fall with weight reduction. Theassociation of obesity and Hypertension manifests in three different ways - Over weight is more prevalent in Hypertensive than in Normotensives individuals. Normotensives obese subjects more likely to become Hypertensive. Hypertensive subjects are at increased risk of becoming over weight, compared to normotensives individuals. Moreover, obesity associated with demostratebaly-increased risk of developing Hypertensive cardiovascular complications. It is observed that change in blood pressure some time is associated with a change in weight.Temperament and stress (mano Dosha): CVS considered to be most independent system . For contraction andrelaxation, heart does not depend on any other controlling mechanisms. But stillANS can manipulate or modulate the functions of heart.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 16
  • 29. Dr.G.H.Ananthasayana 2010 Person who is suffering from mental stress, particularly this ANSspeeds up the heart and this situation remains till the stress is there. but whenstress become a continuous phenomena then also heart speeds up and moreamount of blood pumped out and if this mental stress continues for a longerduration then even after withdrawal of mental stress , heart will continues towork in same manner as it is accosted to speeded working ,which results inHTN.Jati prasakta, Prakruti (Races and Environments): Clues in to the aetiology of HTN may also be obtained fromcomparison of different racial groups. Certain races have a high incidence ofHypertension, others appeared to be relatively immune; for instances theChinese and Negroes of Africa and Negroes in rural circumstances. Thisdifference may not be racial but may be in fact due to environment, diet andoutlook of the life. For the instance under western civilization in urban life theNegroes in America have the same or even a slightly higher incidence ofHypertension, as the rest of population and it may be more severe than inwhites.Ahara (Diet): It has been found that B.P. is slightly lower in vegetarian populationthen non-vegetarian, but it is uncertain why this difference occurs. This has ledto the hypothesis that high animal fat diet itself may be related to Hypertension. Mamsa has been among the causes of “Shonitaja Roga”. Some of thesymptoms of Shonitaja roga are similar to those of EHT. So it can be said thatMamsahara (non-veg. diet) has some role in the pathogenesis of EssentialHTN.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 17
  • 30. Dr.G.H.Ananthasayana 2010Lavana (Salt): When salt consumed in excess, it cannot remain in crystal form incirculation rather it holds water which results in increased blood volume. Asblood pressure is directly proportional to blood volume, blood pressure alsoraises. Sushruta has also described similar fact while describing the qualities ofLavana Rasa in sutra sthana. It has been mentioned that Lavana Rasa iskledakara, which means the substance which causes retention of water.Ultimately peripheral resistance increases, which leads to increase bloodpressure. The Japanese who consume vast amount of salt have a high incidenceof Hypertension Excessive use of Lavana is described in Charaka Samhita as the cause ofShonitaja Roga 20.Cha. Su. 24/5. The symptoms of Shonitaja Roga are similar tothese of EHT. Acharya Charaka has also mentioned that Lavana should not beconsumed in excess and for longer duration 21. When excessively used, it produces fatigue and weakness of the body.Which are the symptoms, usually found in patients of HTN.Physical Activity: Dynamic exercise raises blood pressure and isometric raises it a lot,despite this, there is good evidence, that people who take regular exercise arehealthier and have low blood pressure than those who take none. More recently,a study of the effects of different level of exercise in a randomized controlledtrial have demonstrated that increasing exercise lowers blood pressureindependently from any other dietary manoeuvres. This effect could largelyresult from diminished sympathetic activity. While moderate normal exercise brings about the healthy state of thebody and mind. It also adds to Ayu, Bala, and amplification of Agni, stabilityand normalizes the alleviated Dosas 22.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 18
  • 31. Dr.G.H.Ananthasayana 201011. Smoking: Although tobacco smoking is not causally related to hypertension, it ismajor risk factor. Medical research council party observed that incidence ofstroke and coronary Heart disease in Hypertensive patients who smoke two orthree times greater than in non smoking patients with comparable bloodpressure. It affects both the central and peripheral nervous system. This maycontribute as a risk factor to Hypertension.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 19
  • 32. Dr.G.H.Ananthasayana 2010 SAMPRAPTI In Ayurveda, pathophysiology of any disease is explained in terms of dosha,dushya and mala with their kshaya, vriddhi, and prakopa conditions. The pathogenesis of Essential Hypertension is not yet clear; a hypotheticalpathogenesis has been mentioned in many of the modern texts. But when we look in Ayurvedic view, it seems to be tridoshaja vyadhi withvata as pradhana dosha, pitta and kapha as anubandha doshas and pradhana dushyainvolved is rakta. If we analyze vidhishoniteeya adhyaya, kiyanta sirasiya adhyaya we canconcider HTN as abnormality of rakta dhatu popularly known as shonita dushti. Table 1: Some of the etiological factors of shonita dushti segregated here which are similar to that of HTN 23Sl no SHONITA DUSHTI HYPERTENSION1 Pradushta bahu teekshoshna madya Excessive alcohol intake. ,sura , souveeraka.2 Ati lavana sevana. Excessive salt intake.3 Bhuktwa diva praswapatam drava Sedentary habits, more of snigdha gurunicha. consumption and less utilysation.4 Krodham bhajatam Mental stress5 Shrama , abhighata Physical straine(isometric exercises)6 Sharatkala swabhava Most of the complications of HTN like MI, Stroke happens in winter season.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 20
  • 33. Dr.G.H.Ananthasayana 2010 Table 2: Some of the symptoms of shonita doshti segregated here which are similar to that of HTN 24 Sl no Shonita dushti HTN Complications of HTN 1 Shirasah cha ruk headache 2 klama Tiredness 3 Krodha prachurata Irritability 4 mada delirium 5 kampa Tremors ,seizers 6 Sammoha , tamasah Altered consciousness 7 Akshi roga Visual disturbances 8 bhrama dizziness 9 Ardita, Shirasah kampa, Gala Manya Focal neurological signs Hanu graham, Vatadi roga. It means shonita dushti itself is not HTN but shonita dushti include group ofdiseases from bleeding disorder like raktapitta to skin disorders like kusta. In thisHTN can also be included due to similarities in aetiology, and clinical presentation.Samprapti Ghatakas 1. Dosha Shareerika Vata - Vyana, Prana, Udana Pitta – Pachaka, sadhaka Kapha – Avalambaka .Manasika – Raja, Tama 2. Dushya Rasa, rakta, mamsa, medas 3. Sanchara sthana Rasayani, Raktavahini 4. Agni Jataragni, dhatwagni 5. Ama Sama 6. Srotas Rasavaha, raktavaha, manovaha 7. Srotodusthi prakara Atipravritti, sanga 8. Adhistana Hridaya, dhamani, dhamani pratanaMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 21
  • 34. Dr.G.H.Ananthasayana 2010 9. Udbhava sthana Amashaya, pakwashaya 10. Rogamarga Madyama, bahya 11. Vyakta sthana SarvadhaihikaDosha Dooshyadi Vivechana in Hypertension. The disease Essential Hypertension has not been mentioned directly in ourAyurvedic classical texts. But the recent authors have tried to correlate this withseveral diseases like, Raktagata Vata Pittavruta vata Pranavruta udana Raktavega vruddi Raktachapadhikyata Uccharaktachapa Rasa bhara Dhamani prapurana Rudhir Mada Vyana bala but no single disease correlates exactly with that of essential Hypertension. But our acharyas have directed us to understand anukta roga in terms of doshadushyadi bhava, with these guidelines an interdisciplinary attempt has been made toanalyse the dosha dushya in HTN to understand the nidana panchakadi and for bettermanagement of it. The analysis is made depending on available classical reference and yuktipramana by taking into consideration the sign and symptoms of EssentialHypertension.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 22
  • 35. Dr.G.H.Ananthasayana 2010 Table No.3:Dosha Dushyadi Vivechana in Raktachapadhikyata Shareerika ManasikaSl. Clinical Dushya dosha dosha SrotasNo. Features V P K Raj Tam R Ra Ma Me01 Headache + - - + - -02 Vertigo + + - + + - -03 Palpitation + - + - - -04 Fatigue + + - + - -05 Chest Pain + - + - -06 Insomnia + + - + - -07 Irritability + + - + - -08 Anxiety + - + - -10 Delirium + - + - -11 Anger - + - + + + - -12 Fainting + + - + - - - From the above analysis it is seen that among shareerika dosha, all the threedoshas are involved with predominance of vata dosha and in manasika doshas bothraja and tama are involved and in dushya rasa, rakta, mamsa and medas are involvedand regarding srotas rasavaha raktavaha mamsavaha medovaha and manovaha srotasare involved. Thus from this analysis it can be concluded that essential Hypertension is vatapradhana tridoshaja vyadhi with rakta as pradhana dushaya.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 23
  • 36. Dr.G.H.Ananthasayana 2010 PATHOPHYSIOLOGY OF HTN The pathophysiology of EHTN remains an area of active research, withmany theories and different links to many risk factors. 1 Genetics 2 Autonomic nervous system 3 Renin-angiotensin-aldosterone systemGenetics: Evidence for genetic influence on blood pressure comes from varioussources. There is greater similarity in blood pressure within families thanbetween families, which indicates a form of inheritance. And it was proved thatthis finding wasnt due to shared environmental factors.Overall, however,identifiable single-gene causes of hypertension are uncommon, consistent with amultifactor cause of essential hypertensionAutonomic nervous system: The autonomic nervous system, plays a central role in maintaining thecardiovascular homeostasis via pressure, volume, and chemoreceptor signals.Done by altering peripheral vasculature, and kidneys, causing increased cardiacoutput, increased vascula resistance, and fluid retention. Some studies shownthat hypertensive patients manifest g reater vasoconstrictor responses toinfused norepinephrine than normotensive controls. And that hypertensivepatients doesnt show the normal response to increased circulatingnorepinephrine levels which generally induces down regulation ofnoradrenergic receptor, and its believed that this a bnormal responseis genetically inherited. Exposure to stress increases sympathetic outflow, and repeated stress-induced vasoconstriction may result in vascular hypertrophy, leading toprogressive increases in peripheral resistance and blood pressure.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 24
  • 37. Dr.G.H.Ananthasayana 2010 Persons with a family history of hypertension manifest augmentedvasoconstrictor and sympathetic responses to laboratory stressors, such as coldpressor testing and mental stress that may predispose them to hypertension. This is particularly true of young African Americans. Exaggerated stressresponses may contribute to the increased incidence of hypertension in thisgroup .Renin-angiotensin-aldosterone system : Another system maintaining the extra cellular fluid volume, peripheralresistance and that if disturbed may lead to hypertension is the renin-ngiotensin-aldosterone system. Renin is a circulating enzyme that participates in maintaining extracellular volume, and arterial vasoconstriction, Thus it contributing to regulationof the blood pressure,it perform this function through breaking downangiotensinogen secreted from the liver into the peptide angiotensin I,Angiotensin I is further cleaved by an enzyme that is located primarily but notexclusively in the pulmonary circulation bound to endothelium, that enzymeis ACE producing angiotensin II, the most vasoactive peptide. Angiotensin II is a potent constrictor of all blood vessels. It acts on themusculature of arteries and thereby raises the peripheral resistance, and soelevates blood pressure. Angiotensin II also acts on the adrenal glands too and releasesAldosterone, which stimulates the epithelial cells of the kidneys to increase re-absorption of salt and water leading to raised blood volume and raised bloodpressure.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 25
  • 38. Dr.G.H.Ananthasayana 2010 BHEDA:Hypertension can be classified in several ways.• Systolic and diastolic Hypertension• Essential and secondary Hypertension• Intermittent and established Hypertension• On the basis of severitySystolic and Diastolic Hypertension The Blood pressure is recorded in terms of systolic and diastolic pressures. InHypertension these may raise individually or together depending upon thepathogenesis. When there is rise of only systolic Blood pressure it is termed assystolic Hypertension. When there is rise of only diastolic Blood pressure it is termedas diastolic Hypertension.Essential and Secondary Hypertension• This classification is made based on the causative factors involved.• Essential Hypertension is also called as primary Hypertension where the cause is unknown• Secondary Hypertension is caused secondary to some other primary organ disease such as kidney, endocrine gland, CNS, aorta etc.On the basis of Severity A commonly accepted classification would be one adopted from the 7th reportof the Joint National Committee on detection, evaluation and the treatment of HighBlood pressure (JNC 7).Table 4: Classification of Blood Pressure on the basis of Severity25 BP Classification SBP (mm Hg) DBP( mm Hg) Normal <120 and <80 Prehypertension 120–139 or 80–89 Stage 1 hypertension 140–159 or 90–99 Stage 2 hypertension 160 or 100MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 26
  • 39. Dr.G.H.Ananthasayana 2010Intermittent and Established Hypertension Hypertension may be intermittent (labile) or established (sustained), very oftenthe former is merely an early stage of the latter.Some other forms of Hypertension are; • Borderline Hypertension –Pressure zone between highest acceptable normal Blood pressure and hypertensive Blood pressure. The Fragminham heart study define this as pressure between 140-160 systolic, 90-95 mm Hg diastolic. • Accelerated Hypertension – Advancing rapidly with increasing Blood pressure and associated with acute and rapidly worsening signs and symptoms. • Episodic Hypertension – Manifest intermittently, triggered by anxiety and emotional factors also called as paroxysmal Hypertension. • Benign Hypertension - That runs a relatively long and symptomless course. • Malignant Hypertension – Severe Hypertension that runs a rapid course, causing necrosis of arteriolar walls in kidney, retina, associated with complications like papilledema, retinal exudates, haemorrhage. However these patients usually have Blood pressure around 200/140 mm Hg. • Labile Hypertension – Frequently changing levels of elevated Blood pressure. • Goldsalt Hypertension – Increased Blood pressure following obstruction of blood flow to one kidney. • Renal Hypertension – Hypertension secondary to renal disease. • Gestational Hypertension - Hypertension during pregnancy in a previously normotensive woman or aggravation of Hypertension during pregnancy in a hypertensive woman. • White Coat Hypertension – Is a condition in which Blood pressure is elevated in the presence of a medical personal but falls when the subject leaves the medical environment.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 27
  • 40. Dr.G.H.Ananthasayana 2010Classification of Hypertension 1. Essential Hypertension (90%- 95% of cases) 2. Secondary Hypertension Renal • Acute glomerulonephritis • Chronic renal disease • Polycystic disease • Renal artery stenosis • Renal vasculitis • Renin producing tumours Endocrine • Adrenocortical hyperfunction • Cushing syndrome • Primary aldosteronism • Congenital adrenal hyperplasia • Liquorice ingestion Exogenous harmone- • Glucocorticoids • Estrogen (including pregnancy induced, • Oral contraceptives) Cardiovascular • Coarctation of aorta • Polyarteritis nodosa • Increased intravascular volume • Increased cardiac output • Rigidity of the aorta Neurologic • Psychogenic • Increased intracranial pressure • Sleep apnea • Acute stress including surgeryMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 28
  • 41. Dr.G.H.Ananthasayana 2010 PURVARUPA The premonitory symptoms appear before the appearances of the diseaseare known as Purvarupa or prodromata. Though EHTN is said to be Vata Pittapradhana Tridosaja vyadhi, where Vata is the chief culprit and the Purvarupa ofthe Vata vyadhi said to be avyakta. Most of the Hypertensive patients remain asymptomatic or present withsubjective symptoms, like Shirahshaula, Alpanidra, Bhrama etc. many of thepatients of Hypertension are diagnosed at the visit to clinician with one or moreother problem and the checked the blood pressure.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 29
  • 42. Dr.G.H.Ananthasayana 2010 RUPA Rupa or vyakti avastha of vyadhi is the 5th Kriyakala in the journey ofthe healthy human being towards any disease. This is the stage where dosadushya sammurchhana has already takes place and disease appear with all itssubjective and objective symptomatology. Generally in EHT a few symptoms are recognized. Hence some of thecommon symptoms with which normally a patient goes to the hospital andunexpectedly get diagnosed as Hypertensive patient are described here in under.Shiroruk (headache): In HTN usually throbbing type headache in occipital region or may bein vertical or in frontal region, some times paroxysmal but mainly occurs inmorning hours and remains for whole day. Sushruta has stated that “Vata drute nasti ruja” . That is any type ofShula cannot occur without the vitiation of Vata. Charaka has included ShirahaShula in 80 types of Nanatmaja Vata vyadhi. Further, Charaka while explainingSamanya Samprapti of Shiroroga mentions that Prakupita Vatadidosa causedusti of Rakta and then by localizing in Sira, produce Shiroroga, which includesShiraha Shula also. In this way in Shirahshoola Vata dusti may be considered as a primefactor.Bhram (Giddiness): Giddiness may be a symptom of Hypertension and it should bedistinguished from vertigo, which is more feeling of unsteadiness.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 30
  • 43. Dr.G.H.Ananthasayana 2010It is also a Nanatmaja vata vyadhi according to Charaka. It is said to begenerated due to vitiation of Raja dosa along with vata and pitta dosa obviouslyvata and pitta are main dosa in producing Bhrama.Hriddravata (Palpitation): This is troublesome subjective feeling to the patients. A history ofrecurrent episodes of tachycardia may be due to intrinsic cardiac disease,anxiety, thyrotoxicosis or excessive alcohol consumptionKlama (Easy fatigability): Sushruta has defined klama as fatigue which occurs, without anyexertion. The person feels tired with decreased functions of his Indriyas.Nidranasha : Vitiated Vata, Pitta, manas Santapa are responsible for Nidranasha. It isa result of psychological and strains like anxiety, stress, drug abuse etc.Urahashula (Chest pain): Acharya Sushruta has mentioned Urahashula under the symptoms ofRasa kshaya. As described earlier due to Rasa kshaya vitiated Vyanavayucauses pain in the chest.Chest pain also may be due to the complication of Hypertension (i.e. angina orheart attack.) A large number of hypertensive patients in the early stage have nosymptoms .MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 31
  • 44. Dr.G.H.Ananthasayana 2010 UPASHAYA ANUPASHAYA Upashaya and anupashaya are one of the important diagnostic tools, which areadopted to diagnose the disease in case of ambiguity. Upashaya gives relief where asanupashaya worsens the condition. The risk factors explained for Essential Hypertension like stress, worries,smoking, salt intake, alcohol, are considered as anupashaya. Rest, medication,relaxation exercise and breathing techniques are considered as anupashaya.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 32
  • 45. Dr.G.H.Ananthasayana 2010 SAPEKSHA NIDANA Essential Hypertension should be differentiated from secondary Hypertension. Table 5: Differentiating Essential and Secondary Hypertension Factors Essential HTN Secondary HTNAetiology Unknown Renal disease, vascular disease, economic disease, drug inducedHistory Strong family history of HTN along Often develops before the age of 35 with repeated finding of intermittent or after 55. History of use of pressure elevation steroids or estrogens is of obvious significancePathology Pathogenesis not clearly understood Pathogenesis depends on the disease that had caused HTNSymptomatic Symptomatic /asymptomatic vague Symptoms of underlying disease symptom like headache, vertigo easy fatigability etc., will be presentInvestigation No specific investigation are Depending upon the underlying diagnostic diseasePrognosis Not bad, when benign and is Depends upon the primary disease controllable with regular medicationTreatment Depends upon the cause and Non drug therapy requires drug therapy during severe Life style modifications condition Drug therapy Diuretics Antiadrenergic agents Vasodilator Calcium channel blocker ACE inhibitors ACE receptor antagonistsMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 33
  • 46. Dr.G.H.Ananthasayana 2010 UPADRAVA Complications of HTN depend upon the organ involved.The major consequences can be classified under this heads- Cardiac complications Neurological complications Renal complications Eye complications Vascular complicationsCardiac complications:- Left ventricular hypertrophy (LVH)- It is commonly seen in and severe long- term Hypertensive patients. Congestive cardiac failure (CCF)- With failure of cardiac hypertrophy reserve, left ventricle may go in to failure resulting in to pulmonary congestion and later on developing of congestive cardiac failure. Coronary arterial disease (CAD)- In Hypertensive patients coronary artery disease two times common then normotensives. Myocardial infarction (MI) is two three-fold incidence as compared to normotensives people. Sudden death may occur due to development of arrhythmia in Heart. Heart failure is four times common in Hypertensive women and seven times in Hypertensive men.Neurological complications: - The life threating complication, Hypertensive encephalopathy may occur due to chronic Hypertension and accelerated Hypertension. Cerebrovascular accident is also most common neurological disorder of Hypertension. It may be due to cerebral ischaemia, embolism, thrombosis or hemorrhage.Renal complications: - Athermanous renal artery narrowing or occlusion may occur as a consequence of high blood pressure in older patients.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 34
  • 47. Dr.G.H.Ananthasayana 2010Eye complications: - Visual losing occur due to thromboembolic phenomena or atherosclerotic changes in retinal arteries. Subconjunctival arteriolar hemorrhage is common at all levels of high B.P.Vascular complications: - Aneurysm or dissecting aorta. Obliterative atherosclerotic changes in medium sized arteries. Abrupt acceleration in the blood pressure that is development of malignant Hypertension.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 35
  • 48. Dr.G.H.Ananthasayana 2010 SADHYA - ASADHYATA A physician, who can distinguish between curable and incurable diseases andinitiated treatment in time with the full knowledge, can certainly accomplish hisobject of curing the disease26. Communication gap between the patients and the doctor is the major problemin this disease. The successful treatment of chronic diseases demands persistenttreatment, and that success of long range therapy depends not only on medication butalso on personality factors. After going through the probable Samprapti of EHT, it can be said thatEssential Hypertension is mainly a Vata Pitta pradhana Tridoshaja and chirkalicvyadhi.All Vata vyadhi after one year of manifestation designate as asadhya;27Essential Hypertension is so. The involvement of Heart, Brain and kidney (Trimahamarmas)and Dosas areheld up in Madhyam and Bahyarogamarga, the disease reflects yapya nature. If the patients comes with complicated state associated with end organ damageand has non- compliance to drug therapy, leads the disease an incurable state calledasadhya. Essential hypertension is controllable with proper treatment. It requireslifelong monitoring, and treatment may require periodic adjustments.It is based upon several factors including genetics, dietary habits, and overall lifestylechoices. If individuals’ conscious of their condition take the necessary preventivemeasures to lower their blood pressure, they are more likely to have a much betteroutcome than those who do not.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 36
  • 49. Dr.G.H.Ananthasayana 2010 DIAGNOSIS AND ASSESSMENT Hypertension is generally diagnosed28 on the basis of a persistent high bloodpressure. Usually this requires three separate sphygmomanometer measurements atleast one week apart. Initial assessment of the hypertensive patient should include acomplete history and physical examination. Exceptionally, if the elevation is extreme, or if symptoms of organ damage arepresent then the diagnosis may be given and treatment started immediately. Once the diagnosis of hypertension has been made, physicians will attempt toidentify the underlying cause based on risk factors and other symptoms, if present. Secondary hypertension is more common in preadolescent children, withmost cases caused by renal disease. Primary or essential hypertension is more common in adolescents and hasmultiple risk factors, including obesity and a family history of hypertension. Laboratory tests can also be performed to identify possible causes ofsecondary hypertension, and determine if hypertension has caused damage tothe heart, eyes, and kidneys.Tests typically performed are classified as follows: Table 6Renal Microscopic urinalysis, proteinuria,creatinineMetabolic FBS,PPBS,Lipid profileOther Hematocrit, electrocardiogram, and Chest X-rayMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 37
  • 50. Dr.G.H.Ananthasayana 2010 CHIKITSA The radical removal of causative factors of disease as well as restoration of theDosika equilibrium in the body is known as chikitsa29. Chikitsa comprehendsfollowing measures,Swasthasya swasthya rakshnama i.e. preventive and prophylactic therapyAturasya roganuta.i.e The curative therapy. The later curative therapy is comprehended generally to eliminate the disease.The curative treatment can be divided, in to sub groups- Shodhana ,Shamana, Ahara,and AcharaManagement of Essential hypertensionGoals of Therapy 30 The ultimate public health goal of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality. Treating SBP and DBP to targets that are <140/90 mm Hg is associated with a decrease in CVD complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mm Hg.Benefits of Lowering Blood Pressure 31 In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence averaging 35% to 40%; myocardial infarction, 20% to 25%; and HF, >50%. Reduction of the blood pressure by 5–6 mmHg can decrease the risk of stroke by 40%, decrease the risk of heart disease by 15–20%.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 38
  • 51. Dr.G.H.Ananthasayana 2010Management of Hypertension is divided in to two categories Management Without medication. Management With anti-Hypertensive medication.Management without medication: On the basis of several researches, has settled some life style measure, forlowering the blood pressure. The effects of implementing these modifications aredose- and time-dependent and could be greater for some individuals.Table 7: Lifestyle Modifications to prevent and manage Hypertension 32 Approximate SBPModification Recommendation ReductionWeight Maintain normal body weight (body mass index 5–20 mm 2reduction 18.5–24.9 kg/m ). Hg/10 kgAdopt DASH Consume a diet rich in fruits, vegetables, and low- 8–14 mm Hgeating plan fat dairy products with a reduced content of saturated and total fat.Dietary Reduce dietary sodium intake to no more than 100 2–8 mm Hgsodium mmol per day (2.4 g sodium or 6 g sodiumreduction chloride).Physical Engage in regular aerobic physical activity such as 4–9 mm Hgactivity brisk walking (at least 30 minutes per day, most days of the week).Moderation of Limit consumption to no more than 2 drinks (eg, 24 2–4 mm Hg99alcohol oz beer, 10 oz wine, or 3 oz 80-proof whiskey) perconsumption day in most men and to no more than 1 drink per day in women and lighter-weight persons.DASH indicates Dietary Approaches to Stop Hypertension.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 39
  • 52. Dr.G.H.Ananthasayana 2010 33Drug therapy for Essential Hypertension There are many classes of medications for treating hypertension, togethercalled antihypertensives, which, by varying means ,act by lowering blood pressure.Commonly used prescription drugs include: • ACE inhibitors such as ramipril • Angiotensin II receptor antagonists may be used where ACE inhibitors are not tolerated: e.g.,candesartan • Calcium channel blockers such as nifedipine. • Diuretics: e.g. hydrochlorothiazide (aHCTZ). Diuretics such a furosemide or low-dosages of spironolactone • Alpha blockers such as terazosin. Doxazosin has been shown to the increase risk of heart failure, and to be less effective than a diuretics. • Beta blockers such as metoprolol. Now they are less commonly used because they increase the risk of diabetes. • Direct renin inhibitors such as aliskiren.Follow-Up and Monitoring Once antihypertensive drug therapy is initiated, most patients should return forfollow-up and adjustment of medications at monthly intervals or less until the BP goalis reached. More frequent visits will be necessary for patients with stage2hypertension or with complicating conditions. Serum potassium and creatinine should be monitored at least 1 to 2 times/year.After BP is at goal and stable, follow-up visits can usually be at 3- to 6-monthintervals.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 40
  • 53. Dr.G.H.Ananthasayana 2010The Ayurvedic Management:Dravyabhoota Chikitsa: Since hypertension is a vatapradhana, tridoshaja vyadhi, raktadhatu as dushya,virechana and basti are the shodhana chikitsa that can be adopted. Following are thesome of the drugs that are useful in treatment of Hypertension.Drugs : Sarpagandha, Gokshura, guggulu, gomutra, Arjuna, punarnava, Jatamamsi,shilajatu, mandukaparni, vacha, pippali, rasona, Aswagandha, shankhapushpi,triphala, guduchi,tagara etc.,Yogas: Prabhakaravati, rasasindhura, sarpangandhavati, saraswatarista, Gokshuradiguggulu, kamudugharasa, yogendrarasa, hridayeshwara rasa, chandrakala rasa etc.Patent Medicines : Tab Arjin, tab seliden, tab Abana, Tab sumanas, Tab supersarpa, Tab.Cardostab, Tab Caditone, Arjunin, Tab B.PCure, Tab. Somatone, etc.VIRECHANA KARMA: Virechana is less stressful procedure than Vamana Karma. It has lesspossibility of complications and could be done easily. It is a complete therapeuticmeasure, which has systemic as well as local effects. This fact is further supported bythe word “Virechana”. Its wide range of indications, the special classical method andmode of action are given in Ayurvedic classics.DEFINITION: The act of expelling Doshas through “Adhobhaga” is known as Virechana.Here the meaning of Adhobhaga34 is “Guda” commented by Chakrapani.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 41
  • 54. Dr.G.H.Ananthasayana 2010KARYAKSHETRA OF VIRECHANA:Dosha: • Pitta, Pitta Sthanagata alpa Kapha • Kapha Sthanagata Bahu Pitta, Pittavrita Vata • Sannipatic condition (Bhel)Dushya: Rasa, Rakta, Mamsa, Asthi, Majja, ShukraSrotas: Rasavaha, Raktavaha.Mamsavaha, Asthivaha, MajjavahaCLASSIFICATION OF VIRECHANA DRUGS In Ayurvedic classics, the main drugs for Virechana have been described inthe chapters dealing with Panchakarma. In addition to it scattered references areavailable in the literature regarding Virechana of Drugs. 40-49 According to many references Virechana drugs may be classified infollowing groups: - According mode of action. According Intensity of action.VIRECHANA DRUGS ACCORDING TO THEIR MODE OF ACTION:Sara: The drugs, which move the Malas down words after digestion and breakingtheir bandha, are known as Anulomana. e.g. haritki.Sha. Sushruta has considered Saraas the synonyms of Anulomana. According to Dalhana Anulomana causes expulsionof Vata and Kapha 35.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 42
  • 55. Dr.G.H.Ananthasayana 2010Sransana: The literary meaning of Sransana is to slip or to fall down. The drugs, whichbring the semi, digested and sticky Malas without causing their digestion is known asSransana. e.g. Aragvadha.Bhedana: Meanings of Bhedana are breaking, splitting, piercing, dividing, separationetc. According to Sharangadhara, the Drugs which disintegrate the(“Abaddha orBaddha or Pindita )dried focal mass forms of Malas by facilitating penetration in to itand then evacuating through the lower gut, is known as Bhedana e.g. Katuki,Rechana: The Drugs, which eliminates, digested (Pakvam) and Undigested (Apakvam)Malas or Doshas by making them watery through the lower gut, is known as Rechana.E.g. Trivrit 36 .Virechanopaga: The Virechanopaga Gana37 described in Charaka Samhita has been consideredas helping in inducing Virechana. These are Draksha, Kasmarya, Parusaka, Abhaya,Amalaki, Vibhitaki, Badara, Karkandu and Pilu..VIRECHANA DRUGS ACCORDING TO INTENSITY OF ACTION:These suggested the degree of potency of Drug.Mrudu Virechana: The Drugs, which are Manda in Virya, are when combined with appositeVirya or given in low dose, given to Ruksha patient and causes less purgation isknown as mrudu Virechana. Sharangadhara recommends that the Mrudu VirechanaDrugs i.e. Laksha, milk, warm water, castor oil etc. should be use in MruduKosthayukta patient38.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 43
  • 56. Dr.G.H.Ananthasayana 2010Madhya Virechana: The Drugs, which are moderate in qualities, are known as Madhya VirechanaDrugs. These Drugs are specifically indicated in the patients having Madhya RogaThe administration of these Drugs in Balavana patient is useless, because they areunable to eliminate Dosha completely. Sharangadhara recommends the use of Trivrit,Katuki and Aragvadha for Madhya Kostha39.Tikshna Virechana:The drugs which causes numerous motion (Mahavega) and eliminates the Doshas inlarge quantity by quick (Kshipra) and gentle purgation with out causing either muchGlani (Depression) or pain in Heart area or anus or harmful to internal organs, isknown as Tikshna VirechanaDOSES OF VIRECHANA DRUGS: Matra of the Virechana drug should be in such a quantity, that desired effect ofShodhana may be achieved and may be able to eliminate Dosha from body, butshould not produce the symptoms of Ayoga or Atiyoga.This should be decidedaccording to Aturabala, Agni Bala and Ausadhi. While describing the process ofVirechana the dose of Trivrit yoga is one Aksa (Tola) mentioned.PROCEDURE OF VIRECHANA KARMA:PURVAKARMA: “Prakyat kriete tat purva karmha:”Dalhana.Procedure, which is necessaryprior to pradhana karma, is known as Purvakarma. Patient should be prepare beforeVamana and Virechana procedure, by use of Dipana Pachana drugs and Snehana &Svedana.Dipana-Pachana: Aama and in the patients with Agnimandhya, administration of DipanaPachana drugs are useful for Aama Pachana and to increase the Agni of the patient.There after Snehapana is given.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 44
  • 57. Dr.G.H.Ananthasayana 2010Snehapana: The oral sneha should be given in the morning when the food of the previousevening is well digested. Sneha is recommended for snehapana according to vyadhi,Kala, Vyadhita and Dosha-dusti. Anupana of the sneha should be hot water andpatient is advised to avoid Divasvapa. The duration of snehapana should be 3, 5 ormaximum 7 days, for Mrudu, Madhyama and Krura Kostha respectively. 40. The doseof sneha should be according to Agnibala and Kostha. In such a quantity, that thedesired symptoms of snehapana are obtained within 7days. During these days Drava,ushana and Pramana yukta Ahara should be given.. After snehapana on the 3 gap daysAbhyanga and Svedana are done at least once daily.Abhyanga: Abhyanga is carried out with application of simple or medicated oils or Gheeon the whole body. This may be carried out in the morning and evening. It is to bedone on all over the body. 41Svedana: After Abhyanga, Vaspa sveda is generally employed. During these 3 days ofAbhyanga and Svedana the Snigdha Drava, ushana, odana, amlarasa phala arerecommended 42. Before Virechana such a diet is preferred, which does not increase 43Kapha, otherwise Vamana may occur . The Pitta also should not be increasedotherwise it may cause “Ayoga” as the increased Agni may digest44 Virechana drugs.The patient should be prepared psychologically for the procedure of the Virechana.The dose of Virechana yoga should be decided according to vyadhi Bala,Purushabala and Agnibala. 45.PRADHANA KARMA: This includes administration of Virechana Yogas, observation especially forAusadha jirnta, observation of Shuddhi Lakshanas and management of vyapada ifoccurs..MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 45
  • 58. Dr.G.H.Ananthasayana 2010 About the time of giving Virechana, Vagbhatta mentioned “ Sleshma Kalagate” means after passing Sleshma kala i.e. after 10 A.M. but not before 9 A.M. inany case. Just after administration of Virechana yoga, cold water is sprinkled on theface to avoid vomiting. The patient is asked to gargle with hot water and asked tohave fragrance of flowers. He should be protected from direct cold wind. He isadvised to note retain Vegas as well as do not make Pravahana. Hot water should begiven frequently to the patient to prevent Vibandha and due to its Vatanulomana andYogavahi actions, Virechana occur quickly. If Virechana does not occur then Svedanashould be done on the abdomen46.Karmukatha of virechanaAction of Virechana Karmas can be divided in the following, two ways.Systemic: By which is brings down the morbid Doshas, particularly Pitta from theAmashaya or Pakvashaya, i.e. G. I. T.Local evacuant: This concerned with the evacuation of these Doshas in form of Malas from thegut by purgation. The Vyavayi Guna of Drug is responsible for quick absorption. • The VikasiGuna causes softening and loosing of the bandha. Due to Ushna Guna, the Doshasanghata (compact ness) is Vishyandana (liquefied). Action of Tikshna Guna is tobreak the Mala and Dosha in micro farms.According to Dalhana it is responsible forquick excretion.Due to Shukshma Guna, by reaching in micro channels, disintegratesendogenic toxins, which are then excreted through micro-channels(Anupravanabhava).• Due to Prabhava mainly and also due to Prathvi Jalaconstitution, finally Virechana occurs.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 46
  • 59. Dr.G.H.Ananthasayana 2010 PATHYAPATHYA Since Raktachapadhikyata is yapya vyadhi pathyapathya has a great role toplay in the management of it, both as a preventive measure also as supportive measurewith main treatment. Table No.8. Showing the Patyapathya in Raktachapadhikyata Pathya Apathya Mudga, masoora, youa, palak, Anupa mamasa, dadhi, salt, excess methin, jambera, carrot, fattysubstances, alcohol, junk foods, Papaya, drygrapes, jeeraka, bakery foods. Ahara maricha, jangala mamasa, goksheera, takra, madhu, purana shali, yava. Vyayama, dinacharya, Avyayama, ativyayama, Vihara sadvritta paripalana, dharana vegadharana, diwaswapna, of shokadi manasika vega atichinta, atikrodha, ratri jagarana.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 47
  • 60. Dr.G.H.Ananthasayana 2010 DRUG REVIEW:Drugs used for study at different stages of treatment are • Pancha kola choorna for amapachana. • Moorchita tila taila for shodhananga snehapana. • Trivrit lehya for virechana. • Moorchita tila taila, cap tagara, as shamanoushadha.The properties of drug summarized belowPanchakola choorna: Ingredients are pippali , pippalimoola , chayva , chitraka ,nagara.all of themarehaving deepana and amapachana property. Properties are explained in table no 7.Moorchita tila taila: It is an anubhoota yoga which contains tila taila moorchana with sarpagandha ,ashwagandha , amalaki ,jatamamsi , arjuna. Properties are tabulated in the table no 8.Trivrut lehya: Properties of Trivrut are Rasa : Katu, Tikta, Madhura, Kashaya Guna : Lakhu, Rooksha, Teekshna Virya : Ushna Vipaka: KatuCap Tagara: Its properties are bitter, sweet, pungent and astringent. Valerian is said tobalance the doshas of vata and kapha.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 48
  • 61. Dr.G.H.Ananthasayana 2010 Table 9: Properties of ingredients of panchakola choornaSl. No. Drug Latin name Rasa Guna Veerya Vipaka Prayoga Doshaghnata Karmukata1. Pippali Piper longam Katu Laghu Anushna Madhura Phala Kapha Deepana, truptighna, snigdha sheeta vataghna vatanulomana, mriduvechana, teekshna rasayana, balya2. Pippali Root of Katu Laghu Anushna Madhura Moola Kapha Deepana, truptighna, moola piperlongam snigdha sheeta vataghna vatanulomana, mriduvechana, rasayana, balya3. Chavya Piper Katu Laghu ruksha Ushna Katu Moola Kaphavata Trishana nigraha, rocchana, retrofractum shamaka deepana, grahi, hridya.4. Chitraka Plumbago Katu Laghu ruksha Ushna Katu Moola Kaphavata Deepana, pachana zelanica theekshna shamaka5. Nagara Zingiber Katu Laghu Ushna Madhura Kanda Kaphavata Truptighna, rochna, deepana, officinale snigdha shamaka pachana, vatanulomana, shoola prashamana.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 49
  • 62. Dr.G.H.Ananthasayana 2010 Table 3: Properties of ingredients of Morchita tila tailaSl. Latin Drug Chemical composition Rasa Guna Veerya Vipaka Prayoga Doshaghnata KarmukataNo. name1. Sarpagandha Rauwolfia Reserpine,reserpinine, Tikta Rooksh Ushna Katu Moola Kaphavata Raktabhara shamaka serpentine serpentine, serpentenin, a shamaka hridayavasadaka, rauwolfinin, yohimbin, manasa vikara ajamalin, deserpine shamaka2. Aswagandha Withania Whithaniol acid, Tikta katu Laghu Ushna Madhura Moola Kaphavata Raktabhara shamaka somnifera cuseohyugrini, madhura snigdha shamaka vajkarana anahygrine, trotinic, anaferine, glycosoid,3. Amalaki Emblica ascorbic Lavana Guru Sheeta Madhura Phala Tridosha hara Hridya, Shonita officinalis acidgibberellins, varjita Ruksha (Pitta hamaka) sthapana, Rasayana, triterpene lupeol, pancharasa Sheeta Mutrala4. Arjuna Terminali Aromatic oil, ral, Kashayam Laghu Sheeta Katu Twak Kapha pitta Rakta pittahara a arjuna tannin,glycosoid, ruksha shamaka hridya raktavikara harmime, Harman, shamaka hridroga sterol. hara mootrala5. Jatamamsi Nodostach Volatileoil, tamamsone, Tikta Laghu Sheeta Katu Moola Tridoshara Raktabhara shamaka ys jatamamsik, kashaya snigdha hridaya niyamaka jatamamsi Madhura medya nidrajanana hridravanashaka6. Tila (taila) Sesamum Sesamin, sesamolin Madhura guru Ushna Madhura Beeja Vata Smayoga amskarath indicum snigdha taila vikaranashaka sarvarogapaha tridoshagna pathyaMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 50
  • 63. Dr.G.H.Ananthasayana 2010 Table 4: Drugs used in the study Sarpagandha Ashwagandha Amalaki Arjuna Jatamamsi TagaraMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 51
  • 64. Dr.G.H.Ananthasayana 2010REVIEW OF PREVIOUS WORKSJamnagar1. Role of virechana karma and shamana chikitsa in Hypertension w.s.r.t. uccha raktachapa by Bhayan Ramesh, 2003.2. Role of manasikabhava in the etiopathogenesis of uccharaktachapa and its management with medhyarasayana and shirodhara, 2003.Trivendrum3. A study on the combined effect of Jatamamsi and shigru in HTN by Preethi, G.S., 2003.Mysore4. A Study on Hypertension – An Ayurvedic Approach by Mohammed Rafiq Ullur, 1987.5. A Literary research on Raktachapadhikyata in Ayurveda and the Effect of Virechana – an Observational Study by Sashidhar H. Doddamani, 1999.6. A comparative clinical study to evaluate the effect of Tab Arjin and Gokshuradi guggulu vati in Raktachapadhikyata w.s.r.t. Essential HTN, by Rabakavi Shankarling, 2003.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 52
  • 65. Dr.G.H.Ananthasayana 2010 METHODOLOGY After a thorough review of literature in the first part, the second part of thedissertation is dedicated for methodology. Where a detailed explanation is givenregarding Materials selected, Methods adopted, The observations made, The results and conclusions drawn , based on the clinical study.MaterialsThe drugs used for clinical trial . Panchakola churna Moorchita tila taila Trivrit lehya Cpa.TagaraPanchakola churna For the purpose of study Panchakola churna of our hospital ,manufactured byGCP, Bangalore , was taken.Moorchita tila taila The ingredients of Moorchita tila taila were purchased from Govindarajasetteeand Son’s shop, Mysore. The taila preparation was carried out according to tailapakavidhi at Government Ayurveda Medical College Pharmacy, Mysore.Trivrit lehya For the purpose of study Trivrit lehya of kottekal ayurvedic pharmacy, wastaken for virechana.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 53
  • 66. Dr.G.H.Ananthasayana 2010Cap .Tagara For the purpose of study Cap .Tagara manufactured and sponsored byHimalaya Drug Company was takenMETHODSObjectives of the study: To evaluate the combined effect of shodhana (sneha poorvaka virechana) withshaman measures in the management of essential HTN.Research design: It was an clinical study , single group comprises of pre and post test design.Sources of Data Patients of either sex diagnosed to be suffering from Essential HTN wereselected from the OPD, IPD and also from special camp conducted in GovernmentAyurveda Medical College, Hospital, Mysore.Sampling 45 cases of Essential HTN were selected incidentally. The patients wereregistered for the present study with the help of proforma prepared for the study.Inclusion Criteria • Patients of either sex between the age group 30-70 years were selected. • Freshly detected and untreated cases of Essential Hypertension were selected • Established cases of Essential Hypertension and who have discontinued previous medications were selected. • Both symptomatic and asymptomatic cases were selected. • Stage 1 Essential hypertension and stage 2 Essential Hypertension patients were included for the study.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 54
  • 67. Dr.G.H.Ananthasayana 2010Exclusion Criteria • Patients suffering from any other systemic disorders which interfere with the course of the disease and treatment were excluded. • Patients who are unfit for virechana karma were excluded.Diagnostic Criteria The diagnosis was made based on The Seventh Report of the Joint NationalCommittee on Prevention, Detection, Evaluation, and Treatment of HBP (JNC 7) of Stage 1 hypertension 140–159 or 90–99 Stage 2 hypertension ≥ 160 or ≥ 100Assessment Criteria The assessment was done with respect to the change in Blood pressure, byconsidering systolic, diastolic Blood pressure at various intervals. The data wascollected and evaluated prior to the commencement of treatment, periodically duringthe course of treatment and after the completion of treatment.The data were collected and assessed at following intervals , • Prior to commencement of treatment • after snehapana • After swedana • after virechana • On 25th day of treatment • On 35th day of treatment • After the completion of treatmentInvestigationsThe selected patients were subjected to following investigations . • Blood- Hb% TC, DC, ESR, FBS , PPB,, Lipid profile • Urine -Sugar, Albumin, MicroscopyMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 55
  • 68. Dr.G.H.Ananthasayana 2010Amapachana Panchakola churna was administered to the patients for the purpose ofagnideepana and amapachana, in a dose of 3gm three times a day with ushnodhaka asanupana before food, till nirama lakshana was observed.Shodhananga snehapana. For the purpose of Shodhananga snehapana moorchita tila taila administeredin arohana vidhi i.e. 30, 50, 70, 90, 110, 130, 150, ml till samyak snigdha laxanas areseen.Swedana Sarvanga abhyanga and ushnajala snana was given for 3 daysVirechana with trivrit lehya Virechana was given with trvrut lehya 10 to15 gm depending upon the koshtaof pts. After observing shuddhi laxanas samsarjana karma was advised.Follow up with Shamanoushadhi Moorchita tila taila 30 ml/day and cap Tagara 1 bd administered asshamanoushadhi.Diet and Other Instructions All patients were advised to avoid spicy, very cold, very hot and bakery / hotelfood. Also advised to curtail excess salt and fat intake. The patients were instructedto give up their habit of smoking and alcohol, and also advised to avoid excessworries and tensions.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 56
  • 69. Dr.G.H.Ananthasayana 2010Statistical Methods Applied: • Descriptive statistics, cross tabs procedure, paired samples t test. • The paired sample t test procedure compares the means of two variables for a single group. • The statistical analysis was done by using the Blood pressure value in comparison with various intervals of treatment using paired t test and repeated measure of ANOVA.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 57
  • 70. Dr.G.H.Ananthasayana 2010OBSERVATION AND RESULTS : In the present study 45 patients were registered out of which 30 ptsconsidered for study who taken complete treatment. Table 11: Showing the incidence of Age Frequency Percent Valid Percent Cumulative Percent 30-40 2 6.7 6.7 6.7 41-50 5 16.7 16.7 23.3 51-60 17 56.7 56.7 80.0 61-70 6 20.0 20.0 100.0 Total 30 100.0 100.0 Illustration 3: Showing the incidence of Age 18 16 14Frequency 12 10 8 6 4 2 0 30-40 41-50 51-60 61-70 Age group in years The study revealed that a maximum No. of patients 17 between the age Groupof 51-60 years (56.7%) follow by 6patients of the age group 61-70 (20.0%) , 5patients (16.7%) between 41-50 and 2 patients (10.2%) between 30-40 age group .MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 58
  • 71. Dr.G.H.Ananthasayana 2010 Table No. 12 showing the incidence of SEX Frequency Percent Valid Percent Cumulative Percent Male 20 66.7 66.7 66.7 Female 10 33.3 33.3 100.0 Total 30 100.0 100.0 Illustration 4: showing the incidence of SEX Femal The study showed higher e incidence of Male patients 20 Male (66.7%) than Female patients i.e., 10 (33.3%). Table No. 13 showing the incidence of Occupation Frequency Percent Valid Percent Cumulative Percent House wife 10 33.3 33.3 33.3 Agriculture 8 26.7 26.7 60.0 Govt servant 2 6.7 6.7 66.7 private 10 33.3 33.3 100.0 Total 30 100.0 100.0Illustration 5: Showing the incidence of Occupation The observation revealed a 10 maximum 8 patients of housewives 10 6 Frequency (33.3%) and private 4 2 10(33.3%) followed by 0 agriculturist 8 (26.7%), 2patients (6.7%) were govt servants. Occupational statusMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 59
  • 72. Dr.G.H.Ananthasayana 2010 Table 14 : Showing the incidence of Marital status Frequency Percent Valid Percent Cumulative Percent married 29 96.7 96.7 96.7 Un married 1 3.3 3.3 100.0 Total 30 100.0 100.0 Illustration 6: Showing the incidence of marital status Married The Study included 29 (96.7%) married and 1 (3.3%) unmarried patients. Table 15 : Showing the incidence of religion Frequency Percent Valid Cumulative Percent Percent Valid Hindu 29 96.7 96.7 96.7 muslim 1 3.3 3.3 100.0 Total 30 100.0 100.0 Illustration 7: Showing the incidence of religion Among 30 patients 29 Hindu (96.7%) were Hindu and 1 (3.3 %) were Muslim. MuslimMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 60
  • 73. Dr.G.H.Ananthasayana 2010 Table 16: Showing the incidence of Socio- Economic Status Frequency Percent Valid Percent Cumulative Percent Valid Poor 4 13.3 13.3 13.3 Lower middle 16 53.3 53.3 66.7 Upper middle 10 33.3 33.3 100.0 Total 30 100.0 100.0Illustration 8: Showing the incidence of Socio- Economic Status Out of 30 patients Upper Poor 16 (53.3%) were middle from lower middle class 10 (33.3%) Lower from upper middle middle class, 4 (13.3%) from poor class Table 17: Showing the incidence of Fresh / Treated cases Frequency Percent Valid Percent Cumulative Percent Valid Freshly 22 73.3 73.3 73.3 Treated 8 26.7 26.7 100.0 Total 30 100.0 100.0Illustration 9: Showing the incidence of Fresh / Treated cases Treated The study included 22 Freshly (73.3%) fresh and 8 (26.7%) treated casesMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 61
  • 74. Dr.G.H.Ananthasayana 2010Table 18 : Showing the incidence of Locality Frequency Percent Valid Percent Cumulative Percent Valid Rural 7 23.3 23.3 23.3 Urban 23 76.7 76.7 100.0 Total 30 100.0 100.0Illustration 10: Showing the incidence of Locality Rural Out of 38 patients 23 (76.7%) were from Urban urban locality and 7 (23.3%) from rural Table 19 : Showing the incidence of Symptomatic / Asymptomatic Frequency Percent Valid Cumulative Percent Percent Valid Symptomatic 6 20.0 20.0 20.0 A 24 80.0 80.0 100.0 Symptomatic Total 30 100.0 100.0Illustration11: Showing the incidence of Symptomatic / Asymptomatic A Symptomatic Out of 30 patients 6 (89.5%) were symptom and 24 (10.5%) were Symptomatic asymptomaticMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 62
  • 75. Dr.G.H.Ananthasayana 2010 Table 20 Showing the incidence of Nature of work Frequency Percent Valid Percent Cumulative Percent Valid Hard 7 23.3 23.3 23.3 Moderate 4 13.3 13.3 36.7 Sedentary 19 63.3 63.3 100.0 Total 30 100.0 100.0Illustration 12: Showing the incidence of Nature of work Observation Hard revealed 19 patients Sedentar Medium (63.3%) had y hard sedentary work 7(23.3%) hard, 6 had moderate workTable 21: Showing the incidence of prakruti Frequency Percent Valid Percent Cumulative Percent Valid VP 16 53.3 53.3 53.3 VK 6 20.0 20.0 73.3 KV 5 16.7 16.7 90.0 KP 3 10.0 10.0 100.0 Total 30 100.0 100.0 Illustration 13: Showing the incidence of prakriti The observation revealed a maximum of vatapitta 20 prakriti 16 (53.3%), 15 followed by vatakaphaFrequency 10 prakriti6 (20.0%),kapha vata 5 5 (16.7%) and 3 (10.0%%) 0 patients belonged to kapha VP VK Prakriti KV KP pitta prakritiMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 63
  • 76. Dr.G.H.Ananthasayana 2010 Table 22: Showing the incidence of Kostha Frequency Percent Valid Percent Cumulative PercentValid Mridu 5 16.7 16.7 16.7 Madhyama 22 73.3 73.3 90.0 kroora 3 10.0 10.0 100.0 Total 30 100.0 100.0Illustration 14: Showing the incidence of Kostha Out of 30 patients 22 Kroora Mridu (73.3%) had madyama kostha 5 (16.7%) had mridu Madhyam a kostha and 3 (10.0%) had krura kostha. Table 23: Showing the incidence of Diet Frequency Percent Valid Percent Cumulative PercentValid Veg 5 16.7 16.7 16.7 Mixed 25 83.3 83.3 100.0 Total 30 100.0 100.0 Illustration 15: Showing the incidence of Diet Vegetarian Observation on diet revealed maximum patients had mixed diet 25 (83.3%) Mixed and 5 (16.7%) patients vegetarian diet.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 64
  • 77. Dr.G.H.Ananthasayana 2010 Table 24: Showing the incidence of Habit Frequency Percent Valid Percent Cumulative Percent Valid Absent 18 60.0 60.0 60.0 Smoking 1 3.3 3.3 63.3 Alcoholic 1 3.3 3.3 66.7 Both 10 33.3 33.3 100.0 Total 30 100.0 100.0 Illustration 16: Showing the incidence of Habit 20 15Frequency 10 5 0 Absent Smoking Alcoholic Both Habits The study of revealed 10 (33.3%) patients had the habit of alcohol andsmoking, 1(3.3%) patient had the habit of smoking 1(3.3%) patient had the habit ofalcohol and non smokers , non alcoholics are 18 (60%).MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 65
  • 78. Dr.G.H.Ananthasayana 2010 Table25: Showing the incidence of Family History Frequency Percent Valid Percent Cumulative Percent Valid Absent 17 56.7 56.7 56.7 Present 13 43.3 43.3 100.0 Total 30 100.0 100.0The study of revealed 10 (33.3%) patients had the habit of alcohol and smoking,1(3.3%) patient had the habit of smoking 1(3.3%) patient had the habit of alcohol andnon smokers , non alcoholics are 18 (60%). Table26: Showing the incidence of Salt Frequency Percent Valid Percent Cumulative Percent Valid Absent 12 40.0 40.0 40.0 Present 18 60.0 60.0 100.0 Total 30 100.0 100.0Out of 30 patients 18 (60.0%) patients had history of excesses salt intake and 12(12.0%) had history excesses salt intake. Table27: Showing the incidence of Stress Frequency Percent Valid Percent Cumulative Percent Valid Absent 13 43.3 43.3 43.3 Present 17 56.7 56.7 100.0 Total 30 100.0 100.0Out of 30 patients 13 patients (43.3 %) had no stress and 17 patients (56.7%) hadstress.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 66
  • 79. Dr.G.H.Ananthasayana 2010STATISTICAL ANALYSIS OF RESULTS The data collected at various intervals which are used for the assessment werethe Blood pressure recordings, i.e., systolic, diastolic and mean arterial Blood pressureThe result was assessed with respect to these objective parameters. The statistical analysis of the result was done using Chi-Square Test studentpaired‘t’ test and repeated measure ANOVA test. Table 28: Descriptive statistics of SBP Mean Std. Deviation NSBP_BT 159.4667 9.46767 30SBP_SNE 133.7333 9.06274 30SBP_SWE 135.0000 9.56646 30SBP_VIRE 130.0000 7.94811 30SBP_25D 134.3333 12.48539 30SBP_35D 131.0000 12.72250 30SBP_AT 130.6000 13.02676 30MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 67
  • 80. Dr.G.H.Ananthasayana 2010 Table 29: Paired Samples Statistics of SBP Mean N Std. Deviation Std. Error Mean Pair 1 SBP_BT 159.4667 30 9.46767 1.72855 SBP_SNE 133.7333 30 9.06274 1.65462 Pair 2 SBP_BT 159.4667 30 9.46767 1.72855 SBP_SWE 135.0000 30 9.56646 1.74659 Pair 3 SBP_BT 159.4667 30 9.46767 1.72855 SBP_VIRE 130.0000 30 7.94811 1.45112 Pair 4 SBP_BT 159.4667 30 9.46767 1.72855 SBP_25D 134.3333 30 12.48539 2.27951 Pair 5 SBP_BT 159.4667 30 9.46767 1.72855 SBP_35D 131.0000 30 12.72250 2.32280 Pair 6 SBP_BT 159.4667 30 9.46767 1.72855 SBP_AT 130.6000 30 13.02676 2.37835 Table 30: Paired Samples Test of SBP t df Sig. (2-tailed) Pair 1 SBP_BT - SBP_SNE 14.938 29 .000 Pair 2 SBP_BT - SBP_SWE 13.586 29 .000 Pair 3 SBP_BT - SBP_VIRE 19.715 29 .000 Pair 4 SBP_BT - SBP_25D 9.951 29 .000 Pair 5 SBP_BT - SBP_35D 13.267 29 .000 Pair 6 SBP_BT - SBP_AT 14.439 29 .000 This table shows significant difference in mean systolic blood pressureafter snehapana when it compared with mean systolic blood pressure beforetreatment and it will maintain throughout the treatment with p value 0.000.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 68
  • 81. Dr.G.H.Ananthasayana 2010 Table 31: Paired Samples Statistics( SNE TO AT) Mean N Std. Deviation Std. Error Mean Pair 1 SBP_SNE 133.7333 30 9.06274 1.65462 SBP_SWE 135.0000 30 9.56646 1.74659 Pair 2 SBP_SNE 133.7333 30 9.06274 1.65462 SBP_VIRE 130.0000 30 7.94811 1.45112 Pair 3 SBP_SNE 133.7333 30 9.06274 1.65462 SBP_25D 134.3333 30 12.48539 2.27951 Pair 4 SBP_SNE 133.7333 30 9.06274 1.65462 SBP_35D 131.0000 30 12.72250 2.32280 Pair 5 SBP_SNE 133.7333 30 9.06274 1.65462 SBP_AT 130.6000 30 13.02676 2.37835 Table32: Paired Samples Test( SNE TO AT) T df Sig. (2-tailed)Pair 1 SBP_SNE - SBP_SWE -.845 29 .405Pair 2 SBP_SNE - SBP_VIRE 2.525 29 .017Pair 3 SBP_SNE - SBP_25D -.318 29 .752Pair 4 SBP_SNE - SBP_35D 1.481 29 .149Pair 5 SBP_SNE - SBP_AT 1.332 29 .193 This table shows insignificant difference in mean systolic blood pressureafter swedana ,virechana, during shamanaushadha and at the end of treatmentwhen compared to mean systolic blood pressure after snehapana with p value>0.005. It means mean systolic blood pressure maintained throughout thetreatment after snehapana. Table 33: Descriptive Statistics of DBP Mean Std. Deviation N DBP_BT 90.6000 2.88396 30 DBP_SNE 82.6667 3.94211 30 DBP_SWE 82.2000 5.15551 30 DBP_IRE 81.3333 3.76310 30 DBP_25D 82.9333 6.00536 30 DBP_35D 82.2667 6.23081 30 DBP_AT 80.7333 7.41821 30MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 69
  • 82. Dr.G.H.Ananthasayana 2010 Table 34: Paired Samples Statistics of DBP Mean N Std. Deviation Std. Error Mean Pair 1 DBP_BT 90.6000 30 2.88396 .52654 DBP_SNE 82.6667 30 3.94211 .71973 Pair 2 DBP_BT 90.6000 30 2.88396 .52654 DBP_SWE 82.2000 30 5.15551 .94126 Pair 3 DBP_BT 90.6000 30 2.88396 .52654 DBP_IRE 81.3333 30 3.76310 .68704 Pair 4 DBP_BT 90.6000 30 2.88396 .52654 DBP_25D 82.9333 30 6.00536 1.09642 Pair 5 DBP_BT 90.6000 30 2.88396 .52654 DBP_35D 82.2667 30 6.23081 1.13758 Pair 6 DBP_BT 90.6000 30 2.88396 .52654 DBP_AT 80.7333 30 7.41821 1.35437 Table35: Paired Samples Test T df Sig. (2-tailed) Pair 1 DBP_BT - DBP_SNE 11.208 29 .000 Pair 2 DBP_BT - DBP_SWE 8.154 29 .000 Pair 3 DBP_BT - DBP_IRE 13.601 29 .000 Pair 4 DBP_BT - DBP_25D 5.845 29 .000 Pair 5 DBP_BT - DBP_35D 7.070 29 .000 Pair 6 DBP_BT - DBP_AT 7.153 29 .000 This table shows significant difference in mean diastolic blood pressureafter snehapana when it compared with mean diastolic blood pressure beforetreatment and it will maintain throughout the treatment with p value 0.000.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 70
  • 83. Dr.G.H.Ananthasayana 2010 Table 56: T-Test: Paired Samples Statistics( SNE TO AT) Mean N Std. Deviation Std. Error MeanPair 1 DBP_SNE 82.6667 30 3.94211 .71973 DBP_SWE 82.2000 30 5.15551 .94126Pair 2 DBP_SNE 82.6667 30 3.94211 .71973 DBP_IRE 81.3333 30 3.76310 .68704Pair 3 DBP_SNE 82.6667 30 3.94211 .71973 DBP_25D 82.9333 30 6.00536 1.09642Pair 4 DBP_SNE 82.6667 30 3.94211 .71973 DBP_35D 82.2667 30 6.23081 1.13758Pair 5 DBP_SNE 82.6667 30 3.94211 .71973 DBP_AT 80.7333 30 7.41821 1.35437 Table37: Paired Samples Test( SNE TO AT) t df Sig. (2-tailed)Pair 1 DBP_SNE - DBP_SWE .571 29 .573Pair 2 DBP_SNE - DBP_IRE 2.137 29 .041Pair 3 DBP_SNE - DBP_25D -.224 29 .825Pair 4 DBP_SNE - DBP_35D .355 29 .725Pair 5 DBP_SNE - DBP_AT 1.403 29 .171 This table shows insignificant difference in mean diastolic blood pressureafter swedana , virechana, during shamanoushadha and at the end of treatmentwhen compared to mean diastolic blood pressure after snehapana with p value>0.005. It means mean diastolic blood pressure maintained throughout thetreatment after snehapana.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 71
  • 84. Dr.G.H.Ananthasayana 2010General Linear Model for systolic Blood pressureThe Mean Systolic Blood pressure before treatment is 159.4667The Mean Systolic Blood pressure after snehapana is 133.7333The Mean Systolic Blood pressure after swedana is 135.0000The Mean Systolic Blood pressure after virechana is 130.0000 thThe Mean Systolic Blood pressure on25 day is 134.3333 thThe Mean Systolic Blood pressure on 35 day is 131.0000The Mean Systolic Blood pressure after treatment is 130.6000 Illustration 17: General Linear Model for systolic Blood pressure 165 160 155 150 Mean SBP values 145 140 135 130 125 Before Snehapana Swedana Virechana 25th day 35th day After Treatment Treatment Treatments After applying repeated measure ANOVA, the table showed Highlysignificant differences in mean systolic Blood pressure, before and after treatmentwith P value < 0.001. .MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 72
  • 85. Dr.G.H.Ananthasayana 2010 General Linear Model for Diastolic Blood pressureThe Mean diastolic Blood pressure before treatment is 90.6000The Mean diastolic Blood pressure after snehapana is 82.6667The Mean diastolic Blood pressure after swedana is 82.2000The Mean diastolic Blood pressure after virechana is 81.3333The Mean diastolic Blood pressure on25 th day is 82.9333The Mean diastolic Blood pressure on 35 th day is 82.2667The Mean diastolic Blood pressure after treatment is 80.7333 Illustration 18: General Linear Model for Diastolic Blood pressure 93 91 89 87 Mean DBP 85 83 81 79 Before Treatment Snehapana Swedana Virechana 25th day 35th dayAfter Treatment Treatments The change in Diastolic Blood pressure from before and after treatmentis statistically highly significant with P value < 0.001Illustration 19 General Linear Model for both systolic and Diastolic B P 170 160 150 Mean Blood pressures 140 130 120 110 100 90 80 SBP Before Snehapana Swedana Virechana 25th day 35th day After DBP Treatment Treatment TreatmentsMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 73
  • 86. Dr.G.H.Ananthasayana 2010 Table 38: Showing Overall Assessment Normal Pre-HTN Stage 1 HTN Stage 2 HTNBT 0 0 10 20AT 4 14 12 0 Table 38: HT_CATBT * Treatment Cross tabulation TREATMEN Total BT ATHT_CATBT Stage 1HT Count 10 12 22 % within treatment 33.3% 40.0% 36.7% Stage 2HT Count 20 0 20 % within treatment 66.7% .0% 33.3% Pre HT Count 0 14 14 % within treatment .0% 46.7% 23.3% Normal Count 0 4 4 % within treatment .0% 13.3% 6.7%Total Count 30 30 60 % within treatment 100.0% 100.0% 100.0% Illustration 20: Showing Overall Assessment Stage 2HT Stage 1HT Pre HT Normal 20 15 Frequency 10 5 0 Before treatment After treatment TreatmentsMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 74
  • 87. Dr.G.H.Ananthasayana 2010 Table 39: T-Test: Paired Samples Statistics Mean N Std. Deviation Std. Error Mean Pair 1 WT_BT 62.0667 30 11.34698 2.07167 WT_AT 60.2333 30 9.55450 1.74441 Table 40: Paired Samples Test t df Sig. (2-tailed) Pair 1 WT_BT - WT_AT 3.628 29 .001 Illustration 21: Showing mean wt before and after treatment 62.5 62 61.5Mean weight 61 60.5 60 Before Treatment After Treatment Duration • Mean wt before treatment - 62.0667 • Mean wt after treatment - 60.2333 MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 75
  • 88. Dr.G.H.Ananthasayana 2010GENERAL OBSERVATIONBefore Starting Treatment Most of the pts considered for the treatment are asymptomatic and freshlydetected. Symptomatic HTN cases are 6 out of 30 and they presented with shirahshoola, bhrama, hridrava, klama, anidrata. These are mostly present in treated casesand freshly detected cases are asymptomatic except 2 cases. In both fresh and treated cases, three consecutive blood prssure readings weretaken in supine, sitting and standing position to define initial Blood pressure.During snehapana After amapachana, snehapana in arohana vidhi was done maximum for 7 daysor till samyak snigdha laxanas .During this marked reduction in blood pressure wasobserved. The reduction in BP was more marked in fresh cases than treated one. Along with reduction in BP relief of symptoms like shirah shoola, bhrama,klama, anidrata, hridrava also observed in symptomatic HTN cases. Some pts are uncomfortable with the odour of the medicine.During swedana: During swedana there is slight increase in blood pressure observed.After virechana Reduction in blood pressure observed after virechanaDuring shamanaushadha Blood pressure which was reduced during snehana,swedana and aftervirechana will maintained during shamanaushadha. For 3 pts arjin (1bd), silidine (2 at BT) added due to poor response and alsothem c/o anidrata. And for 2 pts arjin (1BD) added.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 76
  • 89. Dr.G.H.Ananthasayana 2010 DISCUSSION Essential Hypertension is a psychosomatic hemodynamic disease with a multi-factorial pathology and origin of several dietary, environmental and genetic factors.Modern medical science has already invented so many medicines, to keep the bloodpressure in its normal ranges. But all these Drugs have a long list of adverse effectwith them. The Ayurvedic medicine gives side Benefits instead of side effects. The present study was undertaken to find a better way in the management ofHTN in ayurvedic perspectives. The aim of the present study is to asses’ efficacy ofsneha poorvaka virechana with shamanaushdha in the management of Essential HTN.DISCUSSION ON MATERIALSPanchakola churna Panchakola churna was selected for the purpose of deepana pachana and it isindicated in medoroga vatakaphaja rogas. All the drugs present in this are shrestadeepana pachana sroto shodhaka and vatanulomaka.Moorchita tila taila For snehapana tila taila moorchana with sarpagandha ashwagandha, amalaki ,arjuna jatamamsi, was used in arohana vidhi. These drugs are used, considering thebeneficial effect that they provide in lowering blood pressureTila taila: Studies reported that sesamin, a lignan from sesame oil, exertsantihypertensive action by interfering with renin-angiotensin system.The bloodpressure-lowering effect of sesame oil may be due to its richness of antioxidantlignans (sesamin, episesamin, sesamol, and sesamolin), vitamin E, and unsaturatedfatty acids.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 77
  • 90. Dr.G.H.Ananthasayana 2010Sarpagandha: The Constituent that helps to lower HBP is Reserpine, an alkaloid substancewith powerful sedative effect found in the root. Reserpine works by significantlylowering catecholamine’s stored in adrenergic nerves and in the heart. This slowsdown the heart rate and helps open up capillaries and arterioles which in turn cause areduction in blood pressure.Ashwagandha: Ashwagandha is beneficial in stress related disorders, like, arthritis,hypertension diabetes, general debility, etc. It works as a rasayan that helps in preventing early aging and rejuvenates thewhole body. The herb is considered as an adaptogen that stimulates the immune system andimproves the memory.Due to its good penetrating powers, the herb promotescalmness and mental satisfaction.Amalaki: It is the one of the best anti-oxidants acknowledged by mankind. It drasticallyimproves your mental stamina. The fruit is well known as a brain tonic. It aids inimproving your brain function and improves your means of mental concentration. It isa very useful tool for improving the body’s immunityArjuna: The bark of Arjuna which is rich in Co-enzyme Q-10. Co-enzyme Q-10 is acatalyst in the production and transportation of energy required for normalfunctioning of the organs. Incidentally , the heart and the liver have the highestdemand for Co Q-10 because of the nature of their function. Co Q-10 depletes with age and as we reach our fifties, the heart musclesbecome weaker resulting in high blood pressure and palpitations Supplementation ofCo Q-10 is thus required to improve heart function and lower high blood pressureMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 78
  • 91. Dr.G.H.Ananthasayana 2010Jatamamsi: Oil extracted from Nardostachys jatamansi is Spikenard oil. The mainchemical components are bornyl acetate, valeranone, jonon, tetramenthyloxatricylodecanol, menthylthymyl-ether and 1, 8-cineol. Therapeutic properties ofspikenard oil are anti-inflammatory, anti- pyretic, antiseptic, calmative, sedative,laxative and tonic. Sarvadhaihika Abhyanga and swedana (ushna jala snana ) was done for 3 daysfollowed by virechana karma with trivrit lehya(10g to 15g).Shamana yoga: Moorchita tila taila 30 ml /day and cap tagara 500mg bdOn the basis of the principle explained in charaka siddistana 6 th chapter 7 th sloka ,that after shodhan ,for elimination of residual doshas ,again sneha has to beadministered. So in this study after samsarjana karma moorchita tila taila 30 ml/ dayadministered as shamananga snehapana . Tagara can lower the stress and strain and also controls high blood pressure.DISCUSSION ON METHODSSelection of patients The present study consists of patients of both sexes in the age group 30 to 70years with mild to moderate hypertensionDiagnostic and Assessment Criteria The diagnosis was made mainly on the basis of Blood pressure readings.Patients with stage 1 and stage 2 Hypertension as per JNC7 report . The results were assessed on systolic ,diastolic arterial Blood pressure .The rationality behind the consideration of only objective parameter for diagnosis andassessment was asymptomatic nature of Essential HypertensionLaboratory Investigations Since there is no specific laboratory investigation to confirm EssentialHypertension, the patient were subjected to laboratory investigation with followingintentionsMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 79
  • 92. Dr.G.H.Ananthasayana 2010 To rule out secondary form of Hypertension. To assess the complication andtarget organ damage.To detect the presence of other systemic disorders this mayinterfere with the study.Inclusion criteria The persons between the age group of 30-70 of were selected as theoccurrence of essential HTN is more between these groups. As the method of sampling was incidental both treated and untreated caseswere selected. Stage 1 and stage 2 essential HTN were selected as most patients fall to thiscategory and since they are not incompatible to life requiring no emergencymanagements.Exclusion criteria Patients with severe degree of Hypertension were excluded as it requiresemergency management. Patients with other systemic disease like diabetes peripheral vascular disease,cardiac disease, renal disease were excluded as they interfere with the disease as wellas treatment. Patients who were unfit for sneha poorvaka virechana were excluded from thestudy.DISCUSSION ON OBSERVATION:Dropouts Total 45 patients were registered for the study, out of which 14 patients thoughfit for shodhana were un able to take shodhana due to their personal problems .1 ptstarted with snehapana was unable to continue 3ed day onwards .Hence 30 pts wereconsidered for the study.Age In this study majority of 17 patients were in the age group of 51-60 years asBlood pressure raises with age and incidence of Essential Hypertension is more after40 years ofage.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 80
  • 93. Dr.G.H.Ananthasayana 2010Sex The study revealed high incidence of Hypertension in males when comparedto females because males have higher chance of getting Hypertension below the ageof 65 when compared to females. Before age 50, women have a lower prevalence of hypertension than men,particularly in premenopausal women, but after age 55, they have a higherprevalence .In our study: female - 8 ≥55, 2 < 55(54, 48) Male- 11 ≥ 55 , 9< 55Occupation The study shows that house wives and govt servants numbering 10 and 2respectively had sedentary type of life style. Agriculturist and private workersnumbering 8 and 10 were very hard workers. both the sedentary life style and very hard work will have negative impact onCVS.Marital status Maximum of 29 patients were married as Essential Hypertension is a diseaseof advancing age. Here marital status has insignificant role.Religion Out of 30 patients 29 were Hindu , Here Religion has insignificant role.Education There is even distribution of patients as for as education status is concerned.Status of education is having significant relation with Hypertension.Socio –Economic status Maximum of 17 patients from lower middle class is due to majority of lowermiddle class people in the population.Locality Maximum of 23 patients were from urban locality . Here locality has asignificant role since urban life is more stressful.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 81
  • 94. Dr.G.H.Ananthasayana 2010Genetic influence Out of 30 patients 13 are having family history of Hypertension indicatingfamilial occurrence of Essential Hypertension and Though, it is a multi-factorial disease but genetic and constitutional factors aremain. Several studies have already been carried and showed that EHT ran throughfamiliesSymptomatic / Asymptomatic In the study it was observed that maximum of 24 patients were asymptomaticwhen compared to 6 symptomatic patients. As 90 to 95% of Essential HTN cases are asymptomatic and hence the samereflected in our study.Work Out of 30 pt 19 pts had sedentary life style, which is one of the causes forEssential HTN. And 7 pts were hard working which is also had negative influence onCVS.Salt Out of 30 pts 18 pts had history of excess intake of salt which is one of themain aggravating cause for HTN.Prakriti Maximum of 16 patients were of vatapitta prakriti followed by 6 of vatakaphaprakriti indicating vata predominance .Diet Maximum patients 25 had mixed diet. Consumption of excess non-vegetariandiet consisting of high fat content is a predisposing factor for Hypertension.Habit 18 pts were teetotalers. 1 pt was alcoholic , 1 pt was chronic smoker , 10 ptswere both alcoholics and smokers.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 82
  • 95. Dr.G.H.Ananthasayana 2010 Smoking alone can increase blood pressure by 10 mmHg over a non-smoker.Smoking also causes direct damage to blood vessels and can hasten the complicationsof high blood pressure. Consumption of alcohol increases contractibility and excitability of heartwhich increase cardiac output. As cardiac output directly proportional to the bloodpressure , blood pressure also increaseStress The study revealed maximum of 17 patients had stress. People who havemental stress, poor coping mechanisms, and anxiety are at increased risk for highblood pressure. Depression has also been linked to increased risk of hypertension. Thisdemonstrates the mind-body connection and how we must take care of our mental aswell as physical health.DISCUSSION ON RESULTS The result of the study related that sneha poorvaka virechana and shamansneha along with tagara has a definite role in lowering Blood pressure showedstatistically highly significant with P value < 0.001 After shodhananga snehapana there was marked reduction in Blood pressure .After swedana there is slight increase in blood pressure but after virechana again therewas reduction in Blood pressure. Blood pressure which is reduced with snehapoorvaka virechana will maintained through out the treatment (shamanaushdha)except in 5 pts who required additional anti hypertensive drugs. Table shows there is marked reduction in systolic blood pressure aftershodhananga snehapana.ie mean SBP is reduced from 159.4667 mmhg to 133.7333and mean DBP reduced from90.6000 to 82.6667 After swedana there is slight raise in blood pressure observed. I.e. mean SBPis increased from133.7333 mmhg to135.0000 and mean DBP reduced from82.6667to 82.2000 After virechana there is slight reduction in blood pressure observed. I.e. meanSBP is increased from135.0000 mmhg to 130.0000 and mean DBP reduced from82.6667 to 81.3333MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 83
  • 96. Dr.G.H.Ananthasayana 2010 On 25 th day of treatment mean SBP is increased from 130.0000 to 134.3333and Mean DBP to 82.9333 On 35 th day of treatment mean SBP is to131.0000 and Mean DBP is to82.2667 On 48 th day treatment mean SBP is to 130.6000and Mean DBP is to 80.7333Freshly detected cases Out of 30 cases 22 are the freshly detected cases responded very well.About treated HTN cases Out of 30 cases 8 are treated cases. Out of 8 HTN treated cases, 2 pts approaches after stopping allopathic drugs, 3 pts are on ayurvedic drugs like abana, arjin, and these drugs are stoppedduring snehapana, 2 pts are on Aten 25 for 2 to 3 years, and these are possible to stop aftersnehapana, 1 pt is on angiocam (amlodopin+atenlol).for this pt half of this tab reduced thafter snehapana, ¼ was reduced after shamanaushadha.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 84
  • 97. Dr.G.H.Ananthasayana 2010RECOMMENDATION FOR FUTURE STDUY • In future pharmacological as well as photochemical study should be planned. • Study can be conducted with the help of rasaushadhis. • Sublingual administration of antihypertensive drugs can be tried for emergency management. • Study can be conducted with ambulatory blood pressure monitoring (ABPM) device as it is far better method than clinical measurements. It is believed to be able to reduce the white coat hypertension effect.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 85
  • 98. Dr.G.H.Ananthasayana 2010 CONCLUSION • The disease Essential Hypertension cannot be correlated to a single disease entity explained in Ayurveda. • The disease can be understood according to Ayurveda by understanding dosha, dooshyas, signs and symptoms exhibited by the patient. • If we analyze vidhishoniteeya adhyaya , kiyanta sirasiya adhyaya,we can concider HTN as abnormality of rakta dhatu popularly known as shonita dushti • Most of the patients are asymptomatic and a few presented with shirah shoola, bhrama, hridrava, klama, urah shoola. • The symptom like hridrava, anidra, urashoola were observed more in treated and chronic cases. • Sneha poorvaka virechana followed by shamanaushadha i.e. moorchita tila taila along with TAGARA showed highly significant result in freshly detected HTN cases. • Along with medicine, dietic restriction of salt and absence from risks factors also play important role. • Shodhanga snehapana reduces Blood pressure significantly during the treatment. • Systolic Blood pressure reduces faster than diastolic Blood pressure. • Reduction of symptoms and patients well being is also noticed during treatment.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 86
  • 99. Dr.G.H.Ananthasayana 2010 SUMMARY Modern life offers many convenience and comforts not dreamed by ourgrandparents. But we have paid a price for all this in the form of increased hazardsand risks. Beginning of 21st century brings gift of anxiety and more stress for modernsociety. This stress and strain of day today life affects ones bodily organs throughseveral psychological mechanism. Among the psychosomatic diseases, thecardiovascular disorder like hypertension is quite, significant disease. More ever thecomplications of this disease are more grievous than disease itself. Hypertension is one of the important public health problem affecting 30% ofthe population worldwide. Essential Hypertension with unknown etiology constitute95% of all Hypertension. The clinical entity similar to this is not found in any of the classical texts ofAyurveda. If we scan various recent ayurvedic books ,we find various different wordsthat are used for HTN like raktagata vata, siragata vata , raktavruta vata , pittavrutavata ,raktavega vriddi. But if we analyze vidhishoniteeya adhyaya , kiyanta sirasiyaadhyaya,we can concider HTN as abnormality of rakta dhatu popularly known asshonita dushti. It means shonita dushti itself is not HTN but shonita dushti includes groupof diseases from bleeding disorder like raktapitta to skin disorders like kusta. In thisHTN can also be included due to similarities in etiology , and clinical presentation. Also in the pathogenesis of HTN vitiated Vata Dosha was thought to be chiefculprit. Dhatugati (Rasagati) is performed by Vayu it self Pitta and Kaphacompliment the effect of vitiated Vata and aid the process of disease progression.While Rasa Rakta, being the chief mediator of vitiation. Hence the concept goes inaccordance, that the disease is tridosaja.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 87
  • 100. Dr.G.H.Ananthasayana 2010 The present study was carried out to evaluate the combined effect of snehapoorvaka virechana and shamanaoushadha in Essential HTN. The study comprises of two parts. First part deals with review of literature,consisting of paribhasha, shareera vivechana doshadushyadi vivechana, nidanapanchakas, upadrava, sadyasadhyata, chikitsa, pathyapathya and drug review. Alongwith the prevalence, classification and measurement of Blood pressure, functionalanatomy, regulation of Blood pressure, etiology, pathogenesis, pathology, signs andsymptoms, differential diagnosis, complications, prognosis of Essential Hypertension The second part of the dissertation is dedicated to clinical trial; this includesmaterial and methods, observation and results, statistical analysis of the results,discussion and conclusion. 30 patients were incidentally selected for the study excluding dropouts, of bothsexes between the age group of 30 to 70 years. The patients with stage 1 and stage 2 Hypertension as per the JNC 7 report,were taken for the study. The diagnosis was done based on Blood pressuremeasurement, all the patient was subjected to necessary investigation to fit intoinclusion criteria. All patients received deepana, pachana with panchakolachurna and thenshodhananga snehapana with moorchita tila taila in arohana vidhi for 7 days or tillsamyak snigdha laxanas observed. After sarvadhaihika abhyanga and parishekaswedana for 3 days, virechana with trivrit lehya was given . After samsarjana karma, shamanaoushadha was given which includesmoorchita tila taila 30 ml per day as shamananga snehapana along with cap Tagara500 mg 1 bd dose.Total treatment period was 48 days. Observations were done on Blood pressure values at regular intervals. Beforestarting treatment , after snehana,after swedana , after virechana,on 25th day oftreatment and after35th day of treatment and at the end of treatment. The observationsof the study also included the epidemiological features of the diseases. In the present study it was observed that HTN is more between the age groupof 51-60 years in people belonging to urban area, lower middle class and non-MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 88
  • 101. Dr.G.H.Ananthasayana 2010vegetarian and who had stress and strain with or without family history ofHypertension. The result was assessed with respect to these objective parameters. Thestatistical analysis of the result was done using Chi-Square Test student paired ‘t’test and repeated measure ANOVA test. It was observed that there is significant difference in mean systolic, anddiastolic blood pressure after snehapana when it compared with mean systolic anddiastolic blood pressure before treatment and it will maintain throughout the treatmentwith p value 0.000. Sneha poorvaka virechana followed by shamanaushadha moorchita tilataila(30 ml/day) along with TAGARA 1 bd showed highly significant result in freshlydetected HTN cases.Reduction of symptoms and patients well being is also noticedduring treatment. The drugs.. Sarpagandha, Ashwagandha, amalaki, Arjuna, Jatamamsi wereselected for the preparation of moorchita tila taila which was used for bothshodhananga and shmananga snehapana. These drugs are proved to be effective inmanagement of Hypertension. In the management of HTN, blood pressure goal is to achieve <140/90. Inpatients with hypertension and diabetes or renal disease, the BP goal is <130/80mm Hg. In this study Mean systolic and diastolic BP before treatment is 159.46/90.60mmhg, and Mean systolic and diastolic BP after treatment is 130.60/80.73 mmhg. Reduction of symptoms and patients well being is also noticed duringtreatment.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 89
  • 102. Dr.G.H.Ananthasayana 2010 Master Chart E saltSl No Date OP NO AGE SEX RELIGION 0ccu MS EDU DIET KOSHTA SES LOC PRAKRITI F/T E salt I stress FH I stress HABIT 1 21.4.09 47 49 m H Carpenter M p M MA LMC R VP F P A p p A smo,alco 2 05.05.09 3246 60 f H H wife M p V MR LMC U VK F P P A P P A 3 25.05.09 5664 55 f H H wife M UE M MA UMC U VP F P A A P A A 4 11.06.09 7025 42 m H Bissiness M HS M MR UMC R VP F P P P P P A 5 08.07.09 8246 60 m H Agri M UE M MA UMC U KA F A A A A A A 6 09.07.09 10151 62 m H Agri M P M MA UMC U KV F P P A P P smo,alco 7 02.08.09 12809 52 m H electic con M G M MA UMC U VK F A P P A P A 8 19.09.09 17821 42 m H Agri M HS V MA LMC U VP F A P P A P P 9 09.11.09 20267 60 m H Agri M HS M MR POOR U VP F A P A A P smo,alco 10 21.01.09 25403 60 m H Agri M UE M K LMC U VP F P A A P A smo,alco 11 18.03.09 25196 70 f H H wife M UE M MA LMC R VP F A A A A A A 12 09.11.09 21568 65 m H Rtd M G M MA UMC U VK F A A A A A A 13 21.01.10 216 56 m H Finance M G M MA UMC U KV F P P P P P Smo 14 18.03.10 7347 55 f H H wife M UE M MR POOR U VP F A A A A A A 15 01.04.10 9286 60 m H Buisnes M HS V MA LMC U VP F P P A P P A MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 90
  • 103. Dr.G.H.Ananthasayana 2010 BP BP 35 N OF WORK FH S/AS WT BT WT AT CAT OF HTN BP BT BP A sne BP A SWE BP A VIRE 25TH D TH D BP AT H p AS 51 49 Stage 1 154/92 128/88 130/90 128/86 110/80 122/80 120/78 H A S 64 60 Stage 1 150/90 130/84 132/84 134/82 138/86 130/80 120/70 MH A AS 43 45 Stage 2 162/82 152/80 146/76 136/78 162/94 160/90 130/86 MH P AS 66 65 Stage 2 162/94 118/80 138/86 136/84 122/84 124/84 138/90 H A S 72 68 Stage 2 174/92 142/82 140/80 132/80 128/80 148/90 138/80 H A S 76 73 Stage 2 172/96 152/94 158/92 146/90 152/92 164/98 154/98 H P AS 75 69 Stage 2 170/90 140/90 152/94 140/84 160/96 146/90 160/92 H P S 80 77 Stage 1 140/90 126/84 134/84 120/84 130/80 134/82 130/90 H A S 55 54 Stage 2 178/86 142/80 146/82 134/82 130/82 130/80 124/70 H A AS 52 53 Stage 2 174/92 140/80 142/78 150/82 140/80 142/86 146/82 H A S 54 52 Stage 2 160/88 140/80 146/84 140/82 140/82 118/76 146/82 MA A AS 60 58 Stage 1 148/90 138/82 140/84 128/80 126/82 120/80 120/82 SED P AS 74 70 Stage 1 142/92 124/82 120/80 120/80 120/80 120/80 110/74 H A AS 55 53 Stage 2 160/86 136/72 120/78 120/72 154/90 130/78 130/80 MH A AS 55 52 Stage 2 160/92 130/82 132/84 128/80 120/76 110/70 120/70MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 91
  • 104. Dr.G.H.Ananthasayana 2010l No Date OP NO AGE SEX RELIGION 0ccu MS EDU DIET KOSHTA SES LOC PRAKRITI F/T E salt I stress FH E salt I Stress HABIT 16 29.04.10 13156 63 f H H wife M P V MR LMC U VP F P P A SED A S 17 17.05.10 8900 55 m M B ness M HS M K UMC U KP F P A A H P S 18 20.04.10 11687 59 m H tailering M P M MA LMC U KV F P P ALCO H A AS 19 06.04.10 701 34 m H electrical UM HS V MA LMC U KV F P P A SED P S 20 03.04.10 1792 53 m H agri M G M MA LMC U VP F A P smo,alco H P AS 21 31.03.10 58 m H proffesor M PG M MA UMC U KP F A P A SED P AS 22 15.04.10 5240 65 m H agri M UE M MA LMC R VP F A A smo,alco H A AS 23 15.05.10 14045 55 f H H wife M UE M MA LMC U VK F P P A SED A AS 24 03.06.10 17906 47 m H cook M HS M MA LMC U VP F P P smo,alco H P S 25 04.06.10 48 f H H wife M UE M MA LMC R VP F P A A H A AS 26 12.07.10 22215 35 m H build work M P M MA POOR U KP F A P smo,alco H P AS 27 13.07.10 22056 65 f H h wife M UE M MA LMC U VP F P A A SED A AS 28 12.07.10 1257 54 f H H wife M HS M MA UMC U VK F A P A SED P S 29 22.07.10 23496 55 m H agri M UE M M LMC R VP T P A smo,alco H P AS 30 30.07.10 22836 60 f H H wife M UE M K POOR R VK F P A A H A AS MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 92
  • 105. Dr.G.H.Ananthasayana 2010 N OF WORK FH S/AS WT BT WT AT CAT oF HTN BP BT BP A sne BP A SWE BP A VIRE BP 25TH D BP 35 TH D BP AT SED A S 48 50 Stage 2 160/86 124/82 128/84 122/74 130/70 134/82 136/84 H P S 70 66 Stage 1 158/90 146/84 144/84 132/80 148/94 140/90 142/84 H A AS 70 67 Stage 2 164/92 130/82 132/82 120/84 130/84 120/80 146/90 SED P S 84 80 Stage 1 150/94 120/78 130/70 122/74 128/72 130/84 130/80 H P AS 70 68 Stage 2 160/90 140/84 130/80 124/80 126/80 130/80 110/70 SED P AS 62 60 Stage 1 140/90 130/82 128/84 124/88 136/82 110/70 110/70 H A AS 51 52 Stage 2 160/90 130/84 130/78 130/84 130/80 134/70 140/70 SED A AS 49 51 Stage 2 160/94 144/82 132/72 130/80 140/80 144/84 140/82 H P S 57 60 Stage 2 160/90 130/82 130/84 120/82 130/84 132/90 120/80 H A AS 53 55 Stage 2 160/92 126/84 140/86 132/82 140/84 120/80 120/80 H P AS 86 81 Stage 2 160/90 120/88 120/76 122/80 120/80 124/82 120/80 SED A AS 60 58 Stage 2 170/92 136/80 132/82 134/84 124/80 130/84 140/80 SED P S 62 60 Stage 1 156/90 130/80 146/86 136/82 150/90 134/82 130/90 H P AS 52 54 Stage 2 160/94 140/86 130/82 134/80 130/80 120/82 118/76 H A AS 56 55 Stage 2 160/92 128/82 122/80 126/80 136/84 130/84 130/82MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 93
  • 106. Dr.G.H.Ananthasayana 2010 Key to master chart 1. SES= Socio Economic Status; 2. F/H = Family History; 3. S/AS = Symptomatic or Asymptomatic; 4. BT = Before Treatment; 5. DT = During treatment; 6. AT = After treatment; 7. F = Female; M = Male; 8. HW = House wife; 9. P = Poor; 10. UMC = Upper middle class; 11. LMC = Lower middle class; 12. R = Rich; 13. A = Absent; 14. P = Present; 15. R = Rural; 16. U = Urban; 17. M = Mridu; 18. Ma = Madhyama; 19. K = Krura; 20. S = Sedentary; 21. G = Graduate; 22. P = Primary; 23. Hs = High School 24. SNE=Snehana 25. SWE=swedana 26. Wt=Weight 27. Occ=Occupation 28. MS=Marital status 29. Smo=Smoking 30. Alco=alcohol 31. H=hard work 32. MH=medium hard 33. Sed=sedentaryMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 94
  • 107. Dr.G.H.Ananthasayana 2010 34. VP=vata pitta 35. VK=vata kapha 36. KP=kapha pitta 37. KV=kapha vathaMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 95
  • 108. Dr.G.H.Ananthasayana 2010 REFERENCES 1. 7th report of the JNC on prevention, detection, evaluation and treatment of HTN 2. Cha.Vi. 3/44 3. SU.24/18 4. Harrisons Internal Medicine > Chapter 241. Hypertensive Vascular Disease,17 th edition 5. Cha. Chi. 15/36 6. Su. Sa.4/3 7. Su. Sa. 4/34 8. Saptapatha Br. 14/8/4/1 9. Ch. Su. 30/12 10. Cha. Sa. 3/7 11. Cha.Vi. 5/7 12. Cha.Su. 30/12 13. . Su.Sa. 4/29 14. . Cha. Chi 15/17 15. Cha.Su. 30/12 16. Cha.Su. 30/12 17. 7 th report of the JNC on prevention, detection, evaluation and treatment of HTN 18. . Su. Su. 35 19. Su.14/19 20. Cha. Su. 24/5 21. Cha. Vi 1/15. 22. Su. Chi.24/80 23. Cha su .23/4-10 24. Cha su .23/11-22 + ki shi adhyaya 25. 7 th report of the JNC on prevention, detection, evaluation and treatment of HTN 26. . Cha.Su.10/7. 27. Cha.Chi.28/235 28. Haraison principle o Internal medicineMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 96
  • 109. Dr.G.H.Ananthasayana 2010 29. Cha. Su. 9/5. 30. report of the JNC on prevention, detection, evaluation and treatment of HTN 31. 7th report of the JNC on prevention, detection, evaluation and treatment of HTN 32. 7th report of the JNC on prevention, detection, evaluation and treatment of 7th report of the JNC on prevention, detection, evaluation and treatment of HTN HTN 33. 7th report of the JNC on prevention, detection, evaluation and treatment of HTN 34. Cha.Ka. 14 35. Dalhana on Su.Su. 46/529 36. Sa. Pu.4/7 37. Cha. Su. 4/13Sha. U. 4/13-14 38. Cha. Ka. 12/55-68. 39. Sha. U. 4/13-14. 40. Cha.Si.1/6, Cha.Su.13/15 41. As.Hr.Su.2/8-9. 42. Cha. Su. 4, Cha. Su. 9, 43. cha. Ka. 7 to 12, cha. Su 13, 44. Cha. Su. 25, 45. Su. Su. 38-39- 44, 46. As.Sa.Su.6-7-12-13-14-15-17, 47. Cha. Su. 1, 48. Cha. Su. 2, 49. Cha. Su. 4, 50. Cha. Su. 9, 51. cha. Ka. 7 to 12, 52. cha. Su 13, 53. ha. Su. 25, 54. Su. Su. 38-39- 44, 55. As.Sa.Su.6-7-12-13-14-15-17, 56. As.Sa.Ka. 2-3, 57. As. Hr. Su. 5-6-9-15,MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 97
  • 110. Dr.G.H.Ananthasayana 2010 58. As. Hr. Ka. 2, 59. Sha. Pu. 4, 60. Sha. U. 4.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 98
  • 111. Dr.G.H.Ananthasayana 2010 BIBLIOGRAPHY1. Ramasundar Rao, Shareera Kriyavignana 2nd edition 1994 Vijayawada – 22. C Guyton, Text Book of Medical Physiology (1998) edition Arthur, 1 st edition L.B. Sounder’s Company U.S.A.3. Harshamohan, Text Book of pathology 4th Edition (2000) Jaypee Brothers, Medical Publishers (P) Ltd., New Delhi4. Agnivesha, Charaka samhita, Ayurveda Dipika commentary of Chakrapanidatta revised by Charaka and Dridabala, ed, By Vaidya Jadavaji Trikamji Acharya, Chowkamba Sanskrit Samsthan, Varanasi, 5th edition, 2001.5. B.D. Chaurasia Human Anatomy Vol. I 3rd edition C.B.S. Publishers and distributers, New Delhi – 02.6. Chakrapani, Chakradatta (Chikitsa Sara Sangraha), Tatwa Chandrika commentary of Sri. Shivadassen, revised by Pandit Srimad Ashubodha Vidyabhushana and Pandit Srimad Nityabhoda Vaidyaratna, published by Chowkambha Orientalis, Varanasi, 1 st edition, 1993.7. David Son, David son’s principle and practice of medicine by C.R.W. Edwords, 8th edition.8. E. Golwalla Medicine for Students 17th edition The National Book Department, Eros Bulding Churchgate, Mumbai – 20.9. Govinda Dasa, Bhaishajya Ratnavali with Vidyotini Hindi commentary, ed. By Rajeshwara Datta Shastri, published by Chowkambha Sanskrit Samsthan, Varanasi, 10th edition.10. Gray, Gray’s Anatomy, Roger Warwick et. al. editors, 35th ed., jorrold and Sons Ltd., 1973.11. Hareeta, Hareeta Samhita, ed. By Sri Jeevananda Vidya Sagar Bhattacharya, Calcutta, 2nd ed., 1874.12. Harrison, Principles of Internal Medicine, Eugene Braun Wald, Anthony S. Fauci et. al. editors, Vol-I, 15th ed., Mc Graw Hill Publications, 2001 P.No.20013. Hutchison’s Clinical Methods 21 edition Michael Swash, W.B. Saunders Company Ltd., London.14. K.D. Tripathi Essentials of Medical pharmacology 4th edition JaypeeBrothers, Medical publishers (P) Ltd., New Delhi –02.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 99
  • 112. Dr.G.H.Ananthasayana 201015. K.D. Tripathi, essentials of medical pharmacology 6 edition 2003.16. M.M. Williams. Sanskrit English dictionary, edited by professor E. Leumann, prof. C. Cappeller, published by motilal banarasidass 1st edition 1970.17. Madhavakara, Madhava Nidanam, Madhukosha commentary of Vijayarakshita and Shrikantadatta, Vimal and Madhu dhara Hindi commentary of Dr.Brahmananda Tripathi, published by Chowkambha Surabharathi Prakashana, New edition 2000.18. P.J. Mehta, Practical Medicine for Students and practiners 1997 edition Late. Pradip . J. Mehata 12th edition.19. Priyavrit Sharma, Dravyaguna Vijnana, Vol I & II, published by Chowkambha Sanskrit Samsthana, 13th edition, 1992.20. S.G. Deodhore Genaral pathology and Pathology of systems Part 2, 6th edition, Popular Prakashan, Mumbai.21. Sir Monier Williams, Sanskrit English Dictionary Cognate Indo European Languages, Pubished by Motilal Banarasi Das, 1st edition 1990.22. Stedman’s Medical Dictionary Illustrated, edited by Daniel.B.Stone, published by Williams and wilkin’s company, 23rd edition 1976.23. Sushruta, Sushruta Samhita, Nibhandha Sangraha commentary of Dalhanacharta and Nyayachandrika commentary of Gayadas, edited by Vaidya Yadavaji Trikamji Acharya, published by Chowkambha Orientalia, Varanasi, 1994.24. published by chowkambha Sanskrit Series Office Varanasi, 3rd edition, 1967.25. Taranath Tarkavachaspathi, Vachaspathyam, vol V, published by Chowkambha Sanskrit Series Office, Varanasi, 3rd edition, 1970.26. Vagbhata, Ashtanga Sangraha, Shashilekha commentary of Indu, edited by Vaidya Pandit Ramachandra Shashtri Kinjwadekar, Satguni publications, Delhi, 2nd edition, 1990.27. Vagbhata, Astanga Hridayam, Sarvanga Sundara commentary of Arunadatta, Ayurveda Rasayana commentary of Hemadri, edited by Bhishagacharya Harishashtri Paradakara Vaidya, published by Chowkambha Orientalia, Varanasi, 8th edition, 1998.28. Yogaratnakara with Vidyotini Hindi commentary by Vaidya Lakshmipathi shastri, edited by Bhishagratna Brakma Shankara Shashtri, published by Chowkambha Sanskrit Samsthan, Varanasi, 5th edition, 1993.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 100
  • 113. Dr.G.H.Ananthasayana 2010DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA GOVERNMENT AYURVEDA MEDICAL COLLEGE, MYSORE MANAGEMENT OF ESSENTIAL HYPERTENSION IN AYURVEDIC PERSPECTIVESPart A: History and ExaminationPart B : InterprétationPart C: Observation and AssessmentH.O.D. : Dr. S.G. Mangalgi M.D., (Ayu),Guide : Dr.ARUNA, M.D. (Ayu),DNY.,Co-guide : Dr.SHANTARAM, M.D. (Ayu)Researcher : Dr. G.H.ANANTHASAYANAName : Case No. :Age : O.P.No :Sex : I.P.No :Education : UE P HS G Ward No. :Occupation : D.O.A. :Religion :H M C O D.O.C :Marital Status : M Um Result :Socio economic: Poor UMC LMC RichMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 101
  • 114. Dr.G.H.Ananthasayana 2010Case : Freshly detected Treated Under treatedAddress :I. Pradhana Vedana Kalaprakarsha• Shiroruk - Yes / No• Bhrama - Yes / No• Hridrava - Yes / No• Anidra - Yes / No• Klama - Yes / No• Urahshoola - Yes / No• Any other complaints - Yes / NoII. Anubandha VedanaIII. Adhyatana Vedana Vrittanta1. Raktachapadhikyata Freshly detected Kalaprakarsha known2. Shiroruk i. Character of headache and its nature Acute Chronic Continuous Intermittent Localized Radiating ii. Severity with duration iii. Usual time of attackMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 102
  • 115. Dr.G.H.Ananthasayana 2010 iv. Localization Unilateral Frontal Bilateral Occipital3. Bhrama i. Severity with duration ii. Usual time of attack4. Hridrava i. Onset ii. Severity with duration iii. Continuous intermittent iv. Relation to exertion5. Anidra6. Klama7. Urah shoola i. Location ii. Onset : Sudden / Gradual iii. Duration iv. Nature – Cyclic / Non-cyclic v. Characters – Aching / Sharp / Tingling / Burning / Pressure / Stabbing / Crushing / Clenching fist sign vi. Relation - to physical exertion - To emotional experience - to eating - to coughing vii. Radiation - to left arm - to right arm - to back - to neck - to jaw - to epigastric regionMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 103
  • 116. Dr.G.H.Ananthasayana 20108. Any other complaintIV. Poorva Vyadhi VrittantaHistory of diabetes / Renal disorder / Cerebrovascular accidents/ Cardiac disorder /Eclampsia / Pre existing vascular disease /Endocrine disorderV. Chikitsa VrittantaPrevious medication :Allopathic / Ayurvedic / Homeopathic / Folklore / Not takenDrug used : Name Dose DurationResponse : Controlled / Un-controlledPresent status :VI. Kula VrittantaAny family member suffering with HTN / D.M. / H.D. / R.D.VII. Vaiyaktika Vrittantai. Ahara - Type - Veg / Mixed Pattern of intake of food Anashana / Adyashana Samashana / Vishamashana / Pramitashana Snehavarga Rasaii. Vihara - Nature of work Amount of work Stress Exercise Sleep pattern - Nature Duration Day sleep Night awake Sleep time Wake up timeMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 104
  • 117. Dr.G.H.Ananthasayana 2010 Dreamsiii. Agni Samagni Mandagni Vishamagni Teekshnagniiv. Kostha Mridu Hadyama Krurav. Mala pravruttivi. Mootra pravruttivii. behavioural features Aggressiveness Anxiety Delirium Irritabilityviii. Vyasana a. Smoking Yes / No started since Type of substances - Beedi / Cigar / Others Pattern - Daily / Occasionally / chain Present status b. Alcohol – Yes / No Started since Type of drink - Beer / hot / any other Pattern -Daily / occasionally Present status c. Tobacco – Yes / No Started since Pattern – daily / occasionally e. Tea / Coffee – Yes / No Daily / occasionallyMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 105
  • 118. Dr.G.H.Ananthasayana 2010ix. Artava Vrittantax. Prasooti vrittantaVIII. Samanya Pareeksha Shareeroshmata Nadi Oedema Akriti Clubbing Shwasagati Cyanosis Raktachapa Pallor Dehabhara Lymph edinopathy JihwaIX. Vishesha PareekshaPranavaha srotas pareekshai. Cardiovascular systemHeartInspection of precordium Apical impulse / pulsation / heaves / liftsPalpation Apical impulse Thrills, heaves, liftsPercussion Heart sizeAuscultation Rate / Rhythm / murmur / Extra heart soundsPeripheral vascular system Rate / Rhythm / volume / Equality on both sides/ J.V.P.MANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 106
  • 119. Dr.G.H.Ananthasayana 2010Blood Pressure Date Time Pulse Supine Sitting StandingAnnavaha sroto pareekshaMootravaha sroto pareekshaVatavaha sroto pareekshaAturabala Pramana Pareeksha• Prakrititah• Saratah• Samhanatah• Satmyatah• Satvatah• Ahara shakti o Abyavarana o Jarana• Vyayama shakti• Pramanatah• VayatahRogibalaMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 107
  • 120. Dr.G.H.Ananthasayana 2010XI. InvestigationBlood Hb% TC DC ESR F.B.S P.P.B.S Lipid profileUrine Sugar Albumin MicroscopyOther investigationMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 108
  • 121. Dr.G.H.Ananthasayana 2010 PART - IIi. Vikrutitah pareeksha Nidana Samprapti Poorvarupa Rupa Upashayanupashaya Rogabala Upadravaii. Sapeksha Nidanaiii. Vyadhi vinischayaiv. Sadhyasadyata PART – III – Observation and AssessmentIntervention Amapachana Snehapana Swedana Virechana karma ShamanaushadhaMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 109
  • 122. Dr.G.H.Ananthasayana 2010Results, Observation and Assessment Blood Pressure Date Time Pulse Supine Sitting StandingBefore treatmentAfter snehapanaAfter swedanaAfter virecghana25 th day35 th day DayAfter treatmentSignature of the Researcher Signature of the Co-GuideSignature of the Guide Signature of the HODMANAGEMENT OF ESSENTIAL HTN IN AYURVEDIC PERSPECTIVES Page 110