Supported by an Unrestricted
Educational Grant from
Calcutta Medical Research Institution, Kolkata
Apollo Hospital, Secunderabad
Senior Interventional Cardiologist
Fortis Hospital, Kolkata
We have Dr. Amal Banerjee on my right. Dr Amal Banerjee is past president of CSI. He is also the past president of API and then to my right is the general secretary of CSI Dr. M.K. Das and Dr. Shiva Kumar who is going to be the chairman of NIC. They are all sitting here. Amal, I really wanted to ask you, hypertension is a real problem, whether it about the clinical practice or we see the epidemiological data, we find hypertension is really challenging for us. You as a clinician when you come across so many patients of hypertension and they are so called primary hypertension, what is your approach, you like to recommend from the point of non-pharmacological. How will you counsel this patient, what they should do and what they should not do? What is your message for the audience that how we can control hypertension in a non-pharmacological way.
My friends, when I come across a patient with hypertension, first issue is to properly check his blood pressure. I record his blood pressure twice five minutes apart after he takes race for more than five minutes. This is an important issue and the position. The patient should be in a sitting position, to which arm I am recording the BP should be on the table and the patient should be properly and comfortably seated. Then after, when I detect that patient is having hypertension, then I discuss with the patient regarding his lifestyles and all these things. Then I go for, just to convince him, that what are ill effects of the hypertension with the patient, after convincing all these things, I first go for, if his systolic blood pressure is less than 160 mmHg, I usually resort to non-pharmacologic measures just like the reduction of salt, of course the free salt, it should be restricted up to 4 g. Then we resort to other measures like regular exercise, reduction of weight and all these things. I also try to check other risk factors regarding blood pressure and lipid level. Then I try to convince that his/her blood pressure is being reduced in the next three months with non-pharmacological measures then it will be ok, but if not controlled then we will have to go for the pharmacological management.
Amal, I think it is very important, we see a lot of obese patients these days in the age group of 40 to 60 and most of them have central obesity. It is more common in Northern India as compared to the southern part of India, but metabolic syndrome or so called obesity syndrome is a real cluster of hypertension, diabetes and dyslipidemia. If you see hypertension and obesity, do you think that the non-pharmacological treatment is a little different in obese as compared to non obese.
In fact, you know that those patients who are obese they require some rigorous lifestyle changes regarding their food habit and more exercise and these are the very important things, diet, exercise, all these things. They should be a bit different for the non-obese hypertensive.
I think it is very important, like Amal has mentioned very clearly that salt consumption has to be reduced to 4 to 4.5 grams if you really want to reduce blood pressure optimize it to a normal level (4:00) consumption of salt has been to be curtailed. We cannot be a victim of eating the wrong food at a wrong time, at a wrong place, in a wrong dose, in a wrong environment, consuming lot of samosas and pakodas, soya sauce or tomato sauce or potato wafers and what not. Salt reduction is the need of the hour, very nicely expressed by Dr. Amal Banerjee. The second thing what he mentioned is obesity is a very, very important reason. We have to curb obesity. Curbing obesity is curbing hypertension. He is very categoric. He said reducing weight, if you reduce the weight, you can have a significant reduction of blood pressure. It is very important. The reason is all obese individual has hyper renin angiotensin aldosterone activation and there is hyper sympathetic activation, so we have to reduce weight, we have to cut down the salt so that this activation is reduced. We pacify this activation and the blood pressure can be reduced to a very large extent only by non-pharmacology method. I have with me Dr M.K. Das who did a lot of work on antismoking and smoking campaign. I will ask him what is the relationship of smoking with hypertension #1 and #2 Dr. Das, you are welcome to studio. I would like to have your opinion on the drug of choice. How do you choose a drug? Do you believe in a single drug or a fixed dose combination of drug in the low dose so that we can effectively control the blood pressure? Two pints, we want to have your opinion in a very clear way so that the message goes to the masses.
So where the smoking is concerned, it is a biobehavioral problem, so it should tackled in the way any biobehavioral disease is controlled. So there will have to be interaction not only between the physician and the patients or the smokers, we will have to have the support of various other agencies or stakeholders we call it, like the media, community service providers, nurses, then health service providers and also the persons who are related with the delivery of the health care. So, this is a problem which will have to be tackled at many fronts. But if we are to really progress with the antismoking campaign then possibly we are to de-intensify our system of smoking because smoking does what, smoking actually gives a pleasure due to the fact that dopamine is secreted after the smoking. Now if that does not give rise to dopamine secretion by some measures in the form of deep breathing exercise , then yogic meditation, then start drops and pharmacological devices like electronic cigarettes. If these does not give the incentive to have the good sort of feeling, then possibly the person will be smoking less. But more important than these, is the followup of the patients or the smokers. I call them patients because they really cause severe diseases like hypertension as Dr. Chopra was trying to correlate between the smoking and hypertension. So we will have to give the explanation why smoking is very bad. Smoking is bad not only in terms of the various side effects like sore throat and bronchial asthma or airway disease, cancers and peptic ulcers and all, it can cause severe cardiac diseases like hypertension, like coronary artery disease, peripheral vascular disease , these are very, very important diseases and they kill the patients. Now, smoking causes actually the rise in the catecholamines in the system and thereby they vasoconstrict and that is how the hypertension is generated. So if the antismoking devices are taken up along with the antismoking biobehavioral therapies with continuous followup then definitely the smoking incidence can be reduced. Now, so far the hypertension part is concerned.
It is really important Dr. Das I think you mentioned cessation of smoking is the answer if you want to curtail hypertension and there are various gadgets, which are again by psychotherapy or by optimization of the mind set of an individual and of course there are various drugs available to help a person in cessation of smoking. Which are the drugs I think you recommend like you were speaking yesterday about bupropion and other drugs also, are they really used practically or just for theoretical sake or for research data.
This is a very good question indeed because most of us who are giving advise to our patients even do not know what is the brand name of the drugs available in India, but definitely bupropion is an antidepressant drug, which is used for depressive illness so that is available. Similarly the drug that is inhibitor of the alpha 4 beta 2 receptors and acetylcholine antagonists, that is available, the name I do not remember right now as I told you, but this is available in India and if they can be actually of use to some extent , specially in the western counter parts where the cost is not very much a concern, they are using these drugs and they are getting good results, but in our country actually the cost of the drug is prohibitive, specially the second drug which claims that is the main, so if that drug is to be used on general basis then possibly we will not be able to reduce that smoking incidence, reason is very high cost of the treatment. So we will have to again go back to the same concept that is the biobehavioral therapy, we have to prolong the cessation process by monitoring and we have to give certain measures for deintensification including the various governmental agencies that are responsible for taking heath care so they will have to also respond in the right way by increasing the tax for tobacco generation and also giving warning signals.
Dr. Das I think you mentioned very nicely about the smoking and hypertension relationship. My only last question to you is, if a patient comes to you in a clinical setup, what will be your approach, do you give a single drug or a fixed dose combination, which works better, if you take the data as well as your clinical data and its effect on the perfect control of blood pressure.
So far as the fixed dose combination is concerned, it has been always found that the fixed dose combination gives few benefits. The cost becomes less. The patient becomes more compliant with the combination drug. You can actually follow up with the patients in a better way because a single drug you know that it can take care of the disease in a better way. So after saying that some of the patients will respond to that fixed dose combination, some of the patients will not respond.
Dr. M.K. Das I will just like to interrupt you here, logistically if you see hypertension is multifactorial, it is not as single factor. If a patient got increased aldosterone and angiotensin activation and a sympathetic activation simultaneously and there is endothelial dysfunction also, why not to give a fixed dose combination than just giving a diuretic, this gives no meaning. Similarly if you give a combination of beta blockers or ARB and ACE inhibitors in a low dose, we definitely reduce the pill load, the bill load, the memory load and the non compliance load. What is your opinion on this?
That is very much right, but you are to choose the combination of the drugs whether you are going to add beta blockers to ARB or ARB to ACE inhibitor or with the beta blocker or with aldosterone antagonist, so these combinations are sorted out. It is not yet final which combination will be better, but so far ARB combination with calcium channel blocker is a very good combination and you can adjust and readjust the dose so all these combinations, particularly the ARB and/or ACE with calcium channel blocker actually can give all the benefits that is in terms of reducing hypertension, endothelial dysfunction and even they can even be of help in the coronary artery disease.
Thank you very much Dr. M.K. Das. He has given a very clear idea. He said, we should not only control the hypertension, but we should give a drug which has got multiple benefits to take care of the comorbidity produced by the hypertension. It is a brilliant idea and approach should be multiple prolonged and not just only controlling hypertension. Thank you for your expression Dr. M.K. Das. We have with us Dr. Shiva Kumar from Hyderabad who is also the chairman of NIC now. Shiva, I think we heard that the national health survey on hypertension of CSI went on to very big heights now. It is touching the world data. There is no such data produced in the world. We feel very proud as a member of CSI and you being a very active promoter and active supporter and active contributor in this survey, we like to have your opinion how you manage this and what are your impressions about the CSI hypertension survey which is a unique survey for the first time in the world not in India.
Absolutely, I totally agree that on 10/21/15 we did this big BP survey country wide and I must congratulate all the chairman, the president of CSI and the whole organizing team of the CSI, which has taken a fantastic initiation because of this sort was never done in the world where 1.8 lakh people were screened in span of nine hours and I am happy to share that basically like in Hyderabad alone we did a about 20,000 checks in a single day and as you ask rightly the motivation for this came basically from the people. We went to the press about four days or five days in advance and the basic reason what we asked is, I personally also felt all the time is, like we know what is an average rainfall of the city, we know what is the average temperature of the city and we know what is the average humidity of the city, but we do not know what is the average blood pressure of the city. So we went with a motto of saying that what is the Hyderabad’s BP similarly what is the Delhi’s BP, what is the Calcutta’s Bp and what is the Chennai’s BP. So if we know what is the blood pressure of the city , probably we can start doing the corrective measures in that. All of us we know that a slight reduction in the society of systolic or the diastolic pressure will have a large impact on the society and we can probably reduce and achieve much more benefits by reducing a small amount.
Dr. Shiva Kumar I think I have got one more question for you, it is very important you know since we touched the chemicals of heights so far as the hypertension evaluation is concerned, if I talk of Guinness world record or if I talk Limca book of records, Why should we follow Limca world record, why not we create a CSI world record. Why not, world should see CSI world record CSI world record of hypertension for the first time. What shall be your point.
Absolutely, I think we have already created it and it should be termed as a CSI world record because earlier to this there is no records as such done, probably the earlier figures are only 24,000 people being screened in a single day creating a history, we definitely created a history of screening 1.8 lakh people survey in a single day and it should be called as a CSI book of records.
Very nice Shiva Kumar. I think I am very impressed the way you mentioned you must have a CSI world record, you should not bother about the Guinness world record, people should come to us, should complete the CSI world record for hypertension for the time being. Once we grow further, we will go further. I think it is very nice comment and we are very, very impressed by your beautiful expression and I am sure it is going to go a long way and we will definitely work on it. Thank you very much Dr Amal Banerjee, Dr M.K.Das and Dr.Shiva Kumar.