高血压 GAO XUE YA - HYPERTENSION

TRADITIONAL CHINESE MEDICINE PERSPECTIVE

Hypertension is an illness exhibiting a sustained increase in arterial blood pressure, particularly diastolic pressure, as its major clinical manifestation. Resting systolic pressure of 140mmHg or less and diastolic blood pressure of 90mmHg or less are considered normal adult blood pressure. Hypertension is thus defined as resting systolic blood pressure of 160 mmHg and over and diastolic blood pressure of 95 mmHg and over. Blood pressure between these two ranges are considered borderline hypertension.

Hypertension is clinically divided into essential or primary hypertension and secondary hypertension. Although the causes and pathogenic mechanism of essential hypertension have not been clearly determined, its development is often related to chronic mental or emotional tension, diets with high fat and/or high salt content, obesity, tobacco smoking and heredity and age factors. Ultimately, the regulatory functions of the central nervous and endocrine systems are thrown into confusion, followed by generalized sustained spasm of arterioles resulting in hypertension. This condition is most often presented during middle age onward and involves important organs such as the heart, kidney and brain in its later stages. Hypertension can also develop secondarily to certain preexisting conditions, including urogenital, intracranial and endocrine system disorders. In these cases, attention should be given to the primary disease.

Patients suffering from hypertension should avoid mental and emotional stress, use salt in moderation, eat unsaturated fat, and abstain from alcohol and tobacco. Drink boiled water and hot teas regularly, take Vitamin D, and fish oil supplement. 

Etiology and Pathogenesis

Hypertension originates mainly from excesses of the seven affects and improper diet and eating habits. The result is a state of deficiency below and excess above, beginning with a Deficiency of KD Yin in the LowerJiao, then deficiency of both LV and KD Yin and finally profusion of LV Yang in the UpperJiao. Prolonged profusion of LV Yang in the UpperJiao allows transformation of Wind and Fire. When Wind and Fire fan each other, fluids will begin to dry and produce phlegm. In addition, prolonged changes involving deficiency of both Yin & Yang.

TCM Patterns

Deficiency of Yin and Exuberance of Yang
Exuberance of Liver Fire
Obstruction by Phlegm-Dampness
Yin and Yang Deficiency

Deficiency of Yin and Exuberance of Yang

Symptoms: Dizziness and vertigo, headache, aching of the lower back, tinnitus, forgetfulness, vexing heat in the five hearts, palpitations, insomnia.
Tongue: Red with little coating.
Pulse: Thready, wiry.
Treatment Method: Foster LV and KD Yin, subdue LV Yang.

Exuberance of LV Fire

Symptoms: Dizziness and vertigo, distending pain of the head and eyes, red complexion, bloodshot eyes, irritability, dry bitter taste in the mouth, dark urine, constipation.
Tongue: Red with yellow coating.
Pulse: Rapid, wiry.
Treatment Method: Calm the LV, drain fire.

Obstruction by Phlegm-Dampness

Symptoms: Dizziness and vertigo, heaviness and pain of the head, irritability, nausea, oppression in the chest, low food intake, numbness and heaviness of the limbs, obesity.
Tongue: Enlarged with white, slimy coating.
Pulse: Slippery, wiry.
Treatment Method: Dispel phlegm, transform dampness.

Yin and Yang Deficiency

Symptoms: Dizziness and vertigo aggravated by movement, blurred vision, headache, tinnitus, palpitations, shortness of breath, weakness and aching of the lower back and legs, lack of strength, numbness of the hands.
Tongue: Light red.
Pulse: Thready, wiry.
Treatment Method: Supplement KD Yin and Yang.
                                             

BIOMEDICAL PERSPECTIVE

There is still much uncertainty about the pathophysiology of hypertension. A small number of patients -between 2% and 5%- have an underlying renal or adrenal disease as the cause for their raised blood pressure. In the remainder, however, no clear single identifiable cause is found, and their condition is labeled essential hypertension. A number of physiological mechanisms are involved in the maintenance of normal blood pressure, and their derangement may play a part in the development of essential hypertension.

It is probable that a great many interrelated factors contribute to the raised blood pressure in hypertensive patients, and their relative roles may differ between individuals. Among the factors that have been intensively studied are salt intake, obesity and insulin resistance, the renin-angiotensin system, and the sympathetic nervous system. In the past few years, other factors have been evaluated, including genetics, endothelial dysfunction (as manifested by changes in endothelin and nitric oxide), low birth weight and intrauterine nutrition, and neurovascular anomalies.

Cardiac output and peripheral resistance

Maintenance of a normal blood pressure is dependent on the balance between the cardiac output and peripheral vascular resistance. Most patients with essential hypertension have a normal cardiac output but a raised peripheral resistance. Peripheral resistance is determined not by large arteries or the capillaries but by small arterioles, the walls of which contain smooth muscle cells. Contraction of smooth muscle cells is thought to be related to a rise in intracellular calcium concentration, which may explain the vasodilatory effect of drugs that block the calcium channels. Prolonged smooth muscle constriction is thought to induce structural changes with thickening of the arteriolar vessel walls possibly mediated by angiotensin, leading to an irreversible rise in peripheral resistance.

It has been postulated that in very early hypertension the peripheral resistance is not raised and the elevation of the blood pressure is caused by a raised cardiac output, which is related to sympathetic overactivity. The subsequent rise in peripheral arteriolar resistance might therefore develop in a compensatory manner to prevent the raised pressure being transmitted to the capillary bed where it would substantially affect cell homeostasis.

Renin-angiotensin system

The renin-angiotensin system may be the most important of the endocrine systems that affect the control of blood pressure. Renin is secreted from the juxtaglomerular apparatus of the kidney in response to glomerular under-perfusion or a reduced salt intake. It is also released in response to stimulation from the sympathetic nervous system.

Renin is responsible for converting renin substrate -angiotensinogen- to angiotensin I, a physiologically inactive substance which is rapidly converted to angiotensin II in the lungs by angiotensin converting enzyme, or ACE. Angiotensin II is a potent vasoconstrictor and thus causes a rise in blood pressure. In addition, it stimulates the release of aldosterone from the zona glomerulosa of the adrenal gland, which results in a further rise in blood pressure related to sodium and water retention.

The circulating renin-angiotensin system is not thought to be directly responsible for the rise in blood pressure in essential hypertension. In particular, many hypertensive patients have low levels of renin and angiotensin II -especially elderly and black people, and drugs that block the renin-angiotensin system are not particularly effective.

There is, however, increasing evidence that there are important non-circulating ‘local’ renin-angiotensin apocrine or paracrine systems, which also control blood pressure. Local renin systems have been reported in the kidney, the heart, and the arterial tree. They may have important roles in regulating regional blood flow.

Autonomic nervous system

Sympathetic nervous system stimulation can cause both arteriolar constriction and arteriolar dilatation. Thus, the autonomic nervous system has an important role in maintaining a normal blood pressure. It is also important in the mediation of short term changes in blood pressure in response to stress and physical exercise.

There is, however, little evidence to suggest that epinephrine -adrenaline- and norepinephrine -noradrenaline- have any clear role in the etiology of hypertension. Nevertheless, their effects are important, not least because drugs that block the sympathetic nervous system do lower blood pressure and have a well-established therapeutic role. It is probable that hypertension is related to an interaction between the autonomic nervous system and the renin-angiotensin system, together with other factors, including sodium, circulating volume, and some of the more recently described hormones.  

Endothelial dysfunction

Vascular endothelial cells play a key role in cardiovascular regulation by producing a number of potent local vasoactive agents, including the vasodilator molecule nitric oxide and the vasoconstrictor peptide endothelin. Dysfunction of the endothelium has been implicated in human essential hypertension.

Modulation of endothelial function is an attractive therapeutic option in attempting to minimize some of the important complications of hypertension. Clinically effective antihypertensive therapy appears to restore impaired production of nitric oxide but does not seem to restore the impaired endothelium dependent vascular relaxation or vascular response to endothelial agonists. This indicates that such endothelial dysfunction is primary and becomes irreversible once the hypertensive process has become established

Vasoactive substances

Many other vasoactive systems and mechanisms affecting sodium transport and vascular tone are involved in the maintenance of a normal blood pressure. It is not clear, however, what part these play in the development of essential hypertension. Bradykinin is a potent vasodilator that is inactivated by angiotensin converting enzyme. Consequently, the ACE inhibitors may exert some of their effect by blocking bradykinin inactivation.

Endothelin is a recently discovered, powerful, vascular, endothelial vasoconstrictor, which may produce a salt sensitive rise in blood pressure. It also activates local renin-angiotensin systems. Endothelial derived relaxant factor, now known to be nitric oxide, is produced by arterial and venous endothelium and diffuses through the vessel wall into the smooth muscle causing vasodilatation.

Atrial natriuretic peptide is a hormone secreted from the atria of the heart in response to increased blood volume. Its effect is to increase sodium and water excretion from the kidney as a sort of natural diuretic. A defect in this system may cause fluid retention and hypertension. Sodium transport across vascular smooth muscle cell walls is also thought to influence blood pressure via its interrelation with calcium transport. Ouabain may be a naturally occurring steroid-like substance which is thought to interfere with cell sodium and calcium transport, giving rise to vasoconstriction.

Hypercoagulability

Patients with hypertension demonstrate abnormalities of vessel wall ─endothelial dysfunction or damage; the blood constituents: abnormal levels of hemostatic factors, platelet activation, and fibrinolysis; and blood flow: rheology, viscosity, and flow reserve, suggesting that hypertension confers a prothrombotic or hypercoagulable state. These components appear to be related to target organ damage and long term prognosis, and some may be altered by antihypertensive treatment.

Insulin sensitivity

Epidemiologically there is a clustering of several risk factors, including obesity, hypertension, glucose intolerance, diabetes mellitus, and hyperlipidemia. This has led to the suggestion that these represent metabolic syndrome with a final common pathway to cause raised blood pressure and vascular damage. Some hypertensive patients who are not obese display resistance to insulin. There are many objections to this hypothesis, but it may explain why the hazards of cardiovascular risk are synergistic or multiplicative rather than just additive.

Genetic factors

Although separate genes and genetic factors have been linked to the development of essential hypertension, multiple genes most likely contribute to the development of the disorder in a particular individual. It is therefore very difficult to determine accurately the relative contributions of each of these genes. Nevertheless, hypertension is about twice as common in subjects who have one or two hypertensive parents, and many epidemiological studies suggest that genetic factors account for approximately 30% of the variation in blood pressure in various populations. This figure can be derived from comparisons of parents with their monozygotic and dizygotic twin children, as well as their other children, and with adopted children. Some familial concordance is, however, due to shared lifestyle mainly dietary factors.

Some specific genetic mutations can rarely cause hypertension. Experimental models of genetic hypertension have shown that the inherited tendency to hypertension resides primarily in the kidney. For example, animal and human studies show that a transplanted kidney from a hypertensive donor raises the blood pressure and increases the need for antihypertensive drugs in recipients coming from “normotensive” families. Conversely a kidney from a normotensive donor does not raise the blood pressure in the recipient. Increased plasma levels of angiotensinogen, the protein substrate acted on by renin to generate angiotensin I, have also been reported in hypertensive subjects and in children of hypertensive parents.

Hypertension is rarely found in rural or “tribal” areas of Africa, but it is very common in African cities and in black populations in Britain and the United States. Whereas the rural/urban differences in Africa are clearly due to lifestyle and dietary factors, the finding that hypertension is commoner in black people compared with white people may have some genetic basis. There is some evidence from salt loading studies in medical students that black Americans are more susceptible to a given salt load than white Americans and may be more sensitive to the beneficial effects of salt restriction.

Intrauterine influences

There is increasing evidence that fetal influences, particularly birth weight, may be a determinant of blood pressure in adult life. For example, babies who are small at birth are more likely to have higher blood pressure during adolescence and to be hypertensive as adults. Babies who are small for their age are also more likely to have metabolic abnormalities that have been associated with the later development of hypertension and cardiovascular disease, such as insulin resistance, diabetes mellitus, hyperlipidemia, and abdominal obesity. Insulin resistance almost certainly contributes to the increased prevalence of coronary disease seen in adults of low birth weight.

It is possible, however, that genetic factors influence the Barker hypothesis. Mothers with above average blood pressure in pregnancy give birth to smaller babies who subsequently develop above average blood pressure themselves and eventually hypertension. It is entirely likely that the similarity of blood pressures in mother and child are genetic and, in a modern “healthy” society, unrelated to intrauterine undernutrition.

Diastolic dysfunction

In hypertensive left ventricular hypertrophy, the ventricle cannot relax normally in diastole. Thus, to produce the necessary increase in ventricular input, especially during exercise, there is an increase in left atrial pressure rather than the normal reduction in ventricular pressure, which produces a suction effect as described above. This can lead to an increase in pulmonary capillary pressure that is sufficient to induce pulmonary congestion. The rise in atrial pressure can also lead to atrial fibrillation, and in hypertrophied ventricles dependent on atrial systole the loss of atrial transport can result in a significant reduction in stroke volume and pulmonary edema. Exercise induced subendocardial ischemia can also produce an ‘exaggerated’ impairment of diastolic relaxation of the hypertrophied myocardium.

Patients are starting to question whether they could achieve better results with less medication and are turning to Chinese Medicine for help in this endeavor. The primary goal of Traditional Chinese Medicine in the treatment of sustained high blood pressure, is not the immediate lowering of the blood pressure, but the correction of the underlying health problems that are the cause of a sustained high blood pressure.

A growing number of medical doctors agree that this is a practical approach and could be integrated into the standard treatment protocol without risk, potentially reducing the dependency on multiple drugs to control hypertension. Risk from hypertension occurs over long periods of time for almost all patients. Adjustment of the treatment protocol is thus safe, even with a transition period where blood pressure is less controlled, as long as this is monitored by the physician. To insure safety, the patient is encouraged to purchase a blood pressure monitoring device for home use, and this helps the patient to understand which parts of the complementary protocol seem to work best.

DISCUSSION

The dietary protocol Dietary Approaches to Stop Hypertension ─a.k.a. DASH, has been very successful in this regard. Much study has proven that a significant reduction in high blood pressure is achieved for most patients with a diet that is rich in fresh vegetables, some whole grains, and fermented and pickled foods, and includes small daily portions of fresh fruit, nuts, seeds, and healthy dairy products, such as yogurt, farmers cheese, and sour cream. The DASH diet limits meat, poultry and fish to just one or two small portions per day and restricts the consumption of sugar sweetened beverages and foods, as well as salty snacks and fast food.

To achieve an improved potassium to sodium ratio, a more plant-based and fresh food diet is essential. The standard vegetarian diet provides a 5:1 ratio of potassium to sodium, whereas a typical American diet yields a 1:2 ratio of potassium to sodium. This electrolyte imbalance is integral to the pathology of hypertension. A variety of DASH books, with menus and recipes, have been created, and the NIH study found that adherence to this plan produced an average reduction in systolic blood pressure of 6 mmHg, and diastolic of 3 mmHg in normal patients, and 11 mmHg systolic and 6 mmHg diastolic in patients with moderate to severe hypertension.

Other studies have demonstrated similar benefits from daily short aerobic exercise routines, and short periods of controlled breathing exercises and relaxation techniques. Combining these protocols should achieve a reduction in blood pressure greater than what is achieved with medications.

These types of studies and protocols show that experts in the field, and the most respected health organizations, find that it is important to try to control high blood pressure without chronic dependency on medications that have been proven to be less effective that we need them to be, and come with considerable long term side effects and risks themselves. With the addition of Complementary Medicine into this protocol, a great number of patients are finding success in controlling hypertension and creating better overall health and reducing future health problems and health risks.

Complementary Medicine, in the form of acupuncture and herbal/nutrient medicines, will not only aid the immediate control of blood pressure, but get at the underlying causes in an individualized manner. The knowledgeable Licensed Acupuncturist will also be able to provide individualized guidance to help establish an efficient daily routine to reduce hypertension and regain cardiovascular health. Dietary changes, short aerobic exercise routines, changes in habits, such as walking to the grocery store, and 5-10 minutes of relaxed slow diaphragmatic breathing, will both achieve the desired results and improve quality of life.

The measure of success occurs over a period of time, and a discussion with the prescribing primary care physician about gradually lowering dosages and going off of hypertension prescriptions as the health improves, and proven strategies are implemented, is necessary; and treating both consistently sustained high blood pressure and the underlying causes and individualized risk factors of cardiovascular disease is important.

Complementary and Integrative Medicine provides many treatment tools to help achieve these goals in the healthiest manner possible. Standard drug medications to control high blood pressure do nothing to resolve the underlying health problems that caused the hypertension. Ignoring these underlying health problems may be the reason that yearly deaths from cardiovascular disease remain high, and why the number of deaths from heart failure have remained constant from their peak in 1993 to today, despite the large rise in the prescription of anti-hypertensive drugs.

For patients with more severe hypertension, or sustained high blood pressure above 160/100, standard treatment protocol has failed to control this condition in a significant percentage of patients. Experts agree that for the roughly 70 million Americans treated for hypertension, about half still have blood pressure above normal. Dr. Gordon Tomaselli, a cardiologist at Johns Hopkins and president of the American Heart Association has stated that 10-20 percent of hypertension patients are unable to control hypertension even with multiple drug therapy, and many consider this a conservative estimate.

In 2012, medical experts are resorting to renal denervation to achieve results due to the high failure rate of multiple drug therapies for patients with true hypertension. In this procedure, a catheter is inserted through the arteries to the area of the kidney that reacts to chemical and hormonal imbalances, and stimulates increased vascular tension, the glomerular apparatus. The catheter contains a radio-frequency ablater that destroys the nerves in this kidney tissue, much in the way that radio-frequency ablation destroys the tissue nerves that control heart rate to stop episodes of tachycardia and fibrillation. As in the heart tissue, this is expected to reverse in time, though, with a regrowth of the normal tissue and nerves.

In a June 6, 2012 New York Times article, entitled To Cut Blood Pressure, Nerves Get a Jolt, the director of the hypertension center at the University of Chicago medical center, and a principal investigator in the clinical trials to radio-frequency ablation for hypertension, reports that “A lot of people have viewed this superficially as a cure for hypertension, and it is not.” This expert states that it will only allow some patients to take fewer medications or smaller doses, reducing adverse effects. The chief concern is that eliminating the normal mechanism to modulate blood pressure in the kidney will put the patient at risk when acute blood loss or other health problems need the kidney and adrenal apparatus to respond with higher blood pressure.

What is largely overlooked in this discussion are the protocols to treat the underlying causes of the hypertension effectively, utilizing and integrating Complementary Medicine effectively. Once again, allopathic medicine fails to see the need to fix the problem, or problems, not just inhibit the body from what it is genetically programmed to do. Allopathic inhibition of the blood pressure mechanisms is just one tool in the box to protect the patient, and not at all the complete solution.

In 2013, the American Heart Association Professional Education Committee finally released an opinion that medical doctors should integrate what they persist in calling “alternative approaches” beyond medications and diet in the protocol to lower blood pressure. The committee reluctantly admitted that a number of protocols have been understudied but nonetheless have produced reliable evidence of effectiveness. These proven treatments include, in the order of most evidenced to least, aerobic exercise, guided breathing techniques, acupuncture, resistance exercise, meditation, yoga and other relaxation techniques.

Of course, none of these techniques involves any risk of harm to the patient, and certainly they could all easily be combined in a protocol that would be relatively inexpensive, take little time or effort, and integrate well with standard protocol, or drug therapy. These protocols of Complementary Medicine have been practiced for some time in Traditional Chinese Medicine, with short courses of acupuncture combined with guided breathing techniques, and the advice to the patient to adopt better exercise habits, utilize yoga, and take up either meditation or other relaxation techniques.

This review of an expanded integrative protocol was published in the medical journal Hypertension. Surely such a protocol should be tried before kidney ablation surgery and could potentially reduce the need for multiple prescription drugs and thus reduce the adverse effects of these pharmaceuticals and improve quality of life.

In 2013, the American Heart Association Professional Education Committee finally recommended that treating Medical Doctors integrate Complementary Medicine into a thorough and holistic treatment protocol to control high blood pressure, or hypertension. In the United States, experts studying the physiological effects of acupuncture stimulation at the University of California at Irvine noted that their studies elucidate the physiological benefits of acupuncture as an adjunct integrated treatment for essential hypertension, with proof that sustained cardiovascular benefits and neurovascular modulation are achieved with repeated short course of acupuncture.

 

TYPE II DIABETES

OBESITY

METABOLIC SYNDROME

LONGEVITY

 

__________________________________________________________________________________________________________________________________________________________________REFERENCES
-Above Article Compiled and Written by Dr. Osorio, Gloria, DAOM, L.Ac. 2020.

– Barker DJP, Osmond C, Golding J, Kuh D, Wadsworth MEJ. Growth in utero, blood pressure in childhood and adult life and mortality from cardiovascular disease. BMJ 1989;298:564-7.
-Dzau VJ. Circulating versus local renin-angiotensin system in cardiovascular homeostasis. Circulation 1988;77(suppl 1):I4-13.
-Harrap SB. Hypertension: genes versus environment. Lancet 1994;344:169-71.
-Hughes AD, Schachter M. Hypertension and blood vessels. Br Med Bull 1994;50:356-70.
-Kurtz TW. Genetic models of hypertension. Lancet 1994;344:167-8.
-Lip GYH, Li-Saw-Hee FL. Does hypertension confer a hypercoagulable state? J Hypertens 1998;16:913-6.
-Mathias CJ. Role of sympathetic efferent nerves in blood pressure regulation and in hypertension. Hypertension 1991;18:22-30.
-Sagnella G, Macgregor GA. Atrial natriuretic peptides. Q J Med 1990;77:1001-7.
-Beijing University of TCM. Traditional Chinese Internal Medicine, Academy Press, 2000.
-Davidson’s Principles and Practice of Medicine 18^th Edition by Churchill Livingstone, 1999.
-Zhang Dazhao, Diagnosis and Treatment of Common Disease in TCM, WuXiaolong-Hai Feng Publishing Co., 1992.
– http://www.aafp.org/news/health-of-the-public/20151015htnprevrec.html
– http://www.nhlbi.nih.gov/health/allhat/index.htm
– http://www.ncbi.nlm.nih.gov/pubmed/8858082
– http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513905
– http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014308
– http://www.ncbi.nlm.nih.gov/pubmed/25427719
– http://press.endocrine.org/doi/full/10.1210/jcem.84.6.5724