Understanding hypertension in the light of Ayurveda

Abstract

Different theories have been proposed to explain hypertension from an Ayurvedic perspective, but there is no consensus amongst the experts. A better understanding of the applied physiology and etio-pathogenesis of hypertension in the light of Ayurvedic principles is being attempted to fill this gap. A detailed review of available Ayurvedic literature was carried out to understand the physiology of blood pressure and etio-pathogenesis of hypertension from the perspective of Ayurveda. Many parallels were drawn from the concepts such as Shad Kriyakala (six stages of Dosha imbalance) and Avarana of Doshas (occlusion in the normal functioning of the Doshas) to the modern pathogenesis of hypertension to gain a deeper understanding of it. Hypertension without specific symptoms in its mild and moderate stages cannot be considered as a disease in Ayurveda. It appears to be an early stage of pathogenesis and a risk factor for development of diseases affecting the heart, brain, kidneys and eyes etc. Improper food habits and modern sedentary lifestyle with or without genetic predisposition provokes and vitiates all the Tridoshas to trigger the pathogenesis of hypertension. It is proposed that hypertension is to be understood as the Prasara-Avastha which means spread of vitiated Doshas from their specific sites, specifically of Vyana Vata, Prana Vata, Sadhaka Pitta and Avalambaka Kapha along with Rakta in their disturbed states. The Avarana (occlusion of normal functioning) of Vata Dosha by Pitta and Kapha can be seen in the Rasa-Rakta Dhathus, which in turn hampers the functioning of the respective Srotas (micro-channels) of circulation.

Full text

Review Article
Understanding hypertension in the light of Ayurveda
Maanasi Menon
a
, Akhilesh Shukla
b
,
*
a
Dept of Kayachikitsa, Amrita School of Ayurveda, Clappana P.O., Kollam Dist, Kerala, 690525, India
b
Dept of Samhita, Siddhanta, Govt. Ayurveda College, Bilaspur, Chhattisgarh, 495001, India
article info
Article history:
Received 23 May 2017
Received in revised form
18 October 2017
Accepted 22 October 2017
Available online 17 November 2017
Keywords:
Hypertension
Ayurveda
Blood pressure
Etio-pathogenesis
abstract
Different theories have been proposed to explain hypertension from an Ayurvedic perspective, but
there is no consensus amongst the experts. A better understanding of the applied physiology and
etio-pathogenesis of hypertension in the light of Ayur vedic principles is being attempted to fill this
gap. A detailed review of available Ayurvedic literature was carried out to understand the physiology
of blood pressure and etio-pathogenesis of hypertension from the perspective of Ayurveda.Many
parallels were drawn from the concepts such as Shad Kriyakala (six stages of Dosha imbalance) and
Avarana of Doshas (occlusion in the normal functioning of the Doshas) to the modern pathogenesis of
hypertension to gain a deeper understanding of it. Hypertension without specificsymptomsinits
mild and moderate stages cannot be considered as a disease in Ayurveda. It appears to be an early
stage of pathogenesis and a risk factor for development of diseases affecting the heart, brain, kidneys
and eyes etc. Improper food habits and modern sedentary lifestyle with or without genetic predis-
position provokes and vitiates all the Tridoshas to trigger the pathogenesis of hypertension. It is
proposed that hypertension is to be understood as the Prasara-Avastha which means spread of
vitiated Doshas from their specificsites,specifically of Vyana Vata,Prana Vata,Sadhaka Pitta and
Avalambaka Kapha along with Rakta in their disturbed states. The Avarana (occlusion of normal
functioning) of Vata D osha by Pitta and Kapha can be seen in the Rasa-Rakta Dhathus,whichinturn
hampers the functioning of the respective Srotas (micro-channels) of circulation.
©2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
1. Introduction
In this modern era of specialties and super-specialties in medical
care, Ayurveda stands out by its holistic approach towards the body
as one single entity. The body with all its parts co-existing with
interdependence and mutual interaction makes it difficult to
comprehend when approached separately. In recent times, hu-
manity has begun to realize this holistic approach to health with
the multidimensional aspects of body, mind and soul [1] preached
by Ayurveda ages ago. In the present times, life has been made easy
for man with modernization every step of the way, but he has also
paid for it by becoming prey to many lifestyle diseases. The diseases
occur due to his faulty life style and stressful psychological condi-
tions. These factors affect one's mind and homeostasis of the body
by several psychosomatic mechanisms and lead to many lifestyle
diseases such as diabetes and hypertension. As per World Health
Organization report, about 40% of people aged more than 25 years
had hypertension in 2008 [2]. Hypertension is directly responsible
for 57% of all stroke deaths and 24% of all coronary heart disease
(CHD) deaths in India [3]. It is the most potent risk factor for dis-
eases of the brain, kidney, heart and peripheral arteries which may
prove fatal if not managed effectively [4]. Hypertension is a silent
killer because most sufferers (85%) are asymptomatic [5]. In 95% of
the cases of hypertension, the exact underlying causes are still
unknown [6] but is believed to be due to genetic and environmental
factors [7].
Hypertension cannot be considered as a Vyadhi (disease) as per
Ayurveda but it can be understood by assessing the involved Doshas,
Dooshyas (entity which is affected by morbid Dosha), Srotas etc.
Many Ayurvedic scholars have proposed different theories about
how hypertension can be understood in Ayurveda, but there is no
standardized and widely accepted view about the Ayurvedic path-
ogenesis of this condition. There are still many controversies
related to this disease in Ayurveda. Thus, this is an attempt to
*Corresponding author.
E-mail: an2akhilesh@gmail.com
Peer review under responsibility of Transdisciplinary University, Bangalore.
Contents lists available at ScienceDirect
Journal of Ayurveda and Integrative Medicine
journal homepage: http://elsevier.com/locate/jaim
https://doi.org/10.1016/j.jaim.2017.10.004
0975-9476/©2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Ayurveda and Integrative Medicine 9 (2018) 302e307

thoroughly understand hypertension and interpret it in terms of
Ayurvedic principles, considering all the existing views.
2. Previous theories eAyurvedic view
Various Ayurvedic scholars have coined different names for hy-
pertension such as: Raktagata Vata,Siragata Vata,Avrita Vata,
Dhamani Prapurana,Rakta Vikshepa,Vyana Prakopa,Raktamada,
Uchharaktachapa,Vyana Atibala etc. [8]. In each of these terms,
different points of view have been adopted, but no one has denied
the fact that in hypertension, the main pathogenesis occurs in Rakta
along with the blood vessels. This being the only factor in common,
many previous authors have given separate views on the Ayurvedic
pathogenesis of this condition. As modern science is well advanced
in understanding hypertension, we must understand all that is
known about this disease and suitably correlate it to Ayurvedic
principles for better understanding.
3. Concept of blood pressure in Ayurveda
At first, it is essential to understand the physiological aspects of
blood pressure in Ayurveda which is fundamentally based on the
theory of Tridosha [9]. The blood first ejected out of the heart, is
then distributed to all parts of the body, and, thereafter, is returned
back to the heart through the blood vessels termed as ‘Sirah’in
Ayurveda [10]. This return of Rasa (blood) towards heart is
controlled by the function of Samana Vata [9,11]. As it is known,
blood pressure is the lateral pressure exerted by the flow of blood
on the walls of the arteries [12]. The two components of blood
pressure are the systolic and diastolic blood pressure [13]. The heart
has its pacemaker (SA node) that generates electrical impulses on
its own, which makes the heart contract during the systole. This
self-excitatory function of the heart can be attributed to the func-
tioning of the Vata Dosha, in particular the Vyana Vata as it is seated
in the heart and is responsible for blood circulation [9,14]. Charaka
clearly describes that Vyana Vata, a component of Vata Dosha
constantly forces the blood out of the heart and distributes it [9,15].
Thus it can be said that the systolic BP attained during contraction
of the heart is controlled by Vata (Vyana Vata). Though the SA node
generates impulses on its own, the rate of its impulse generation is
controlled by the autonomic nervous system via sympathetic and
para-sympathetic nerve fibers emerging from the brain. It is the
Prana Vata situated in the Moordha (Brain) [Ashtanga Hridaya, Sutra
Sthana, 12/4] that controls the Hridaya (heart) and does Dhamani
Dharana (arterial perpetuation) [16] and thus heart rate is
controlled by Prana Vata. In this context it can be understood as
Vyana Vata and Prana Vata denote the nervous control of circulation
because Vata, in general, denotes all neural mechanisms [9,17]. The
diastole is attained when the heart muscles relax. Here, diastolic
blood pressure is only due to blood flowing through the narrow
structures of the chambers of the heart and arteries and there is no
active push by the heart. Thus diastolic BP can be taken under the
domain of Kapha Dosha (Kapha maintains the structural integrity of
body organs), mainly the Avalambaka Kapha [Ashtanga Hridaya,
Sutra Sthana, 12/15] because it is the resistance offered by the
structure of the heart and the blood vessels that controls the dia-
stolic blood pressure. Thus the peripheral resistance (faced by
blood in the blood vessels) determines the diastolic BP. This is
mainly influenced by the diameter and elasticity of the blood ves-
sels which can be considered under the purview of Kapha Dosha.
The vascular tone is also controlled by the autonomic nervous
system which alters the diameter of the arteries as and when
required [18].AsDhamani Dharana is a function of Prana Vata
[Asthanga Samgraha, Sutra Sthana, 20/2], the peripheral resistance
offered by the arteries due to vasoconstriction caused by
sympathetic action of nerves can be understood as a function of
Prana Vata. The Auto-rhythmicity of the heart is due to the action
potential created by the rapid influx of Na
þ
and Ca
þþ
ions and efflux
of K
þ
ions across the membrane of the SA node [19]. The involve-
ment of these chemical ions can be taken under the purview of Pitta
due to its Tikshna (rapidness) Drava (fluidity) and Sara (diffusion/
dispersion) Guna, [Asthanga Samgraha, Sutra Sthana, 1/26] mainly
Sadhaka Pitta situated in the heart. The basal metabolic rate (BMR)
has a direct but imperfect positive correlation with the pulse rate
and pulse pressure of the heart [20]. This is on the basis of Read's
and Gale's formulae [21,22]. This means to say that variations in the
basal metabolic rate cause changes in blood pressure as well. Thus
the basal metabolic rate can be understood as a result of the action
of Agni or Pitta, more precisely, Pachaka Pitta [Ashtanga Hridaya,
Sutra Sthana, 12/10e12]. The blood volume and viscosity can be
determined by the quality and quantity of the Rasa and Rakta
Dhatus. These also determine the cardiac output. The heart (Hri-
daya) and the blood vessels (Rasavaha Dhamanis) form the Prana
Vaha Srotas and their Srotomulas which are mainly involved in the
blood circulation [23] along with that Medavaha Srotas,Mutarvaha
Srotas,Swedavaha srotas and Udakavaha Srotas play an important
role. Thus the Doshas,Dhatus and Srotas involved in the blood
pressure have been discussed.
4. Blood pressure regulation and the role of Tridosha
Blood Pressure in the body is regulated by multiple mechanisms.
Short-term Neural mechanisms and Long-term Renal, Hormonal
and Local vascular mechanisms [9].
Short term mechanisms include the Nervous mechanism
controlled by the vasomotor center of the brain via autonomic
stimulation through Baro-receptor and feedback of Chemorecep-
tors [24,25]. This CNS regulation of Blood pressure can be under-
stood mainly as a Vata function, typically Prana Vata (taking the
help of Kapha in case of Baro-receptors and Pitta in case of Chemo-
receptors).
Long term regulation of blood pressure is by:
1) Pressure Diuresis and Pressure Natriuresis eKidneys excrete
water and sodium through urine (Kleda nirvahanam) [Asthanga
Samgraha, Sutra Sthana, 19/20] to bring down the blood volume
to regulate the blood pressure. This mechanism can be attrib-
uted to elimination of Kapha in the form of Kleda by the function
of Apana Vata [Asthanga Samgraha, Sutra Sthana, 20/2]
2) Renin-Angiotensin Mechanism eThe Kidneys secrete Renin in
response to low blood pressure as a result of which Angiotensin
II is secreted to bring about vasoconstriction along with defec-
tive sodium and water homeostasis and thereby increasing
blood pressure [26]. This can be attributed to the function of
Pitta.
3) Hormonal regulation of Blood pressure: There are about 15
different hormones secreted which can create variations in the
blood pressure. They are Adrenalin, Nor-Adrenalin, Thyroxin,
Aldosterone, Vasopressin, Angiotensins, Serotonin, Bradykinin,
Prostaglandins, Histamine, Acetylcholine, Atrial Natriuretic
Peptide etc. [27].
All these being chemical substances causing regulation of blood
pressure, may come under the perview of Pitta Dosha.
4) Local mechanism of BP regulation at the blood vessel level-
There are local vasocontrictors like endothelins and local vaso-
dilators like CO
2
,H
þ
ions, Lactate, Adenosine and Nitric oxide
which cause change in peripheral resistance thus influencing
the BP [28]. This again can be understood as a function of Pitta.
M. Menon, A. Shukla / Journal of Ayurveda and Integrative Medicine 9 (2018) 302e307 303

Thus, the role played by the Tridoshas in regulation of blood
pressure has been discussed.
5. Etiological risk factors related to hypertension
By definition, the causes of essential hypertension are unknown
but many genetic and environmental factors and their mutual in-
teractions act as risk factors for the development of this condition
[7]. These factors are: high salt and spicy food intake, alcohol
consumption and use of tobacco, low Calcium and Potassium
intake, psychological stress, heredity, intake of fatty food which
causes obesity and hyperlipidemia leading to atherosclerosis in
blood vessels and physical inactivity (sedentary lifestyle) [29].
Among these, high salt and spicy food, alcohol consumption, use of
tobacco, low Calcium and Potassium intake and psychological
stress may vitiate Pitta,Vata and Rakta, while physical inactivity,
dullness and habitual intake of fatty foods are Kapha and Medo-
vardhaka Nidanas (etiological factors increasing fat) [Charaka
Samhita, Sutra Sthana, 21/4]. Family history (heredity) is due to
Beeja dosha (genetic defects). Most of these Nidanas are mentioned
together as Rakta Dusti Karana by Charaka in the Vidhishonitiya
Adhyaya [Charaka Samhita, Sutra Sthana, 24/5e10] and in the
context of Pittaja Hridroga [Charaka Samhita, Sutra Sthana, 17/32].
6. Pathology of hypertension in Ayurveda based on the
modern view
Essential hypertension is defined as chronic elevation in arterial
blood pressure (BP) >140/90 mmHg with no definable causes [30].
The various genetic and environmental factors mentioned earlier
interact with each other and influence the pathogenesis of this
condition. The main determinants of blood pressure as seen earlier
are the cardiac output and peripheral resistance. Cardiac output is
determined by the stroke volume and heart rate [31]. So, for
increase in blood pressure, there should be increase in either car-
diac output or peripheral resistance. This happens when due to the
influence of risk factors one or more of the different regulatory
mechanisms of blood pressure gets hampered causing the blood
pressure to increase. Defects in renal Sodium homeostasis causes
decreased Na excretion leading to increased salt and water reten-
tion [32]. This increases the plasma and extra cellular fluid thus
increasing the cardiac output. This is one mechanism which leads
to hypertension. This may be understood as the pathology due to
Dooshana (vitiation) of Pitta and Rakta due to Ati Katu &Lavana Rasa
sevena (excess intake of pungent and salty items) [Charaka Samhita,
Chikitsa Sthana, 4/6]. The other mechanism is increased functional
vasoconstriction due to impaired hormonal actions leading to
increased peripheral resistance [33]. This may be understood as
Pitta Dushti due to endocrinal defects. Impaired functioning of the
autonomic nervous system causing rise in blood pressure may be
seen as Dushti of Vata.Sushruta has mentioned that Vata Dooshita
Rakta (blood vitiated by Vata) is both Sheeghra gama (fast moving)
and Askandi (hemodilution) [Sushruta Samhita, Sutra Sthana, 14/
21]. Both these factors lead to changes in peripheral resistance.
Hemodilution increases cardiac output [34] and Vata being Ruksha
(dry) and Sheeta (cold) in nature may causes stiffness of vessels
which increases peripheral vascular resistance and leads to hy-
pertension [35].
The third mechanism is due to defects in the vascular smooth
muscles (atherosclerotic changes caused by factors like hyperlip-
idemia) where the blood vessels lose their normal tone and this
increases peripheral resistance, thus causing hypertension [36].
This pathology may be due to the vitiation of Kapha Dosha and
Medo Dhathu. Based on these points it can be deduced that the
pathology of hypertension involves one or all the three Doshas
which in turn affects the Rasa and Rakta Dhatus to cause this
condition [Hypothetical Samprapti (pathogenesis) of hypertension
is shown in Flow Chart 1].
Flow Chart No. 1. Hypothetical Samprapti flow chart of hypertension.
M. Menon, A. Shukla / Journal of Ayurveda and Integrative Medicine 9 (2018) 302e307304

7. Concept of Avarana in the pathogenesis of hypertension
As blood circulation is mainly the function of Vata (Vyana
vata)[9], its impairment is certain in Hypertension [37] It may be
impaired by its own Prakopa (aggravation) due to Vataja Nidanas
(etiological factors for Vata) or may get vitiated by the influence of
other Doshas and Dhathus. This is where the concept to occlusion of
normal functioning of Vata plays a major role in the pathogenesis of
hypertension. The normal course of Vata can be occluded by Pitta,
Kapha,Rakta and or Medas [Charaka Samhita, Chikitsa Sthana; 28/
61e69]. These Anya-Dosha Avarana pathologies can be considered
under the hypertension due to increased hormonal and enzymal
action [38], decreased sodium excretion [39], change in the
chemical constituents in the blood and atherosclerotic changes in
the arteries due to lipid deposition [40]. Another type of occlusive
pathology happens when there is Anyonya Avarana of Vata (mutual
occlusion between subtypes of Vata). The subtypes of Vata such as
Prana and Vyana Vata obstruct each other and cause the
disease [Charaka Samhita, Chikitsa Sthana, 28/200e215]. This
condition can be considered as hypertension due to hampered
autonomic nervous system as it plays an important role in the
regulation of blood pressure [41,42,33].Charaka and Sushruta have
enumerated and explained many different types of mutual occlu-
sions of Dosha and occlusion of one Dosha by other Dosha or Dhatu
and in many of these conditions; symptoms of hypertension such as
giddiness, headache, and fatigue have been mentioned. These
conditions are: Pittavritavata,Vyanavrita Prana,Pittavrita Prana,
Pittavrita Vyana,Pittavrita Samana and Pittavrita Udana [Charaka
Samhita, Chikitsa Sthana, 28/221e230]. Other conditions where
these symptoms are seen together are Amashayagata Vata [Sus-
hruta Samhita, Nidana Sthana, 1/32e39]. Rakta Dushti &Pradoshaja
Vikara [Charaka Samhita, Sutra Sthana, 24/5e10] and Pittaja Hri-
droga [Charaka Samhita, Sutra Sthana; 17/32]. Vyana Vata is said to
be responsible for Sweda (sweat) and Asruk Sravana (ejection of
blood) and if it gets vitiated it produce diseases which will affect
the entire body [Charaka Samhita, Sutra Sthana, 24/11e16]. This can
be correlated to hypertension as excessive perspiration is a symp-
tom of hypertension.
8. Symptomatology of hypertension and Samprapti based on
Kriyakala
Mild to moderate hypertension in most cases does not exhibit
any symptoms. But sudden or severe hypertension produces
symptoms like headache, giddiness, palpitations, excessive sweat-
ing, fatigue, exertion dyspnoea and insomnia [43].InAyurveda,a
disease should have specificLakshanas (symptoms) to be called a
Vyadhi [44], thus hypertension being asymptomatic (in its mild and
moderate forms) is not described as a disease in Ayurveda. In the
different stages of a disease, Prasarvastha is the stage where the
Doshas move out from their respective sites and along with Rakta
circulate all over the body, causing certain mild, nonspecific
symptoms [Sushruta Samhita, Sutra Sthana, 21/28]. This in turn
hampers the functions of the respective Srotas in the beginning and
later they bring about structural changes as well, leading to Kha-
Vaigunya. Then, these Doshas get lodged at susceptible sites of Kha-
Vaigunya which in this case can be: heart, brain, kidneys, eyes and
blood vessels. It is at this stage that the actual Sthana Samshraya
(vitiated Doshas getting stuck in a particular site) and Vyakta
Avastha (manifestation of specific symptoms) occur, causing dis-
eases of these vital organs. Later, in the Bheda avastha (complicated
stage), there occurs severe damage to these organs, making the
disease Asadhya (incurable) and sometimes leading to death itself.
Thus, hypertension can be taken as a sub-clinical condition where
the disease process is still in progress making it a risk factor for
more dangerous diseases of the heart, brain, kidneys, eyes etc. ac-
cording to Ayurveda (probable pathogenesis of hypertension based
on Shad Kriyakala is shown in Flow Chart 2).
Flow Chart No. 2. Samprapti (pathogenesis) of hypertension based on Kriyakala (stages of Dosha imbalance).
M. Menon, A. Shukla / Journal of Ayurveda and Integrative Medicine 9 (2018) 302e307 305

9. Principles of management
Ayurveda gives more emphasis tothe prevention and promotion
of the health. Avoiding etiological factors of disease is considered as
the first line of management [Sushruta Samhita of Sushruta, Uttara
Tantra, 1/25]. In the management of hypertension, non-
pharmacological methods such as correction of lifestyle, diet etc.
is proven to reduce the risk of Coronary heart disease (CHD) which
is leading cause of morbidity and mortality worldwide [45]. The
role of Ayurveda is more pertinent here, many of the chapters in
classical texts such as Dinacharya Adhyaya,Ritucharya Adhyaya,
Matrashiteeya,Navegannadharniya Adhyaya etc. are particularly
dedicated to healthy lifestyle. These include the harmonious living
pattern by a deeper understanding of human life and its interaction
with nature. Adopting Ayurveda guidelines may be helpful to
reduce the increasing incidence and management of lifestyle dis-
orders which include hypertension [46,47]. This will also reduce
the risks which are associated with the drug therapy. Long-term
drug treatment can be expensive and side-effects can threaten
patients' adherence to the medicines [48]. In general, reducing
body weight, stopping smoking, healthy diet and increasing phys-
ical exercise are routinely recommended by most of the physicians
[49]. While treating this condition Prasara Avastha of all the Trido-
sha and Rasa,Rakta and Meda Dushti should be taken in to
consideration and along with lifestyle modifications, appropriate
Vata Anulomana (maintaining normal course of Vata)Tridoshahara
(normalizing all Tridosha), and Rasa,Rakta Prasadakar (blood pur-
ifying), Medohara (reducing excess fat) Chikitsa may be adopted.
10. Conclusion
Improper life-style and food habits, psychological stress factors
like Atichinta (excess worry), Bhaya (fear), Krodha (anger), Alasya
(dullness) etc., with or without genetic predisposition provokes and
vitiates all the three Doshas to trigger the pathogenesis of hyper-
tension. Anya Dosha Avarana and Anyonya Avarana are the mecha-
nisms of pathogenesis. Though modern science considers
hypertension as a disease, from the Ayurveda point of view it should
be understood as the Prasaravastha of all the Doshas along with
Rakta which circulate all over the body until they get lodged at a site
of Kha-Vaigunya. This decides the organ of impact of the disease
process (whether brain, heart, kidneys, eyes or blood vessels). With
the help of recent advancements in the medical science the, diag-
nosis of this condition has been made possible at an early stage and
thus effective management can be offered at this stage itself to
avoid risk of damage to vital organs. Thus, hypertension can be
understood as a psycho-somatic hemodynamic condition where
Vata Pradhana Tridoshas are vitiated affecting the Rasa-Rakta Dhatus
as Dooshyas with both Sarva Shareera (whole body) and Manas
(mind) as its Adhisthana (site). For effective management of hy-
pertension, lifestyle modifications should be given more emphasis
and if necessary appropriate drug therapy should also be given.
Sources of funding
None.
Conflict of interest
None.
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