Director of Apollo Institute for Blood Pressure Management
Apollo Blood Pressure Clinics,Hyderabad
Today we are one of the renowned pioneer for the hypertension management and hypertension guidelines for India, Dr. Venkat Ram who currently is a director for the blood pressure management in Apollo Hospital at Hyderabad and also is a director of World Hypertension League which is associated with the WHO for the South Asia. Apart from the clinical practice he is also one of the leading scientific author for the various articles of hypertension who wrote almost more than 400 articles and also book on disease of hypertension. So sir, it is a warm welcome for you on this particular talk. So sir, regarding if you talk about hypertension definitely there is no doubt it is almost one of the major concern for the cardiovascular segment for the management of the hypertension. Definitely it is one of tip of iceberg but the major complications are that (01:00) in spite of having proper treatment at a longer level of age. So, with having such of wide experience in hypertension management, what is your key opinion to control the blood pressure when having disease of hypertension.
Thank you very much, greetings and best wishes to all the viewers. As all of you know, India is now burdened with chronic cardiovascular disease. The major reason for illness, disability, and death in India has been due to cardiovascular disease. Cardiovascular disease is going to govern the future of India and the health of its citizens. The number of risk factors for cardiovascular disease such as hypertension, diabetes, dyslipidemia, obesity, lack of physical activity, (02:00) tobacco consumption, of all the causes, the supreme reason for cardiovascular disease in India is chronic hypertension. A number of people have chronic untreated hypertension, a number of people have chronic undiagnosed hypertension, and a number of people with chronic hypertension are treated but not at goal, so hypertension whether treated or untreated is driving the so-called endemic of cardiovascular disease in this country. Therefore, it is important to diagnose hypertension early and to treat hypertension early and to convert hypertension to normotension. As long as the patients have hypertension, they are crossing the red light at signals (03:00) and when you cross the red light you are always at a risk of an accident. The accidents that occur in patients with hypertension are so called stroke, cerebrovascular accident, heart attack which is a myocardial accident, chronic kidney failure, which is a kidney accident. All these accidents occur because you are going through the red light of uncontrolled hypertension. Fortunately when you diagnose hypertension early, when you treat hypertension successfully, and keep the blood pressure down, all these complications can be avoided.
So definitely sir it is very well mentioned that the control of blood pressure in hypertensive disease is very, very important and otherwise it can lead to as you rightly said that when you are crossing a red signal, then you can be met with an accident. If you talk about the major complications of hypertensive disorders not at active but at a chronic level, (04:00) so what is your take on, on that as per your response.
Patients who have uncontrolled hypertension for a long period of time develop atherosclerosis and one of the manifestations of atherosclerosis is coronary artery disease and one of the manifestations of coronary artery disease is heart failure from ischemic heart disease. High blood pressure by itself can also cause congestive heart failure because hypertension causes left ventricular hypertrophy and left ventricular hypertrophy is harbinger for the development of congestive heart failure. So, two types of complications attributable chronically to hypertension are coronary artery disease that can cause congestive heart failure or hypertension by itself causing congestive heart failure. When you treat hypertension, you can prevent coronary artery disease and you can prevent congestive heart failure. (05:00) Another thing that occurs in patients with hypertension with chronic untreated hypertension is left ventricle hypertrophy, so it becomes stiff. When the left ventricle becomes stiff, then the stiffness is transferred upward towards the atria. When ventricle hypertrophies and becomes stiff, the pressure in the atrium increases left atrial pressure, left atrial overload, and that might cause chronic atrial fibrillation, so atrial fibrillation is more common in patients with untreated hypertension compared to those who either have no hypertension or whose blood pressure is well controlled. So, one of the indirect but important consequences of hypertension is atrial fibrillation. As it is well known now, atrial fibrillation has been now designated by all the (06:00) government and non-governmental agencies as a chronic disease. Previously people used to think atrial fibrillation is acute manifestation and they used to treat it acutely, but now chronic atrial fibrillation is in the same league as chronic hypertension, diabetes, dyslipidemia, etc, so it has become a chronic cardiovascular disorder. Atrial fibrillation as you know is not a benign witness to cardiac function. Atrial fibrillation is an important cause of thromboembolic stroke and a variety of cardiac complications, so one of the bonuses of treating hypertension is prevention of atrial fibrillation by causing regression of LVH and also prevention of left atrial overload by treating LVH. So so-called bonus side benefit is a prevention of atrial fibrillation (07:00) and there are clinical trials in hypertension which have shown that when the blood pressure is controlled affectively it reduces cardiovascular morbidity and mortality. Antihypertensive trials such as life study have shown when you control the blood pressure to keep it down but at the same time in those patients where atrial fibrillation is prevented or treated, they have better prognosis than controlled hypertension but continued atrial fibrillation. So in prevention of so-called thromboembolic events in patients with hypertension, blood pressure control is important but prevention of atrial fibrillation and treatment of atrial fibrillation would further reduce the risk of thromboembolic complications.
So sir, you have said very rightly that both the diseases are a part of chronic hypertension as well as due to the chronic hypotension, there is a chronic AI, so it is very difficult to (08:00) manage both the things simultaneously, so how you are managing this kind of the patients in your practice.
No, obviously in patients who have atrial fibrillation and hypertension, blood pressure has to be controlled and that antihypertensive drug therapy, lifestyle changes, weight reduction, physical activity, abstinence from tobacco, and so-called hygienic changes they have to continue plus antihypertensive drugs to reduce the blood pressure and that you have to do it, but at this stage this is not suffice to treat atrial fibrillation so that has to be treated now as so called comorbidity. It is a comorbidity of hypertension and comorbidity has to be treated and that would be according to the guidelines for treating atrial fibrillation. Proper diagnosis, by usual noninvasive methods, and treatment for atrial fibrillation with anti-arrhythmic drugs and most importantly (09:00) to prevent thrombosis and embolism because as you know the left atrium is the major nidus for the deposition of clot and for the propagation of clot, so anticoagulation actually according to all guidelines is a part of chronic atrial fibrillation treatment.
So, definitely sir has mentioned very rightly that hypertension definitely is a some major concern for society, to control the blood pressure obviously it is a prime target so that if you control the blood pressure then you can reduce the chronic complications as well and along with that to control the ACS and control the congestive heart failure as per the life study also mentioned by controlling hypertension you can also reduce the incidence of atrial fibrillation and its complications as well and these both diseases are correlated, so management part with using antihypertensive we have to use anti-arrhythmic (10:00) and also to prevent the thrombus formation there should be use of the oral anticoagulants. So with this note, we are ending our discussion. So, Dr. Venkat Ram sir, it is so nice of you that you have given indirect description of antihypertensive and how you have correlated with atrial fibrillation, it is very, very grateful to us. Thank you for providing valuable expert comments.