SYSTEMIC SYSTEMIC HYPERTENSION AND HYPERTENSION AND

SCOPE OF SCOPE OF HOMOEOPATHYHOMOEOPATHY

FromFromDr. Smita Brahmachari, M.D. Dr. Smita Brahmachari, M.D.

(Repertory) from N.I.H., (Repertory) from N.I.H., Kolkata.Kolkata.

M.O., Dept. of ISM &Homoeopathy, M.O., Dept. of ISM &Homoeopathy, Govt. of NCT Delhi.Govt. of NCT Delhi.

World Health Day 2013World Health Day 2013

The focus of the World Health Day 2013 (7th April

every year) is on one of the main non-communicable

disease (NCD) risk factors, hypertension. It is currently

the leading risk resulting in considerable death and

disability worldwide and accounted for 9.4 million

deaths and 7 per cent of disability adjusted life years

(DALYs) in 2010. In India, hypertension is the leading

NCD risk and estimated to be attributable for nearly

10% of all deaths1.

World Hypertension Day 2013World Hypertension Day 2013

The theme for 2013 World Hypertension Day (17th May every year) is “Healthy heart beat – healthy blood pressure” emphasizing on the importance of blood pressure control and control of arrhythmias1.

Epidemiology of hypertension Epidemiology of hypertension (globally)(globally) As per the World Health Statistics 2012, of the estimated 57

million global deaths in 2008, 36 million (63%) were due to non-communicable diseases (NCDs). The largest proportion of NCD deaths is caused by cardiovascular diseases (48%). In terms of attributable deaths, raised blood pressure2 is one of the leading behavioral and physiological risk factor to which 13% of global deaths are attributed.

Hypertension is reported to be the fourth contributor to premature death in developed countries and the seventh in developing countries. Recent reports indicate that nearly 1 billion adults (more than a quarter of the world’s population) had hypertension in 2000, and this is predicted to increase to 1.56 billion by 20252.

Epidemiology of hypertension Epidemiology of hypertension in Indiain India The prevalence of hypertension in the last six decades has increased from 2% to

25% among urban residents and from 2% to 15% among the rural residents in India2.

According to Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, the overall prevalence of hypertension in India by 2020 will be 159.46/1000 population2.

The number of hypertensive individuals is anticipated to nearly double from 118 million in 2000 to 213 million by 20251.

It is estimated that 16 % of ischaemic heart disease, 21 % of peripheral vascular disease, 24 % of acute myocardial infarctions and 29 % of strokes are attributable to hypertension underlining the huge impact effective hypertension prevention and control can have on reducing the rising burden of cardiovascular disease 1.

This has been taken into cognizance in the newly launched National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) which has hypertension and diabetes as the main focus areas1.

CLINICAL APPROACHCLINICAL APPROACHHypertension is easily diagnosable and treatable with lifestyle modifications and effective medicines. Thus, hypertension control provides an entry point to deal with other non-communicable diseases (NCDs) as any intervention will help concomitantly address other NCDs as well.

Measurement of blood Measurement of blood pressure (BP)pressure (BP)

• The health related toxic effects of mercury are recognized world over and mercury sphygmomanometers are being replaced by aneroid and digital sphygmomanometers.

• BP should be measured with a well – calibrated sphygmomanometer.

• The bladder width within the cuff should encircle at least 80% of the arm circumference.

• Readings should be taken after the patient has been resting comfortably, back supported in the sitting or supine position, for at least 5 minutes and at least 30 minutes after smoking or tea/ coffee ingestion.

• A video demonstrating the correct technique can be found at http://www.abdn.ac.uk/medical/bhs/tutorial/tutorial.htm.

Measurement of blood Measurement of blood pressure (BP)pressure (BP)The first appearance of the sound (Phase I Korotkoff) is the systolic

BP. The disappearance of the sound (Phase V Korotkoff) is the diastolic BP.

For confirmation of diagnosis of hypertension, record at least 3 sets of readings on different occasions.

Measure the blood pressure in both arms at the first visit and use higher of the two readings.

In older persons aged 60 years and above, in diabetic subjects and patients on antihypertensive therapy, the BP should be measured in both, supine/sitting and in standing positions to detect postural hypotension.

For home measurement. blood pressure, readings of more than 135/85 mm Hg should be considered elevated.

DIAGNOSIS OF HYPERTENSIONDIAGNOSIS OF HYPERTENSION Hypertension is diagnosed when systolic blood pressure is consistently

elevated above 140 mm Hg, or diastolic blood pressure is above 90 mm Hg.

A single elevated BP is not sufficient to establish the diagnosis of hypertension.

2 major exceptions to this rule are hypertensive presentations with evidence of life threatening end-organ damage and in hypertensive urgency where BP > 220/125 mm Hg but life threatening end-organ damage is absent.

Hypertension is diagnosed at lower levels when based on measurements taken outside the office environment.

BP is normally lowest at night and loss of this nocturnal dip is strongly associated with cardiovascular risk, particularly thrombotic stroke.

An accentuation of normal morning increase in BP is associated with likelihood of cerebral haemorrhage.

BP Classification Systolic BP, mm Hg

Diastolic BP,mm Hg

Normal < 120 < 80

Prehypertension 120 – 139 80 – 89

Stage 1 hypertension 140 – 159 90 – 99

Stage 2 hypertension ≥ 160 ≥ 100

Classification of Classification of hypertensionhypertension• Primary essential hypertension (95%

cases) as a result of complex interactions between multiple genetic and environmental factors.

• Secondary hypertension (5% cases) have identifiable specific causes (should be suspected in patients in whom HTN develops at an early age/ who 1st exhibit HTN over 50yrs/ those previously well controlled become refractory to treatment).

EXACERBATINGEXACERBATING FACTORSFACTORS1. Obesity esp. truncal obesity in Indians (weight reduction lowers

BP moderately).

2. Sleep apnea (treatment with continuous positive airway pressure improves BP).

3. Increased salt intake.

4. Alcohol (HTN difficult to control in patients consuming >40g ethanol i.e., 2 drinks daily).

5. Cigarette smoking (accentuates cardiovascular risk).

6. NSAIDS (increase in BP averaging 5 mm Hg)

7. Metabolic syndrome (associated with development of HTN and adverse cardiovascular outcomes).

8. OC pills use (a significant increase of BP > 140/90 mmHg in obesed older than 35 yrs who have been treated for more than 5 yrs).

Identifiable specific causes of hypertension(secondary hypertension)

Chronic kidney diseasePrimary aldosteronismRenovascular disease (renal artery stenosis)Long term corticosteroid therapy and Cushing syndromePheochromocytomaCoarctation of aortaHypertension associated with pregnancy (preeclampsia

and eclampsia)Thyroid and parathyroid disease (hypo and hyper)

When to suspect secondary hypertension When to suspect secondary hypertension clinically?clinically?

Absence of family history of hypertension. Severe hypertension > 180/110 mm Hg with onset at age < 20 years or > 50

years. Difficult-to-treat or resistant hypertension with significant end-organ damage

features. Combination of pain (headache), palpitation, pallor and perspiration – 4 P’s of

phaeochromocytoma. Polyuria, nocturia, proteinuria or hematuria – indicative of renal diseases. Absence of peripheral pulses, brachio femoral delay and abdominal or

peripheral vessel bruits. History of polycystic renal disease or palpable enlarged kidneys. Cushingoid features, multiple neurofibromatosis. Significant elevation of plasma creatinine with use of ACE inhibitors. Hypertension in children. History of snoring, daytime somnolence, obesity, short and thick neck –

Obstructive Sleep Apnoea.

Complications of untreated hypertensionComplications of untreated hypertension

Hypertensive cardiovascular disease (left ventricular hypertrophy, CCF, MI, ventricular arrhythmias and sudden death).

Hypertensive cerebrovascular disease (haemorhagic and ischaemic stroke) and dementia (vascular and Alzheimer’s types).

Hypertensive kidney disease (nephrosclerosis). Aggressive BP control to 130/80 mmHg or lower slows the progression of all forms of chronic kidney disease.

Atherosclerotic complications. Hypertensive encephalopathy (headache, irritability, confusion, altered mental

status due to cerebrovascular spasm). Hypertensive patients with diabetes are at particularly high risk for

cardiovascular events. More aggressive treatment of hypertension in these pt.s prevents progressive nephropathy.

Malignant hypertension (encephalopathy or nephropathy with accompanying papilledema).

Systolic pressure

1. Hypertensive LVH is closely related to degree of systolic BP reduction.

2. Hypertensive cerebro vascular complications are closely correlated with systolic than diastolic pressure.

Pulse pressure (SystolicBP-DiastolicBP)

Clinical findings …symptomsEssential hypertension is asymptomatic for years.Accelerated hypertension is associated with somnolence,

confusion, nausea, vomiting and visual disturbances (hypertensive encephalopathy).

In pt.s with phaechromocytoma typical attack lasts from minutes to hours with headache, anxiety, palpitations, pallor, tremor, nausea and vomiting. BP is markedly elevated and angina/ pulmonary edema may occur.

In primary aldosteronism, pt.s have muscular weakness, polyuria, nocturia due to hypokalemia.

Chronic HTN leads to LVH and diastolic dysfunction which can present with exertional and paroxysmal nocturnal dyspnoea.

Blood pressure: taken in both arms. Lower extremity pulses are diminished or delayed in coarctation of aorta; an orthostatic drop is present in phaechromocytoma; older pt.s have falsely elevated reading because of noncompressible vessels; direct measurement of intra-arterial pressure is done in pt.s with severe HTN who do not tolerate therapy.

Retina: narrowing of arterial diameter to <50% of venous diameter, copper/ silver wire appearance, exudates, haemorrhages or papilledema are associated with a worst prognosis.

Heart: a left ventricular heave indicates severe or long standing hypertrophy.

Pulses: radio-femoral delay in coarctation of aorta; loss of peripheral pulses in atherosclerosis.

EvaluationEvaluation

Evaluation of patients with documented hypertension has three objectives:

To identify known causes of high blood pressure To assess the presence or absence of target

organ damage To identify other cardiovascular risk factors or

concomitant disorders that may define prognosis and guide treatmentData for evaluation is acquired through medical history, physical examination, laboratory tests, and other special diagnostic procedures.

Medical HistoryMedical History• Duration and level of elevated blood pressure, if known.

• History of previous antihypertensive therapy, including adverse effects experienced, if any.

• Past history or current symptoms of coronary artery disease (CAD), heart failure, cerebrovascular disease, peripheral vascular disease, CKD, diabetes mellitus, dyslipidaemia, obesity, gout, sexual dysfunction and other co-morbid conditions.

• Family history of hypertension, obesity, premature CAD and stroke, renal diseases, dyslipidaemia and diabetes.

• Symptoms suggesting secondary causes of hypertension.

• History of smoking or tobacco use, physical activity, dietary assessment including intake of sodium, alcohol, saturated fat and caffeine.

• Socioeconomic status, professional and educational levels.

• History of use / intake of all prescribed and over-the-counter medications, herbal remedies, liquorice (Yashtimadhu/ Jestamadha), illicit drugs, corticosteroids, NSAIDs, nasal drops. These may raise blood pressure or interfere with the effectiveness of antihypertensive drugs.

• History of oral contraceptive use and hypertension during pregnancy.

• Psychosocial and environmental factors.

PHYSICAL EXAMINATION Record three blood pressure readings separated by 2 minutes, with the patient

either supine or sitting position and after standing for at least 2 minutes. Record height, weight and waist circumference. Examine the pulse and the extremities for delayed or absent femoral and

peripheral arterial pulsations, bruits and pedal oedema. Look for arcus senilis, acanthosis nigricans, xanthelasma and xanthomas. Examine the neck for carotid bruits, raised JVP or an enlarged thyroid gland. Examine the heart for abnormalities in rate and rhythm, location of apex beat,

fourth heart sound and murmurs. Examine the lungs for crepitations and rhonchi. Examine the abdomen for bruits, enlarged kidneys, masses and abnormal

aortic pulsation. Examine the optic fundus and do a neurological assessment.

Laboratory findings

• Haemoglobin, urinalysis and kidney function study to detect haematuria, proteinuria, casts (primary kidney disease/ nephrosclerosis).

• Fasting blood sugar level (diabetes and hyperglycemia is a feature of pheochromocytoma).

• Lipid profile (atherosclerosis).

• Serum uric acid (if elevated then contraindication for diuretic therapy).

• Serum electrolytes.

• Echocardiography (cardiac disease as ECG is not sensitive for LVH).

• Specific tests like 24-hour urine free cortisol, plasma metanephrines and plasma aldosterone/ renin ratio for endocrine causes of HTN.

• Renal USG (polycystic kidney, obstructive uropathy).

• Renal arteriography (renal artery stenosis).

Lifestyle modifications to manage hypertensionLifestyle modifications to manage hypertension

Modification Recommendation Approx. systolic BP reduction, range

Weight reduction Maintain normal body weight (BMI,18.5-24.9)

5-20 mm Hg/10 kg weight loss

Adopt DASH eating plan

(Dietary approaches to stop hypertension)

Consume a diet rich in fruits, vegetables and low fat dairy

products with a reduced content of saturated fat and total fat

8 – 14 mm Hg.

Dietary sodium reduction Reduce to 2g sodium or 6g sodium chloride

2 – 8 mm Hg.

Physical activity Engage in regular aerobic physical activity such as brisk walking at

least 30 minutes/day. Also relaxation techniques like yoga

and meditation.

4 – 9 mm Hg.

Moderation of alcohol consumption

Not more than two drinks per day (30 ml ethanol).

2 – 4 mm Hg.

Stop smoking

Lifestyle modifications to manage hypertension Lifestyle modifications to manage hypertension (contd.)(contd.)

• Initial management of hypertension uses a two-pronged approach, with emphasis on lifestyle measures and add – on medicinal management.

• Lifestyle management has an important role in both non-hypertensive and hypertensive individuals. Whilst these modifications shows modest reduction in BP, all too often these treatments are not adopted and, even if they are, but not sustained.

• In non-hypertensive individuals, including those with pre-hypertension, lifestyle modifications have the potential to prevent hypertension and more importantly to reduce BP and lower the risk of BP-related clinical complications.

• In hypertensive individuals, lifestyle modifications can serve as initial treatment before the start of medicinal treatment and as an adjunct to medicinal treatment in persons already on medication. In hypertensive individuals with medication – controlled BP these modifications can facilitate medicinal step-down in individuals who can sustain lifestyle changes.

Food items to be avoided in Food items to be avoided in hypertensiveshypertensives

• Table salt

• Mono sodium glutamate (Ajinomoto)

• Baking powder

• Sodium bicarbonate

• Fried foods

• Alcohol

• Sugar, mithais, candies

Salt preserved foods

• Pickles and canned foods

• Ketchup and sauces

• Prepared mixes

• Ready to eat foods (soups)

Highly salted foods

• Potato chips, cheese, peanut

• Butter, salted butter, papads

Bakery products

• Biscuits, cakes,

• Breads and pastries

GOALS OF TREATMENTGOALS OF TREATMENT

• Early treatment initiation reduces overall cardiovascular risk.

• The BP target for hypertensive pt.s at the greatest risk for cardiovascular events, particularly pt.s with diabetes and with chronic kidney disease should be lower (<130/80 mm Hg).

• Over-enthusiastic treatment has adverse effects: there is an association between lower BP and cognitive decline in elderly.

• Excessive lowering of diastolic pressure below 70 mm Hg should be avoided in pt.s with coronary disease.

• Antihypertensive therapy prevents fatal myocardial infarction and cardiovascular mortality and recent advances have placed focus on control of systolic BP.

Drug therapy in conventional medicine

Current antihypertensive agents include:

1. Diuretics (useful for isolated or systolic HTN)

2. β –adrenergic blockers (useful in individuals with angina, MI, CCF, migraine headaches and somatic manifestations of anxiety).

3. Renin inhibitors (Aliskiren was recently approved by FDA)

4. Angiotensin-Converting Enzyme inhibitors (useful in type 1 diabetes with frank proteinuria or evidence of kidney dysfunction; drug of choice in pt. c CCF when given in conjunction with a diuretic and a β –blockers)

5. Calcium channel blockers (useful for in angina, arrhythmias, in prevention of CAD, stroke, cardiovascular death and total mortality)

6. Angiotensin II Receptor Blockers (useful in related conditions like heart failure and type2 DM with nephropathy; given in combination with ACE inhibitor).

Follow-up of pt.s receiving hypertensive therapy

• Once BP is controlled on a well tolerated regimen, follow-up visits can be infrequent and laboratory testing limited to tests appropriate for the pt.

• Yearly monitoring of blood lipids is recommended and an ECG should be repeated at 2- to 4-year intervals depending on whether initial abnormalities are present, the presence of coronary risk factors and age.

• Pt.s who have excellent BP control for several years, especially if they have lost weight and initiated favorable lifestyle modifications should be considered for step-down of therapy to determine whether lower doses or discontinuation of medications are feasible.

HYPERTENSION: HOMOEOPATHIC CONCEPT HYPERTENSION: HOMOEOPATHIC CONCEPT

Homoeopathy considers health as a state indicating harmonious functioning of the life force. Disease is a deviation from health, which develops when the life force is unable to overcome obstructions to its smooth functioning. It can be seen as the total response of the organism to adverse environmental factors, internal or external, conditioned by constitutional factors, inherited or acquired. This stands true for all diseases, including hypertension11.

Thus in the case of hypertension, homoeopathy focuses on the patient with the hypertension, rather than on the hypertension itself. The totality of various characteristic signs and symptoms exhibited by this patient leads the homoeopath to the similar remedy. The similar remedy relieves the totality of symptoms, and with it the symptom of an elevated blood pressure.

Exacerbating factors High salt intake - desire for salt is a pseudo psoric

trait. Obesity - tendency for obesity is sycotic. High fat intake - desire for fat is pseudo psoric. Alcohol consumption - desire for alcohol is pseudo

psoric. Psychological factors – tendency to be affected by

suppressed emotions, grief, sorrow is psoric.

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

Pathogenesis and pathology : The initial phase in the development of hypertension is

though to be due to the hyper reactivity of the vasculature or due to a hyperactive sympathetic nervous system. Hyperactivity is a psoric trait.

Later on hypertrophic changes occur in the walls of the arteries and arterioles. Sclerotic changes also occur as age advances. These represent the sycotic and tubercular influences.

In malignant hypertension, the predominant pathology is necrosis of the arterioles, showing a clear influence of the syphilitic miasm.

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

Clinical presentation :

1. The asymptomatic presentation in many cases, in spite of sustained hypertension with pathological changes, clearly indicate that psora is not the only miasmatic influence.

2. The purely psoric patient is usually the victim of many unpleasant sensations. It is the syphilitic or sycotic stigmata which usually present with only a few or no symptoms at all.

3. On examination of the more common symptoms, we find that occipital headache is syphilitic in origin. Vertigo is the other symptom more frequently complained of, and the psoric miasm is known to produce many kinds of vertigo. But it is the union of syphilis and psora which stresses it to a marked degree

4. From the miasmatic analysis given above, it is clear that hypertension is a disorder with multi-miasmatic influences, with strong psoric and pseudo-psoric influences. Many authors10 have classified hypertension under the pseudo-psoric miasm.

5. But it is quite possible that the individual presentation and course of the disease depends on the relative predominance of different miasmatic influences.

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

A. Psoric predominance Patients with psoric predominance13 typically have labile hypertension or hypertension

caused by emotional disturbances like anger, anxieties worry, grief etc. They are prone to be more symptomatic, complaining of dizziness, dyspnea,

palpitations etc. which are better by lying down and keeping quiet and worse after eating.

Neuralgic and stitching pains in the chest > rest, and band sensations around the heart may also be complained of.

Sensations like rush of blood to the chest, weakness, fullness about the chest are common.

The psoric element makes sure that there are many sensations, concomitants and modalities, giving a true picture of the suffering10.

The heart symptoms are always associated with great anxiety and fear, always fear that they will die from heart trouble. The symptomatology is strongly influenced by emotions like joy, grief, anxiety etc

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

B. Syphilitic predominance The predominantly syphilitic patient is usually asymptomatic. They

may have for many years a slight dyspnea or pain or perhaps no symptoms at all. They have few subjective symptoms, desires. Typically, they have little mental disturbance accompanying the heart conditions, even when they are critical.

But it is these patients who are prone to die suddenly and without warning.

The syphilitic influence13 leads to widespread destructive changes in the vital organs like heart, kidney, retina and brain. Many of the life threatening complications of hypertension, like cerebral and myocardial infarction, malignant phase etc. shows the influence of this miasm

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

C. Pseudo-psoric predominance The pseudo psoric10 or tubercular miasm reflect many of the subjective symptoms. Hypertensives13 with the tubercular dimension are likely to have wide fluctuations

in blood pressure to very high levels of systolic and diastolic pressures. They are prone to haemorrhagic manifestations like epistaxis, retinal haemorrhage,

cerebral haemorrhage etc. In the tubercular10 as in the psoric heart conditions, the patient wants to keep still.

They are much aggravated by higher altitude, climbing stairs or ascending. Vertigo and palpitation are greater than that of psora and are accompanied by rush

of blood to heart and chest. The pains are worse sitting, better lying, and are so severe that they are associated

with dimness of vision, ringing in the ears and great weakness. The heart complaints may be associated with a greater falling away of flesh.

Hypertension…miasmatic influences (contd.)Hypertension…miasmatic influences (contd.)

D. Sycotic predominance In the predominantly sycotic patient, the subjective symptoms are less, like the

syphilitic. We find none of the fears and apprehensions of the psoric patients, but these are the conditions that have a fatal outcome10.

In hypertension, the sycotic element may be responsible for marked ventricular hypertrophy12. The combination of psora with sycosis may also cause marked changes of structure of the heart, as well as dropsical conditions10.

As a rule the sycotic patients are fleshy and puffy, their obesity contributing to their dyspnea. The dyspnea is seldom painful, as opposed to the psoric or tubercular miasms12.

There may be soreness and tenderness and pains radiating from heart to scapula or from shoulder to heart. These pains are ameliorated by motion, walking, riding or gentle exercise.

The heart complaints may be accompanied by or there may be a past history of suppressed rheumatic symptoms13.

HOMOEOPATHIC MANAGEMENT OF HYPERTENSIONHOMOEOPATHIC MANAGEMENT OF HYPERTENSION

Based on the principle of similia. The totality of symptoms guides the physician to the indicated remedy.

Being a chronic disease, it requires constitutional, antimiasmatic treatment. Smaller or lesser known remedies may be required to control high blood

pressure or to manage the complications. Agrees with the conventional school on the necessity for lifestyle

modifications along with medications for proper management. Any medicine in the materia medica may be potentially capable of bringing

down the elevated blood pressure. In the search for the similar remedy, homoeopathy lays emphasis on the individuality of the patient. In §153 of the Organon of medicine5, Hahnemann makes it clear that it is the peculiar, characteristic and individualizing symptoms, and not the common symptoms that denote the similimum.

HOMOEOPATHIC MANAGEMENT OF HYPERTENSION (CONTD.)HOMOEOPATHIC MANAGEMENT OF HYPERTENSION (CONTD.)

“In all corporeal diseases, the condition of the disposition and mind is always altered”…. § 210, Organon of Medicine5.

“In all cases of disease to be cured, the patient’s emotional state should be noted as one of the most preeminent symptoms, along with the symptom complex, if one wants to record a true image of the disease in order to be able to successfully cure it homoeopathically”…. § 210, Organon of the Medical Art7.

Hahnemann stressed the prime importance of the mental symptoms in all physical disorders.

He said that the mental disposition and emotional reactions are too be particularly noted, as they often determine the remedy selection. This will apply quite naturally to cases of hypertension, where psychological factors play a significant part in the causation of illness.

HOMOEOPATHIC MANAGEMENT OF HYPERTENSION (CONTD.)HOMOEOPATHIC MANAGEMENT OF HYPERTENSION (CONTD.)

While treating diseases with multimiasmatic influenced diseases like hypertension, it is also important that the remedy selected correspond to the dominant miasm10. This is very often found to be the psoric miasm… §80, Organon of medicine5. Afterwards, the dormant syphilitic or sycotic miasm, as the case may be, manifests itself and may call for appropriate changes in remedy. Even in predominantly psoric cases, several antipsoric remedies may be required, each one homoeopathically chosen in consonance with the group of symptoms remaining after completion of action of the previous remedy….. §171, Organon of medicine5.

Difficulties in Homoeopathic treatmentDifficulties in Homoeopathic treatment

ONE SIDED EXPRESSIONONE SIDED EXPRESSION• Paucity of symptoms or the absence

of peculiar symptoms • 1st selected medicine is partially

suitable due to lack of symptoms.• This medicine will produce

accessory symptoms (disease).• 2nd medicine selected on basis of

present picture of disease (old existing symptoms + accessory symptoms).

• Subsequent prescriptions are to be made depending on the symptoms remaining, until recovery is complete.

PATIENTS UNDER PATIENTS UNDER CONVENTIONAL TREATMENTCONVENTIONAL TREATMENT

• Majority of patients approach homoeopaths after taking allopathic medicines.

• Cases which have undergone prolonged treatment for hypertension and other illnesses are very difficult to treat, as the original symptomatology is often not available14.

• Prolonged drugging also weakens the vital force, and develop their own chronic symptoms. Such cases require a much longer time for their recovery, often indeed are they incurable5.

PATIENTS UNDER CONVENTIONAL TREATMENTPATIENTS UNDER CONVENTIONAL TREATMENT5,145,14

• An attempt should be made to trace the symptoms before the onset of treatment, to get an idea about the original form of the disease.

• One should not discontinue the allopathic treatment abruptly; sudden withdrawal may do more harm than good.

• When the homoeopathic remedies seem to have an effect, the drugs may be reduced very cautiously.

• These cases also requires knowledge of the allopathic drugs on the part of the homoeopathic physician

Hypertension as described in repertoryHypertension as described in repertory Many authors have grouped remedies under the heading of the related

pathological process of “arteriosclerosis”, and these may be useful in cases of hypertension.

Another related term, that is described in the materia medica and repertory is “threatened apoplexy”. The remedies grouped under this heading also may be useful in high rise of blood pressure, especially when symptoms of cerebral congestion are present.

In recent times repertories have separate rubric for “hypertension’’ like Murphy’s Repertory (Blood, Hypertension, high blood pressure); Complete Repertory (Generalities - Hypertension).

Under Phatak Repertory, HTN c low diastolic: Bar-mur and For sudden rise of B.P. medicine is Coffea (single medicine).

In Synthesis Repertory (9.1 version) following medicines for hypertension (HTN) are discussed under chapter Generalities in the subrubric hypertension.

Hypertension as described in Hypertension as described in repertory (contd.)repertory (contd.)Here I have mostly discussed rubrics with single medicine [Synthesis 9.1version] HTN c apoplexy : Glon. and Op. HTN c DM : Sec cor. HTN c albuminous urine : Viscum alb. HTN c headache : Loxosceles laeta; if <morning : Fumaric acid. HTN c hypertrophy of heart : Crataegus oxyacantha. HTN c kidney complaints : Cupr met., Picric ac., Plb met. Renal hypertension : Melilotus. HTN from dialysis : Acon-ferox, Adren., Eel serum. Excessive HTN : Toxoplasma – gondii. HTN after lung complaints : Nat-ox-act. HTN due to disturbed nervous mechanism : Aur-mur-natonatrum. Pulmonary hypertension : Brassica napus oleifera. Sudden HTN : Adren., Coff., Lactrodectus mactans

Control of high rise of blood pressureControl of high rise of blood pressure

• Even though constitutional treatment is the mainstay of homoeopathic management, it may be very much necessary in some cases to bring down the high blood pressure without delay.

• These may be cases where the blood pressure elevation is very high, or there are already some damage to the vital organs, making the occurrence of a cardiovascular complication very likely.

• In such situations, the initial prescription should be one capable of bringing the blood pressure down to reasonable limits.

• Here the knowledge of drugs known to be effective in such conditions, especially smaller or partially proved drugs, may be useful. They may also be required in cases when there is a paucity of characteristic symptoms, especially the ones dependent on allopathic drugs.

• As mentioned earlier, the rubric for “threatened apoplexy” may be helpful in some cases, especially when symptoms of cerebral congestion are present.

Frequently used anti – miasmatic Frequently used anti – miasmatic homoeopathic medicineshomoeopathic medicines

Anti – psoric medicines : Baryta mur., Con., Lach., Lyco., Nat mur., Sepia., Sulphur.

Anti – syphillitic medicines : Aur met., Con., Crotalus hor., Fluoric acid., Lach., Phos.

Anti – sycotic medicines : Calc carb., Lach., Lyco., Medo., Nat sulph., Nit acid., Sepia, Staphy.,Thuja.

Therapeutic hints in Hypertension Therapeutic hints in Hypertension

From sudden shock due to bad news15 - Gelsemium sempervirens Hypertension because of some insult16 - Staphysagria With personal or parental history of coronary thrombosis 15 - Thuja occ. As an intercurrent remedy, in persons wasting in health17 - Tuberculinum. In fleshy persons who eat a great deal, especially non-vegetarians15 - Allium

sat Hypertension in those engaged in mental work, teachers and professionals

who are exhausted from worry18 - Avena sativa Nervous hypertension, levels go up and down - Ignatia, Nux vom. With high difference between systolic and diastolic pressures17-Baryta mur. With cracks on fingers - Baryta carbonica With roaring in ears15 - Adrenalinum HTN c hyperthyroidism and valvular heart disease6 – Lycopus virginicus.

Therapeutic hints in hypertension (contd.) Therapeutic hints in hypertension (contd.)

With acute nasal obstruction6 - Iodum With insomnia18 - Passiflora incarnata, Crataegus oxyacantha. With redness of face19 – Bell., Adrenalin, Asterias rub, Strontium carb With throbbing headache, flushed face, tachycardia, hot body and cold

extremities19 - Bell. and Adrenalin. With red face, feeling of hot air around the head, and fear of

apoplexy6,19Asteria rub With profuse nose bleed ameliorating the headache6 - Hammamelis,

Melilotus alba. With full hard, bounding pulse, and congestive symptoms6,20 - Verat vir. With obstinate occipital headache15 – Carbo animalis With suppurative conditions in warm blooded persons – Calcarea sulph. Hypertension with pulmonary lesions17 – Phosphorus.

Therapeutic hints in Hypertension (contd.) Therapeutic hints in Hypertension (contd.)

Hypertension with hyperthyroid phenomena21 - Thallium metallicum Hypertension with diabetes mellitus - Lac vaccinum defloratum Hypertension with albuminuria6 – Mer cor and Viscum album In pregnant women with pre-eclampsia, hypertension, oedema -Apis mel. Hypertension at climacteric17 – Glon., Sang can, Lach., Sepia, Cactus g.,

Amyl nit., Sulphuric acid, Con mac. Hypertension with arteriosclerosis17 - Adrenalin, Baryta carb, Baryta

mur, Aurums, Plb met, Strophanthus hisp., Viscum alb., Sumbul mosch. Hypertension with cardiac hypertrophy22- Crataegus oxyacantha Hypertension with nephrosis22 - Fumaricum acidum Insufficiency of the left ventricle due to hypertension - Baryta carb,

Sulphur, Lachesis, Aurum met., Glonoine.

Therapeutic hints in Hypertension (contd.) Therapeutic hints in Hypertension (contd.)

Tissue remedies23 Arteriosclerosis – Nat phos., Silicea, Nat sulph. High blood pressure due to arteriosclerosis – Calc flour, Fer phos.

Nosodes6 Streptococcinum : HTN c hypercholestrolemia. Toxoplasma gondii : HTN c LVH and hypertensive emergencies

Drainage remedies24

Drainage of arteries in arterial hypertension – Sulphur, Cereus bonplandii

Indian drugs6

Boerhaavia diffusa : marked diuretic properties, HTN with dropsy in feet, ringing in ears and heat in the vertex.

Rauwolfia serpentina : HTN without marked atheromatous changes in the vessels. Terminalia arjuna : HTN c functional and organic changes in heart with angina pectoris.

Bowel nosodes6 Bacillus morgan : keynote is congestion, HTN with venous congestion resulting in varices,

venous stasis of legs and feet, congestive headache, vertigo and intense nervous excitement.

Potency selection

The selection of the potency in hypertension is not different from that for other disease conditions. Various factors like susceptibility, degree of similarity, presence or absence of structural changes, general vitality of the patient etc. are taken into account before selecting the appropriate potency in each case.

Potencies suggested by various authors Potencies suggested by various authors

However, various authors have mentioned the potencies they have found most

useful in cases of hypertension. These represent only the individual experience

of the authors. The potencies suggested for the different remedies and their

authors are given in next few slides. `X` denotes decimal potencies, all the

others are in the centesimal scale.

References of author as superscript : M – Dr. Farokh. J. Master22 T – Dr. T.P. Chatterjee25 P – Dr. S.G. Palsule18 C – Dr. J. H. Clarke20 G – Dr. R.L.Gupta26 B – Dr. William Boericke6 W – Dr. W. A. Dewey27 D – Dr. Bishamber Das15 F – Dr. Francoise Cartier28

Potencies suggested by various authors(contd.) Potencies suggested by various authors(contd.)

Aconitum nap: 1C,6T,F, 30T,F

Adrenalinum: 3W, 6W, 12W Allium sativum: QD Amylenum nitrosum: 30P Aurum metallicum: 200M, 6G

and 30B,G

Aurum muriaticum: 30G Avena sativa: QP, 200P

Baryta carbonica: 30G

Baryta mur: 200P, 6G, 30G

Belladonna: 6G, 30G Crataegus oxyacantha: QM

Diphtherinum: 200M Fumaricum acidum: 200M

Gelsemium: 1MD Glonoinum: 3F,6G,200P, 30G

Potencies suggested by various authors (contd.) Potencies suggested by various authors (contd.)

Hypophysis posterior: 200M

Ignatia amara: 200D, 30G Lachesis: 200M, 1MD, 30G Morgan pure: 200M Natrum iodatum: 1XW, 3XW, 6XW

Natrum muriaticum: 200D Passiflora incarnata: 200P, 1MP

Plumbum metallicum: 6G, 30G Psorinum: 200M

Serum anguillae: 200M Spartium scoparium: QM Syphilinum: 200M Toxoplasma nosode: 200M Tuberculinum bovinum: 200Viscum album: 200M, QC Veratrum vir.: 30P,6XG ,30G

A prospective, double-blind, randomized, placebo-controlled, parallel-arm clinical trial was conducted at the Outpatient Clinic of the Mahesh Bhattacharyya Homoeopathy Medical College and Hospital, West Bengal, between April 2011 and Feb 2012 to evaluate whether individualized homoeopathy can produce any significant effect different from placebo in essential hypertension by comparing the lowering of blood pressure between groups. Natrum muriaticum, Calcarea carbonica, Sulphur, Thuja occidentalis, Nitric acid and Medorrhinum were frequently prescribed. The result showed individualized homoeopathic treatment produced statistically significantly result than placebo.Reference :Saha S, Koley M, Hossain SI, Mundle M, Ghosh S, Nag G, Datta AK, Rath P. Individualized homoeopathy versus placebo in essential hypertension: A double-blind randomized controlled trial. Indian J Res Homoeopathy 2013;7:62-71

CONCLUSIONCONCLUSION The increasing hypertension and NCD burden presents a formidable challenge to the

Indian health care system. The gap between what is known and actually done for hypertension prevention, detection and management is disconcerting and requires to be addressed as a public health priority.

Given the high prevalence of hypertension in India, blood pressure assessment in all adults at every opportunity is both prudent and justified. In addition, simple non-laboratory based risk scores based on simple assessment of age, waist circumference, physical activity, and family history could be used to assess total cardiovascular risk as well as co-morbidities and refer those requiring further detailed evaluation to the secondary and tertiary health care system.

What we can see in above slides that hypertension is easily diagnosable and treatable with lifestyle modifications and cost - effective homoeopathic medicines.

It is important for all of us to work more meticulously, on modern scientific parameters, creating enough documentary proofs as per the need of the hour, without jeopardizing the tenets of Homoeopathy, so that our studies leave no gaps when such analyses are repeated.

ReferencesReferences1. Mohan S et al. Time to effectively address hypertension in India. Indian J Med Res April 2013; 137: 627-31

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11. Dhawale M.L. Principles and Practice of Homoeopathy. 2nd ed. Bombay : Institute of Clinical Research; 1985, p. 10-11,38,450-454,281,447

12. Allen J.H. The Chronic Miasms - Psora, Pseudo Psora and Sycosis Vol I & II. 1 st ed. Reprint. New Delhi : B Jain Publishers (P) Ltd; 1996.

13. Muzumdar KP. Lectures on Homoeopathic Therapeutics. 1st ed., Bombay: Paramanand Prakashan; 1995

14. Vithoulkas G. The Science of Homoeopathy. Indian ed.. New Delhi : B Jain Publishers (P) Ltd., 1998

15. Das B. Select Your Remedy. 17th ed.. Bishamber Free Homoeopathic Dispensary, 1996

References (contd.)References (contd.)16. Rastogi D.P. Homoeopathic Gems. 2nd ed. New Delhi: B Jain Publishers (P) Ltd., 1997.

17. Banerjee N.K. Blood Pressure - Its Aetiology and Treatment. Revised ed., Reprint. New Delhi: B Jain Publishers (P) Ltd., 1998.

18. Palsule S.G. Homoeopathic Treatment for Asthma and Blood pressure 3rd ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1999.

19. Vithoulkas G. Materia Medica Viva (vols.1-6) Accessed from Encyclopaedia Homoeopathica, RADAR, by Archibel, Belgium.

20. Clarke J.H. The Prescriber. Indian ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1998

21. Julian O.A. Dictionary of Homoeopathic Materia Medica. Translated by Dr. Rajkumar Mukerji. English ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1999.

22. Master F.J. Bedside Clinical Tips.1st ed. New Delhi:B Jain Publishers (P) Ltd., 1999 .

23. Boericke & Dewey. The Twelve Tissue Remedies of Schussler. 6th ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1990.

24. Bernoville F. Remedies of the Circulatory and Respiratory system. 2nd ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1999.

25. Chatterjee TP. My Random Notes on Some Homoeo-Remedies. Accessed from Encyclopaedia Homoeopathica, RADAR, by Archibel, Belgium.

26. Gupta RL. Directory of Diseases and Cures in Homoeopathy. Accessed from Encyclopaedia Homoeopathica, RADAR, by Archibel, Belgium.

27. Dewey WA. Practical Homoeopathic Therapeutics. 3rd ed. Reprint. New Delhi: B Jain Publishers (P) Ltd., 1996

28. Cartier F. Arterial hypertension. The Homoeopathic Herald 1947; Vol VII, No. 10. Accessed from Encyclopaedia Homoeopathica, RADAR, by Archibel, Belgium.

29. Arun Prasad K.P . Efficacy Of Homeopathic Medicines In the Management Of essential hypertension : a clinical study. Accessed from www.similima.com

I HEREBY ACKNOWLEDGE DR. VINITA GOEL, I HEREBY ACKNOWLEDGE DR. VINITA GOEL, DR. PARAMJEET KAUR AND DR. JITHESH T.K. DR. PARAMJEET KAUR AND DR. JITHESH T.K. FOR THEIR CONTRIBUTIONS .FOR THEIR CONTRIBUTIONS .

THANK THANK YOUYOU