Transcript Hypertension - South African Tibb Association

An Overview of the Clinical Pathophysiology of Hypertension, its
Interpretation According to Tibb Philosophy and its Relationship with
Temperament- Investigating whether a trend exists between blood
pressure readings and patient temperament and its responsive to the
respective Tibb medications.
ABSTRACT
 According to Tibb philosophy, hypertension results from either hot and moist or as cold
and dry excess. Therefore, those with a dominant or subdominant Sanguinous or
Melancholic temperament respectively are more susceptible to the development of
hypertension. Sanguinous hypertension conventionally correlates with primary or
essential hypertension and would present with both high systolic and diastolic blood
pressure readings, whereas the melancholic hypertension which is clinically seen as
secondary hypertension presents with a high systolic and a normal or slightly elevated
diastolic. The aim of this research was to evaluate and interpret the clinical
pathophysiology according to Tibb philosophy and to assess whether a relationship
between blood pressure readings and temperament exist. Our results found that most
patients who suffered with hypertension for which there was no known clinical cause had
a Sanguinous Dominant or subdominant temperament, the interpreted hypothesized
pathophysiology concurs with Tibb philosophy, however the blood pressure readings
recorded presented with no particular trend and were across the board according to the
clinical classification stages of blood pressure readings. Only a small sample of
melancholic patients were assessed, where 50% presented with isolated systolic
hypertension which results from excess dryness, and the other half had not known the
cause of their hypertension. The interpreted pathophysiology did not support that
secondary hypertension results from excess melancholic humour as there are many
secondary causes with multi-factoral pathologies. The onset of raised blood pressure in
secondary hypertension results either from increase cardiac output (hot and moist) or
increase systemic vascular resistance (cold and dry) or both.
Definition and classification of hypertension
 Hypertension is defined as an abnormal elevation
in diastolic pressure and/or systolic pressure.
Hemodynamic Basis of Hypertension
 Increase in arterial blood pressure is caused by either
 an increase in systemic vascular resistance (SVR)

determined by the vascular tone (i.e., state of constriction) of
systemic resistance vessels
 an increase in cardiac output (CO)

determined by heart rate and stroke volume
Categories of Hypertension
 Primary Hypertension-idiopathic
 Secondary Hypertension-identifiable cause
 According to Tibb
 Sanguinous Hypertension = primary hypertension
 Melancholic hypertension = secondary hypertension
Primary Hypertension
 Pathogenesis
 Early elevations of blood volume and cardiac output initiates
changes in systemic vasculature (increased resistance).
 Inability of the kidneys to regulate sodium

↑Na retention = ↑ blood volume
 Chronic long-standing hypertension



Blood volume and cardiac output are normal
↑↑systemic vascular resistance ∵thickening of the walls and reduction
in lumen diameter.
↑vascular tone ∵ enhanced sympathetic activity or ↑angiotensin II


↓nitric oxide is produced and vascular smooth muscle is less senstive to the
action of this vasodilator.
↑endothelin production- enhance vasoconstrictor tone
Interpretation According to Tibb Philosophy
 Sanguinous Hypertension
 Later oxidation leads to ↑ dryness
 C & D Hypertension
Secondary Hypertension
Renal Artery Stenosis
Chronic Renal Disease
 ∵ diabetic nephropathy; glomerulonephritis etc.
 Damage caused to the nephrons
 Impaired excretion of sodium →sodium retention and
↑blood volume → ↑ cardiac output by Frank Starling
mechanism
 May also result in ↑ release of renin
Primary Aldosteronism
Stress
 Activation of sympathetic nervous system →
↑norepinephrine in heart and blood vessels → ↑
cardiac output and ↑ systemic vascular resistance
 Adrenal medulla secretes catecholamines
(epinephrine and norepinephrine)
 ↑ angiotensin II, aldosterone and vasopressin
 Cardiac and vascular hypertrophy = sustained ↑ blood
pressure
Sleep Apnea
 Higher incidence of hypertension
 The mechanism of hypertension may be related to
sympathetic activation and hormonal changes
associated with repeated periods of apnea-induced
hypoxia and hypercapnea, and from stress associated
with the loss of sleep.
Hyper- or hypothyroidism
 Excessive thyroid hormone induces systemic
vasoconstriction, an ↑ blood volume, and ↑ cardiac
activity, all of which can lead to hypertension.
 Hypothyroidism unclear
 may be related to ↓ tissue metabolism reducing the
release of vasodilator metabolites, thereby producing
vasoconstriction and increased systemic vascular
resistance.
Pheochromocytoma
 ↑↑ catecholamines (both epinephrine and
norepinephrine)
 This leads to alpha-adrenoceptor mediated systemic
vasoconstriction and beta-adrenoceptor mediated
cardiac stimulation → ↑↑ arterial pressure.
Pre-eclampsia
 3rd trimester of pregnancy
 ↑ blood volume and tachycardia
 The former increases cardiac output by the Frank-
Starling mechanism
Aortic coarctation
 Elevated pressures proximal to the coarctation (i.e.,
elevated arterial pressures in the head and arms)
 Distal pressures are not necessarily reduced
 Reduced systemic blood flow and reduced renal blood flow
→ ↑ renin and an activation of the renin-angiotensinaldosterone system → ↑ blood volume and arterial pressure
 Baroreceptor reflex in blunted due to structural changes in
the walls of vessels where the baroreceptors are located
 Baroreceptors become desensitized to chronic elevation
in pressure and become "reset" to the higher pressure
Isolated Systolic Hypertension
 Defined as SBP ≥ 140mmHG and DBP ≤ 90mmHG
 60% of hypertensives > 80 years old
 From age 35/40 many people have elevated systolic or
diastolic pressure and this elevation leads to the
widening and stiffening of the aorta
 ↓ elasticity and ↓ compliance of the large blood vessels
→ ↑ SBP and ↓ DBP
Interpretation according to Tibb Philosophy
 Renal Artery Stenosis- ↑cardiac output and ↑vascular
resistance
 Multifactoral
 Pt and temperament specific
 Chronic renal disease- impaired salt homeostasis
 Sanguinous
• Primary aldosteronism - ↑blood volume

Sanguinous
Continued…
 Stress - ↑ cardiac output and ↑ systemic vascular
resistance
 Pt and temperament specific
 Sleep apnea – more prevalent in obese pt
 Phlegmatic or sanguinous
 Hyperthyroidism
 Bilious
 Hypothyroidism
 Phlegmatic
Continued…
 Pheochromocytoma- ↑ systemic vascular constriction and
↑ cardiac output
 Pt and temperament specific
 Pre-eclampsia- ↑blood volume and tachycardia → ↑ cardiac
output
 Aortic coarctation
 Associated with moistness
 Congenital condition in children
 Isolated systolic hypertension- increased resistance of large
arteries
 Elderly pt
 melancholic
Blood pressure relationship with
Temperament
Age
Sex
Dominant
Subdominant
initial BP
synthetic medication
65 F
Melancholic
Phlegmatic
170/100
N
45 M
Sanguinous
Phlegmatic
160/120
Y
74 F
Melancholic
Bilious
140/76
Y
45 M
Sanguinous
Bilious
140/90
Y
61 F
Sanguinous
Bilious
180/110
N
72 F
Melancholic
Phlegmatic
200/80
N
49 F
Sanguinous
Phlegmatic
130/100
N
43 M
Sanguinous
Phlegmatic
160/110
N
44 M
Sanguinous
Bilious
140/96
N
Continued….
57 F
Sanguinous
Bilious
160/90
Y
55 F
Phlegmatic
Sanguinous
160/98
Y
54 F
Sanguinous
Phlegmatic
119/78
Y
53 F
Sanguinous
Phlegmatic
164/90
Y
54 M
Phlegmatic
Sanguinous
140/90
Y
49 F
Phlegmatic
Sanguinous
170/110
Y
52 F
Phlegmatic
Sanguinous
140/100
N
35 M
Phlegmatic
Sanguinous
130/95
N
22 F
Phlegmatic
Sanguinous
150/100
N
68 F
Sanguinous
Bilious
160/90
Y
30 F
Melancholic
Bilious
150/110
N
50 F
Bilious
Sanguinous
200/100
Y/N
Sanguinous dominant or subdominant pts
Age
Sex
Dominant
Subdominant
initial BP
synthetic medication
45 M
Sanguinous
Phlegmatic
160/120
Y
45 M
Sanguinous
Bilious
140/90
Y
61 F
Sanguinous
Bilious
180/110
N
49 F
Sanguinous
Phlegmatic
130/100
N
43 M
Sanguinous
Phlegmatic
160/110
N
44 M
Sanguinous
Bilious
140/96
N
57 F
Sanguinous
Bilious
160/90
Y
55 F
Phlegmatic
Sanguinous
160/98
Y
Continued…
54 F
Sanguinous
Phlegmatic
119/78
Y
53 F
Sanguinous
Phlegmatic
164/90
Y
54 M
Phlegmatic
Sanguinous
140/90
Y
49 F
Phlegmatic
Sanguinous
170/110
Y
52 F
Phlegmatic
Sanguinous
140/100
N
35 M
Phlegmatic
Sanguinous
130/95
N
22 F
Phlegmatic
Sanguinous
150/100
N
68 F
Sanguinous
Bilious
160/90
Y
50 F
Bilious
Sanguinous
200/100
Y/N
Melancholic pts
Age
Sex
Dominant
Subdominant
initial BP
synthetic medication
65 F
Melancholic
Phlegmatic
170/100
N
74 F
Melancholic
Bilious
140/76
Y
72 F
Melancholic
Phlegmatic
200/80
N
30 F
Melancholic
Bilious
150/110
N
SB case studies
 21 total pt
 17 pt sanguinous dominant or subdominant
81%
 4 pt melancholic dominant or subdominant
 19%
 Sanguinous/dominant subdominant pt
 15 ↑↑SBP and ↑↑DBP
 88%
 22 -68 years old
 1 Normal BP- using synthetic medications
 1 normal SBP and ↑↑ DBP
 Melancholic dominant/subdominant pt
 2 ↑↑ SBP and normal DBP
 50%
 Age > 70years
 2 ↑↑ SBP and ↑↑ DBP
 30 and 65 years old

Dr. Andreas Kefaldelis Research
Project
Age
Sex
Dominant
Subdominant
BP
synthetic medication
37 F
Sanguinous
Phlegmatic
136/95
N
46 F
Phlegmatic
Sanguinous
148/110
N
35 M
Sanguinous
Phlegmatic
168/117
N
55 F
Sanguinous
Bilious
144/93
N
23 F
Sanguinous
Phlegmatic
139/92
N
49 F
Phlegmatic
Sanguinous
181/102
Y
56 F
Phlegmatic
Sanguinous
193/92
N
33 F
Sanguinous
Phlegmatic
149/105
Y
43 M
Phlegmatic
Sanguinous
187/152
Y/N
64 M
Sanguinous
Bilious
210/110
N
Continued…
31 F
Sanguinous
Phlegmatic
150/114
N
52 F
Sanguinous
Phlegmatic
205/155
Y
64 F
Phlegmatic
Sanguinous
210/160
Y/N
47 F
Sanguinous
Bilious
165/115
Y
29 F
Sanguinous
Phlegmatic
134/105
N
47 F
Phlegmatic
Sanguinous
145/116
N
62 F
Phlegmatic
Sanguinous
160/129
N
27 M
Sanguinous
Phlegmatic
140/100
Y
51 F
Sanguinous
Bilious
192/111
N
49 M
Sanguinous
Phlegmatic
167/67
N
55 f
Sanguinous
Phlegmatic
154/99
Y
Continued…
41 M
Sanguinous
Phlegmatic
162/102
N
35 F
Phlegmatic
Sanguinous
145/89
N
58 F
Sanguinous
Phlegmatic
160/93
N
36 M
Sanguinous
Phlegmatic
157/85
N
50 M
Phlegmatic
Sanguinous
172/118
N
57 M
Sanguinous
Phlegmatic
182/112
N
35 M
Sanguinous
Bilious
135/91
N
53 F
Sanguinous
Bilious
134/84
N
40 F
Sanguinous
Phlegmatic
158/102
N
27 M
Sanguinous
Phlegmatic
148/95
N
75 M
Sanguinous
Phlegmatic
202/105
Y
Continued…
57 M
Sanguinous
Bilious
167/120
Y
24 F
Sanguinous
Phlegmatic
130/96
N
27 M
Sanguinous
Bilious
151/100
N
24 F
Phlegmatic
Sanguinous
153/94
N
50 M
Sanguinous
Phlegmatic
178/112
N
53 F
Sanguinous
Phlegmatic
163/100
Y
52 F
Phlegmatic
Sanguinous
156/102
N
51 M
Phlegmatic
Sanguinous
151/103
N
40 F
Sanguinous
Phlegmatic
148/113
N
21 F
Sanguinous
Phlegmatic
138/91
N
49 M
Phlegmatic
Sanguinous
145/97
Y
53 M
Sanguinous
Phlegmatic
184/118
N
49 F
Phlegmatic
Sanguinous
148/94
N
38 F
Sanguinous
Phlegmatic
147/102
N
Dr. Andreas Kefaldelis Research
Project
 46 total pts
 100% dominant/subdominant sanguinous temperament
 36 pts ↑↑ SBP and ↑↑ DBP
 78%
 24-75 years old
 6 pts ↑↑ DBP
 13%
 21-37 years old
 3 pts ↑↑ SBP
 7%
 35-49 years old
 1 pt had wide pulse pressure
 1 pt prehypertension
Effects of synthetic medication on
blood pressure readings
Stage 1
Stage 2
mixed
144/93 N
168/117 N
136/95 N
154/99 Y
181/102 Y
148/110 N
148/95 N
187/152
139/92 N
153/94 N
210/110 N
193/92 N
145/97 Y
205/155 Y
149/105 Y
148/94
210/160
134/105 N
140/90 Y
165/115Y
145/116 N
140/96 N
160/129 N
140/100 Y
140/90 Y
192/111 N
167/67
Prehypertension
134/84 N
172/118 N
145/89 N
182/112 N
160/93 N
202/105 Y
157/87 N
178/112 N
135/91 N
163/100 Y
158/102
184/118 N
130/96 N
160/120 Y
151/100 N
180/110 N
156/102 N
170/110 N
151/103 N
200/100
148/113
o
138/91
147/102
130/100 N
160/90 Y
160/98
164/90 Y
140/100 N
130/95 N
150/100 N
160/90 Y
Stage 1
Stage 2
Mixed
4N
10 N
18 N
4Y
6Y
5Y
1 non compliant
3 non compliant
6 non compliant
Prehypertension
1N
Stages of blood pressure readings
on mixed BP measurements
 Stage 1/Stage 2
 12 patients



2 hypotensive medication
7 no medication
3 non compliant
 Stage 2/Stage 1
 6 patients



3 hypotensive medication
2 no medication
1 non compliant
 Prehypertension/stage 1 or 2
 8 patients


7 no medication
1 non compliant
 Stage 1 or 2/prehypertension
 3 patients


2 no medication
1 non compliant
 90-95% pts suffer with primary hypertension
 91% of total pts in this study
 Sanguinous dominant/subdominant temperament
 Concludes primary hypertension = sanguinous
hypertension
 No relationship exists between the blood pressure
reading and the quality of hypertension
 Synthetic medication did not affect the overall results
as most patients were not using any hypotensive
agents
 Elderly melancholic pts are more susceptible to
developing isolated systolic hypertension
 Research suggests that obese pt have higher cardiac
outputs BUT lower total peripheral vascular resistance
compared to lean patients
 More research on melancholic patients with
hypertension is needed
Response to Tibb medication
 Most patients responded positively when given a combination of
pressure eeze and pressure eeze forte
 Pathogenesis generally complex and multi-factoral
 Combination therapy combats both ↑ cardiac output (pressure eeze
forte) and ↑ systemic vascular resistance (pressure eeze)




1 elderly isolated SBP pt had no response to Rx
1 elderly isolated SBP pt responded well to pressure eeze alone
1 sanguinous pt had ↓DBP but an ↑ SBP
2 sanguinous pt had no response when given pressure eeze in
isolation but responded positively with combination Rx
 1 sanguinous pt had no response to both pressure eeze and
pressure eeze forte
 1 sanguinous pt had ↓SBP but no response in diastolic blood
pressure
Considerations
 Compliancy to lifestyle factors were not considered in this
study
 White coat hypertension- anxiety in dr’s office may ↑ BP by
26mmHg
 Small sample- findings not absolute
 Effects of other chronic disease on hypertension
 Dyslipidaemia
 Hyperinsulinaemia and hyperglycaemia (type II diabetes)

endothelial dysfunction
 Free radical damage
 ↓nitric oxide bioavailability
References
 1. cardiovascular physiology, www.cvphysiology.com
 2. isolated systolic hypertension: an update,





www.medscape.com/viewarticle/407695
3. low diastolic ambulatory blood pressure is associated with greater all
cause mortality in older patients with hypertension,
www.medscape.com/viewarticle/587808
4. hypercholesterolaemia and its potential role in the presentation and
exacerbation of hypertension, www.medscape.com/viewarticle/490536
5. white coat effect and white coat hypertension: what do they mean?,
www.medscape.com/viewarticle/462098
6. the relationship between body weight and the prevalence of isolated
systolic hypertension in older subjects,
www.medscape.com/viewarticle/407698
To assess the relationship between the qualities associated with chronic
disorders and the temperament of the person affected. By Dr Andreas
Kefaladelis