an overview of the clinical pathophysiology of hypertension, its interpretation according to tibb...

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 hypertensionHypertension 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 HypertensionPrimary Hypertension-idiopathicSecondary Hypertension-identifiable causeAccording to Tibb

Sanguinous Hypertension = primary hypertension

Melancholic hypertension = secondary hypertension

Primary HypertensionPathogenesis

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 HypertensionLater 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

StressActivation 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 vasopressinCardiac and vascular hypertrophy = sustained

↑ blood pressure

Sleep ApneaHigher incidence of hypertensionThe 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 hypothyroidismExcessive 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-eclampsia3rd trimester of pregnancy ↑ blood volume and tachycardia The former increases cardiac output by

the Frank-Starling mechanism

Aortic coarctationElevated pressures proximal to the coarctation

(i.e., elevated arterial pressures in the head and arms)

Distal pressures are not necessarily reducedReduced systemic blood flow and reduced renal

blood flow → ↑ renin and an activation of the renin-angiotensin-aldosterone system → ↑ blood volume and arterial pressure

Baroreceptor reflex in blunted due to structural changes in the walls of vessels where the baroreceptors are located Baroreceptors become desensitized to chronic

elevation in pressure and become "reset" to the higher pressure

Isolated Systolic HypertensionDefined as SBP ≥ 140mmHG and DBP ≤

90mmHG60% of hypertensives > 80 years oldFrom 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 PhilosophyRenal Artery Stenosis- ↑cardiac output and

↑vascular resistanceMultifactoralPt and temperament specific

Chronic renal disease- impaired salt homeostasisSanguinous• Primary aldosteronism - ↑blood volume Sanguinous

Continued…Stress - ↑ cardiac output and ↑ systemic

vascular resistancePt and temperament specific

Sleep apnea – more prevalent in obese ptPhlegmatic or sanguinous

HyperthyroidismBilious

HypothyroidismPhlegmatic

Continued…Pheochromocytoma- ↑ systemic vascular

constriction and ↑ cardiac outputPt and temperament specific

Pre-eclampsia- ↑blood volume and tachycardia → ↑ cardiac output

Aortic coarctation Associated with moistnessCongenital condition in children

Isolated systolic hypertension- increased resistance of large arteriesElderly pt melancholic

Blood pressure relationship with TemperamentAge Sex Dominant Subdominant initial BP synthetic medication

65F Melancholic Phlegmatic 170/100 N

45M Sanguinous Phlegmatic 160/120 Y

74F Melancholic Bilious 140/76 Y

45M Sanguinous Bilious 140/90 Y

61F Sanguinous Bilious 180/110 N


49F Sanguinous Phlegmatic 130/100 N

43M Sanguinous Phlegmatic 160/110 N

44M Sanguinous Bilious 140/96 N

Continued….57F Sanguinous Bilious 160/90 Y

55F Phlegmatic Sanguinous 160/98 Y

54F Sanguinous Phlegmatic 119/78 Y


54M Phlegmatic Sanguinous 140/90 Y


52F Phlegmatic Sanguinous 140/100 N

35M Phlegmatic Sanguinous 130/95 N


68F Sanguinous Bilious 160/90 Y

30F Melancholic Bilious 150/110 N

50F Bilious Sanguinous 200/100 Y/N

Sanguinous dominant or sub-dominant ptsAge Sex Dominant Subdominant initial BP synthetic medication


45M Sanguinous Bilious 140/90 Y







Continued…54F Sanguinous Phlegmatic 119/78 Y








50F Bilious Sanguinous 200/100 Y/N

Melancholic ptsAge Sex Dominant Subdominant initial BP synthetic medication


74F Melancholic Bilious 140/76 Y


30F 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 ProjectAge Sex Dominant Subdominant BP synthetic medication









43M Phlegmatic Sanguinous 187/152 Y/N


Continued…31F Sanguinous Phlegmatic 150/114 N


64F Phlegmatic Sanguinous 210/160 Y/N








55 f Sanguinous Phlegmatic 154/99 Y

Continued…41M Sanguinous Phlegmatic 162/102 N











Continued… 57M Sanguinous Bilious 167/120 Y














Dr. Andreas Kefaldelis Research Project46 total pts100% dominant/subdominant sanguinous temperament36 pts ↑↑ SBP and ↑↑ DBP

78%24-75 years old

6 pts ↑↑ DBP13%21-37 years old

3 pts ↑↑ SBP 7%35-49 years old1 pt had wide pulse pressure

1 pt prehypertension

Effects of synthetic medication on blood pressure readings

PrehypertensionStage 1 Stage 2 mixed

134/84 N

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

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

o138/91

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

Prehypertension

Stage 1 Stage 2 Mixed

1 N

4 N 10 N 18 N

4 Y 6 Y 5 Y

1 non compliant 3 non compliant 6 non compliant

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 hypertension91% of total pts in this study

Sanguinous dominant/subdominant temperamentConcludes primary hypertension = sanguinous

hypertensionNo relationship exists between the blood

pressure reading and the quality of hypertensionSynthetic 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 medicationMost patients responded positively when given a

combination of pressure eeze and pressure eeze fortePathogenesis 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 Rx1 elderly isolated SBP pt responded well to pressure eeze

alone1 sanguinous pt had ↓DBP but an ↑ SBP2 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 studyWhite coat hypertension- anxiety in dr’s office may

↑ BP by 26mmHgSmall sample- findings not absoluteEffects of other chronic disease on hypertension

DyslipidaemiaHyperinsulinaemia 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/4076953. 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

an overview of the clinical pathophysiology of hypertension, its interpretation according to tibb...

Documents

tibbsanguinous hypertension

secondary hypertension

essential hypertension

development of hypertension

isolated systolic hypertension

arterial blood pressure

onset of raised blood

tibb philosophy