I. Concept, Etiology, and Pathogenesis of Hypertension

I. Concept, Etiology, and Pathogenesis of Hypertension (---) Classification and Etiology of Hypertension Hypertension is divided into primary hypertension and secondary hypertension. The term "hypertension" generally refers to primary hypertension. Of course, many diseases can cause secondary hypertension; kidney diseases are the most common cause, and almost all kidney diseases can lead to hypertension in the later stages, such as nephritis, chronic pyelonephritis, renal tuberculosis, and other systemic diseases like systemic lupus erythematosus or allergic purpura with renal involvement. (II) Concept and Pathogenesis of Hypertension Primary hypertension, also known as essential hypertension, is defined as systolic blood pressure ≥ 140 mmHg (18.6 kPa) and diastolic blood pressure ≥ 90 mmHg (12 kPa). In the past, we often overlooked the importance of systolic pressure alone. However, according to the World Health Organization's Guidelines for the Diagnosis and Treatment of Cardiovascular Diseases, if either systolic or diastolic pressure exceeds these thresholds, a diagnosis of hypertension can be made. Additionally, if systolic pressure is ≥ 130 mmHg and diastolic pressure is ≥ 82.6 mmHg, it should be considered a yellow-card warning. So how does hypertension develop? It is closely related to renal factors: when the afferent arteriole of the renal glomerulus encounters adverse conditions, the renal tissue releases an active substance called renin. Renin acts on angiotensinogen, converting it into angiotensin, which causes constriction of small arteries throughout the body, thereby raising blood pressure. Currently, seven types of angiotensin have been identified (including angiotensin I, II, III, IV, V, VI, and VII), but only angiotensin I and angiotensin II have been thoroughly studied. Angiotensin I-converting enzyme converts angiotensinogen into angiotensin I, while angiotensin II receptors, upon stimulation, convert angiotensinogen into angiotensin II. Based on these physiological and pathological mechanisms, two major classes of antihypertensive drugs have been developed: one is angiotensin I-converting enzyme inhibitors, which inhibit the production of angiotensin I and reduce the contraction of small blood vessels, thus lowering blood pressure. Representative drugs include captopril, enalapril, and benazepril. The other class is angiotensin II receptor antagonists, which prevent the formation of angiotensin II, eliminating the contraction of small arteries and consequently reducing blood pressure. Representative drugs include losartan (Cozaar), valsartan (Diovan), and irbesartan (Avapro). Other angiotensins—III, IV, V, VI, and VII—are still under development. Angiotensins I and II alone are sufficient to raise blood pressure. The WHO’s cardiovascular expert committee, led by American scientists, frequently organizes expert meetings to summarize experience and publish guidelines. Here, we recommend the Chinese Medical Forum Newspaper, a cutting-edge medical journal that collects and compiles the latest advances, hottest discussions, and most advanced knowledge in the global medical field, making them available to healthcare professionals worldwide. II. Symptoms of Hypertension The main symptoms of hypertension include headache, dizziness, tinnitus, lower back pain, and leg weakness—typical manifestations of kidney deficiency in Traditional Chinese Medicine. If accompanied by spontaneous sweating and aversion to cold, it indicates kidney yang deficiency; if accompanied by hot flashes and night sweats, it indicates kidney yin deficiency. Although TCM lacks experimental research, it has accurately described all the symptoms of hypertension thousands of years ago, which is truly remarkable. If hypertensive patients experience chest tightness, palpitations, or shortness of breath, it suggests that the disease has already affected coronary artery sclerosis; if they exhibit significant memory loss and mild cognitive impairment, it may indicate cerebral artery sclerosis. Hypertension is essentially a manifestation of arterial sclerosis. Wherever there is hypertension, there is also arterial sclerosis—but not all cases of arterial sclerosis are caused by hypertension. All hypertensive patients have arterial sclerosis, whereas only about 30% of those with arterial sclerosis also have hypertension. Therefore, whenever “hypertension” is diagnosed, adding “arterial sclerosis” as a follow-up diagnosis is absolutely correct. (I) Formation of Arterial Sclerosis High blood lipids play a crucial role in the formation of arterial sclerosis. Blood lipids mainly include cholesterol, triglycerides, low-density lipoprotein, and high-density lipoprotein. A general guideline to remember is: cholesterol should be ≤5.7 mmol/L, triglycerides ≤1.7 mmol/L, and low-density lipoprotein (formerly known as β-lipoprotein) ≤4.92 mmol/L. If any of these values exceed the standard, it indicates hyperlipidemia. Low-density lipoprotein is counteracted by high-density lipoprotein, which specifically lowers low-density lipoprotein levels. If high-density lipoprotein falls below 0.7 mmol/L, low-density lipoprotein will rise, leading to hyperlipidemia. Hyperlipidemia is classified into four types (the latest classification method): Type I is cholesterol-type, meaning cholesterol >5.7 mmol/L; Type II is triglyceride-type, meaning triglycerides >1.7 mmol/L; Type III is combined cholesterol and triglyceride-type, where both exceed the standard; and Type IV is high-density lipoprotein-type, meaning high-density lipoprotein <0.7 mmol/L. These classifications may differ from those in textbooks, as textbooks often lag behind in the age of information technology. Elevated blood lipids have four important implications: ① arterial sclerosis worsens, as lipids infiltrate and embed themselves in blood vessels, accelerating vascular hardening; ② blood viscosity increases, as elevated lipids make the blood thicker; ③ high lipids can lead to increased uric acid levels. Fatty acids break down into uric acid, and elevated uric acid can cause gout; ④ elevated lipids promote higher blood pressure. Therefore, lipid-lowering treatment is indispensable in managing hypertension. Behind hypertension, high blood viscosity, high uric acid, and high blood lipids lies a dominant factor: high blood sugar, which must never be ignored. When high blood sugar occurs, it acts like fish in water for the aforementioned “four highs.” Once supported by high blood sugar, the “four highs” surge forward, disrupting overall metabolism and leading to metabolic syndrome (the “five-high syndrome”). Metabolic syndrome is a major cause of mortality among the elderly. Among the five high syndromes, the core is hypertension and arterial sclerosis, with diabetes as the leading factor. In recent years, diabetes has risen sharply in China, affecting approximately 1 in 20 middle-aged and elderly individuals, compared to 1 in 5 with hypertension. High blood sugar and hypertension mutually reinforce each other, gradually pushing middle-aged and elderly people toward death, harming public health, and causing economic losses for the nation. (II) Locations of Arterial Sclerosis The aorta has a large lumen and high pressure, so even if atherosclerosis develops, it rarely leads to stenosis or obstruction. Small capillary arteries, even if obstructed, have a limited area of perfusion and therefore do not cause significant harm. Thus, the most dangerous locations for arterial sclerosis are medium-sized arteries, particularly those supplying the heart, brain, and kidneys. The blood vessels of these three organs are not only medium-sized but also highly branched and tortuous, much like natural rivers: where rivers meet and bend, sediment tends to accumulate, forming deltas. Where two rivers converge, a city often emerges—for example, the confluence of the Yangtze and Jialing Rivers created Chongqing, the Yangtze and Han Rivers formed Wuhan, and the Yangtze and Huangpu Rivers gave rise to Shanghai. Similarly, when the Yellow River reaches Sangyuanzi Gorge, it suddenly turns north, forming Lanzhou; at Tongguan, it turns east, creating the 800-li Qin Plain and ultimately Xi’an. Arterial sclerosis follows the same principle: branching and bending of arteries facilitate lipid deposition. The heart, brain, and kidneys have the most branches and bends in their blood vessels. Take the brain, for instance: the cranial cavity is fixed in size and contains all brain tissue, so blood vessels can only branch and curve within this limited space. The heart is about the size of a fist, so its coronary arteries can only branch and curve. The kidneys are similar: they have abundant blood vessels with many bends and branches, making their arteries prone to sclerosis and turning them into major sites of arterial sclerosis. III. Treatment of Hypertension Including Western medicine and Traditional Chinese Medicine treatments. 61 (I) Western Medical Treatment of Hypertension

1. There are five main categories of drugs: (1) Simple vasodilators. Forty years ago, there were reserpine, jiangya ling, and corlind, among others. (2) Calcium channel blockers (CCBs). Nifedipine (Xintongding) and nitrendipine, etc. Calcium ions enter cells through ion channels, causing vasoconstriction and raising blood pressure. Calcium channel blockers block these channels, preventing calcium ions from entering cells, thereby dilating blood vessels and lowering blood pressure. However, these drugs can cause side effects in some patients, such as headache, facial flushing, lower limb edema, and rapid heartbeat. (3) Beta-blockers. Such as propranolol (Xindean) and metoprolol (Betaloc), etc. Here, we need to explain what beta receptors are. Both beta and alpha receptors are sympathetic nerve receptors; their overstimulation can excite the sympathetic nervous system, causing vasoconstriction and raising blood pressure. For example, the pressor drugs we use—norepinephrine, dopamine, and metaraminol—can stimulate both alpha and beta receptors; isoproterenol, however, only stimulates beta receptors. Therefore, when rescuing shock patients, we often use norepinephrine, dopamine, and metaraminol. In recent years, the combination of dopamine and metaraminol has become more common, significantly boosting blood pressure and correcting shock. Isoproterenol, on the other hand, is better at bronchodilation and is often used clinically to treat bronchial asthma. Tolazoline is an alpha-receptor blocker that lowers blood pressure too much and has unstable efficacy, so it is now rarely used. Propranolol, metoprolol, and atenolol are all beta-blockers with stable and gentle blood pressure-lowering effects, making them relatively common. (4) Renin-angiotensin system (RAS) drugs. Angiotensin I-converting enzyme inhibitors: captopril, benazepril, and enalapril. Angiotensin II receptor antagonists: losartan (Cozaar), valsartan (Diovan), and irbesartan (Avapro). (5) Diuretics: better at lowering diastolic pressure, such as hydrochlorothiazide, amiloride, and furosemide. 62
2. In addition, it is necessary to lower blood lipids, blood viscosity, blood uric acid, and blood sugar. (1) Lowering blood lipids: Previously, rutin, nicotinic acid, maodongqing, evening primrose, lantern flower, compound danshen, and weinaolutong were commonly used. In recent years, statins have been introduced, such as fluvastatin (Laisike), simvastatin (Shujiaozhi), and atorvastatin (Ale), whose remarkable efficacy has basically solved the problem of high blood lipids. (2) Lowering blood viscosity: Aspirin, an old drug with new uses, can improve blood viscosity. Patients with good gastrointestinal health can take 100 mg daily for long periods. In recent years, clopidogrel and warfarin have also been frequently used clinically. (3) Lowering blood uric acid: When blood uric acid >480 mmol/L, it can lead to gout and increase blood viscosity. Uric acid is heavy and tends to settle, often causing gouty arthritis in the toes and ankles. People often think that carnivorous animals like cats and tigers get gout because they stand on all fours and can develop gout in both front and hind limbs, proving the effect of gravity on uric acid. If the kidneys cannot excrete uric acid effectively, it can deposit and form urinary tract stones. Western medicine treats gout with colchicine, allopurinol, and probenecid. (4) Diabetes treatment: Mainly two types of drugs are used: sulfonylureas (such as damai kang) and biguanides (such as metformin). Recent research on diabetes treatment has found that insulin should be administered early, preferably recombinant human insulin containing protamine (NovoRapid, NovoMix). Insulin injection can prevent many complications. Previously, complications of diabetes were thought to be infections, cataracts, and pulmonary tuberculosis, but now these are considered secondary; the most serious complications arise in the heart, brain, and kidneys. If treatment is delayed or improper, most patients eventually die from these complications. (II) Western Medical Treatment of Hypertension Traditional Chinese Medicine’s understanding of hypertension and arterial sclerosis dates back to the “Inner Canon of the Yellow Emperor,” which states, “When blood and qi move upward together, great collapse ensues.” Zhang Xichun further elaborated on this idea in his work “Compendium of Internal and External Medicine,” arguing that hypertension results from the upward movement of qi and blood, and that treating hypertension requires guiding the blood downward. Zhang conducted repeated clinical trials and found that achyranthes root could effectively guide blood downward, so he formulated the “Calming Liver and Extinguishing Wind Decoction” using achyranthes as the principal herb. This formula pioneered the use of TCM in treating hypertension, with blood pressure-lowering effects comparable to modern Western medicines. Most hypertensive patients present with a strong, string-like pulse at the cun position, indicating powerful blood flow that continues to exert force even after passing through the chi and guan positions, leaving the chi pulse relatively weak. TCM describes this phenomenon as kidney yin deficiency and liver yang excess, or “water unable to contain wood,” leading to the “Qi Ju Di Huang Tang” formula, which focuses on nourishing yin and subduing yang. Although this formula does have some blood pressure-lowering effect, its strength is relatively weak; its main function is to regulate the body’s reactivity and alleviate symptoms. In Zhang Xichun’s “Calming Liver and Extinguishing Wind Decoction” (containing achyranthes, yuan shen, and tian dong), 60 grams of achyranthes emphasize the effect of guiding blood downward, while adding ingredients like yuan shen and tian dong enhances the therapeutic effect. Besides the “Calming Liver and Extinguishing Wind Decoction,” Zhang also formulated the “Jian Ling Tang” for treating hypertension. This formula is refined in taste and highly effective. In my version of the “Jian Ling Tang,” I added coptis, scutellaria, phellodendron, and gardenia to clear heat, drain fire, and detoxify, calling it the “Pei’s Jian Ling Tang,” which is even more effective than the original. There are many other formulas available for treating hypertension and arterial sclerosis, but I won’t go into detail here. Of course, TCM also has many effective prescriptions and medicines for lowering lipids, reducing viscosity, treating gout, and managing diabetes, so I won’t elaborate further. IV. Diseases of Three Target Organs (---) Heart Arterial sclerosis affects the heart, leading to coronary heart disease. Previously, coronary heart disease was classified as angina pectoris and myocardial infarction. Now it is divided into acute coronary syndrome (ACS) and stable angina.
3. Acute Coronary Syndrome (ACS) Includes electrocardiograms showing ST-segment elevation and non-elevation (both can be accompanied by pathological Q waves; the former has a 95% probability of being associated with myocardial infarction, while the latter has a 5% probability. The presence of pathological Q waves means the myocardial infarction is irreversible, and there may also be T-wave inversion, which indicates myocardial ischemia). By the way, let me briefly describe the areas indicated by the electrocardiogram in myocardial infarction: V3 shows lesions—infarction in the anterior and posterior walls; V5 shows lesions—infarction in the lateral wall; V1 shows interventricular septal infarction; standard III leads show inferior wall infarction, while standard I leads show superior wall infarction. ACS also includes unstable angina (recurrent attacks that cannot be controlled by any medication). The division of acute coronary syndrome is entirely to meet the needs of cardiac intervention, and this indication applies to cardiac interventions. Necessary rescue measures can still be taken before intervention. The most appropriate rescue measures are “THABC”: T—thrombolysis, 500,000–1,000,000 units mixed with 250 ml of 5% glucose solution for intravenous drip, which can be repeated as needed. H—anticoagulation, 5,000 units of heparin mixed with 250 ml of 5% glucose solution for intravenous drip, or 0.3–0.5 ml of low-molecular-weight heparin injected intramuscularly; blood and coagulation times must be checked. A—aspirin. B—beta-blockers. C—ACEI and ARB (remember the abbreviations).
4. Stable Angina Chest tightness, palpitations, and shortness of breath are often present, and the first and second of the “five highs” may also occur. This is an indication for traditional Chinese medicine treatment, providing a platform for TCM to demonstrate its effectiveness.
5. TCM’s Understanding of Coronary Heart Disease The “Inner Canon of the Yellow Emperor” states, “True heart pain, severe pain in the heart, extremities turn blue up to the joints, death in the morning and resurrection in the evening, resurrection in the evening and death in the morning.” Ancient people vividly depicted myocardial infarction. Zhang Zhongjing’s “Golden Cabinet Essentials” contains numerous passages on treating coronary heart disease. In TCM, “chest obstruction” is equivalent to modern coronary heart disease, a point widely recognized. The “Golden Cabinet Essentials” says, “The disease of chest obstruction manifests as wheezing, coughing, chest and back pain, shortness of breath, a deep and slow pulse at the cun position, a tight and rapid pulse at the guan position, and is treated with the Gualou Shabai Baijiu decoction.” “Chest obstruction prevents lying down, and severe heart pain radiates to the back—this is treated with the Gualou Shabai Banxia decoction.” “Chest obstruction causes chest discomfort, qi stagnation in the chest, fullness in the chest, and reverse qi rushing to the heart—this is treated with the Zhishi Shabai Guizhi decoction; the Renshen decoction is also effective.” “Chest obstruction causes qi blockage in the chest, shortness of breath—this is treated with the Fuling Xingren Gancao decoction, and the Ju Zhi Jiang decoction is also effective.” “For chest obstruction with alternating severity, the Yiyi Fuzi San is effective.” “For chest discomfort, qi stagnation, and severe heart pain, the Gui Zhi Shengjiang Zhishi decoction is effective.” “For severe heart pain radiating to the back and back pain radiating to the heart, the Wutou Chishizi Wan is effective.” A total of seven passages describe all types of coronary heart disease and propose effective treatment formulas. Let’s take the first passage as an example and delve deeper into TCM’s understanding of treating coronary heart disease. Chest obstruction means qi and blood in the chest are blocked and cannot circulate freely; when qi and blood are blocked, chest and back pain, wheezing, coughing, and shortness of breath occur—pain arises precisely because of the blockage. “A deep and slow pulse at the cun position, a tight and rapid pulse at the guan position”—the cun position is the upper burner, the location of the heart; the guan position is the middle burner. “A tight and rapid pulse at the guan position” indicates abundant yin energy, with the rich food and fat of the middle burner overpowering the yang position. The upper burner is empty, the middle burner is full, yin occupies the yang position, and the lipid-rich food from the middle burner flows up to the heart. When circulation is blocked, pain arises—chest pain radiates to the back, and back pain radiates to the chest. This perfectly aligns with Western medicine’s view that high blood lipids lead to coronary heart disease. All of this is not based on isolated speculation, but on practical experience. Therefore, TCM treatment of coronary heart disease mainly uses formulas containing gualou, shabai, and banxia. Since Chen Keji and others proposed the “Coronary Heart No. 2” formula based on the “Blood Mansion Removing Stasis” decoction, and until the advent of the “Danshen Drop Pill,” using methods to activate blood circulation and remove stasis to treat coronary heart disease has made significant progress. In clinical practice, I often use these formulas, adjusting them slightly to treat unstable angina, achieving nearly 100% effectiveness. We must both inherit the wisdom of our ancestors and understand modern medicine—that is, the “sixteen-character guideline” I proposed: ---------Western diagnosis, TCM differentiation, TCM as the mainstay, Western medicine as the supplement. I mainly prescribe TCM formulas for treatment, occasionally using Western medicine. Western antibiotics are very effective, but TCM’s heat-clearing and detoxifying medicines cannot compare with third-generation cephalosporins—they can only compete with penicillin, which is currently only used for prevention. (II) Renal Arterial Sclerosis Currently, Western medicine is far ahead in researching coronary heart disease, and its cardiac intervention treatments are highly effective. However, when it comes to stable angina, Western medicine is like a tiger eating a mosquito—its efforts are wasted. Given that renal arterial sclerosis is most likely to lead to renal failure, Western medicine has few solutions, only able to use diuretics or perform dialysis. In contrast, TCM has long had a deep understanding of the symptoms caused by renal arterial sclerosis. TCM’s “phlegm-fluid” corresponds to modern medical manifestations of renal arterial sclerosis, such as edema, proteinuria, and renal failure, and ancient practitioners left behind many formulas for treating phlegm-fluid. The “Golden Cabinet Essentials” states, “There are four types of fluid: phlegm-fluid, overflow fluid, suspended fluid, and supporting fluid.” “Fluid flowing through the intestines, making gurgling sounds, is called phlegm-fluid; fluid circulating throughout the body, reaching the limbs, but failing to sweat when it should—this is called overflow fluid; fluid flowing under the ribs, causing coughing and pain—this is called suspended fluid; fluid flowing above the diaphragm, causing coughing and difficulty breathing—this is called supporting fluid.” “Wuling San, Wupi Yin, Gui Fu Ba Wei Wan, and Jisheng Shenqi Tang can all be used.” “Edema below the waist should be relieved by promoting urination, while edema above the waist should be treated by inducing sweating.” Ma Huang