By Ariaratnam Gobikrishna –

Ariaratnam Gobikrishna MD

At the tail end of World War II, with victory looming in the backdrop, the Allied Heroes convened in Yalta to chart the postwar future of Europe. Seated between Churchill and Stalin was Roosevelt, looking majestic and jubilant, so we thought, but with the benefit of hindsight, one can sketch a contrasting picture portraying a sick man in the middle, experiencing fleeting bouts of memory lapses. But in 1945 no one knew about transient small strokes or sentinel bleeding (warning leaks), portending a major catastrophe around the corner. High blood pressure was not even in the medical lexicon, let alone its effect on bargaining power against Stalin. In fact, Franklin Roosevelt was a sick man, noticeable to his comrades but not to his personal physicians.

Back home, on his daughter’s insistence, Roosevelt was examined by a cardiologist at Bethesda who found the President in heart failure with significantly elevated blood pressure, but elevated blood pressure was not considered a malady then so he was  prescribed digitalis — a drug to increase  pumping of the heart— to ameliorate his heart failure. He was also prescribed rest, reduction in the number of cigarettes he smoked and alcohol he consumed. All in all, it was the right move in the right direction, but it proved to be too little, too late. Shortly thereafter, Roosevelt would succumb to a cerebral bleed.

On the other side of the Atlantic, one and a half centuries before President Roosevelt’s somber fate, an Indian named Sake Dean Mahomed arrived in Ireland, armed with a multitude of talents in surgery, shampoo baths, and Indian cuisine. He was a trailblazer in many regards: the first to introduce shampoo baths, the first Indian to pen an autobiography in English, and later the pioneer behind England’s enduring love affair with chicken tikka masala through the establishment of a curry house. From this culinary venture emerged a second-generation descendant, a physician named Frederick Akbar Mahomed, who would go on to invent the sphygmograph (1870s) to measure blood pressure and coin the term “Essential Hypertension”—elevated blood pressure without antecedent causes (At that time, hypertension was perceived as an offshoot of kidney disease). During his brief lifespan, he would also accurately predict the long term complications associated with essential hypertension.

But Dr. Frederick Akbar Mahomed’s discovery and predictions would simply be ignored for another century by the medical establishment. Consequently, President Roosevelt would fall victim to this intellectual malaise, paying the ultimate price. However, his death served as an eye-opener for America, prompting President Truman to declare the National Heart Act, which laid the groundwork for the Framingham Heart Study (FHS) in 1948.

As the name implies, “Essential Hypertension” was interpreted as essential for normal bodily functions until as late as the 1960s, despite mounting evidence to the contrary. Expert after expert ridiculed the notion of treating hypertension, considering it a great folly. Although, early on, the FHS identified high blood pressure as a detriment to healthspan, the scientific community faced opposition from influential detractors, including renowned cardiologists like Dr. Paul Dudley White — who once said “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” — and Dr. John Hay, the British cardiologist credited with describing heart block. Dr. John Hay, for that matter, vacillated in his beliefs, infusing strong ambiguity into its discourse, as he once stated, “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.” It’s fair to say that both cardiologists later walked back their statements and became strong believers in the detrimental effects of hypertension. It is also fair to say that the ambiguity emanated from many luminaries certainly delayed drug development.

However, the life insurance companies held a different perspective. Early on, they classified individuals with elevated blood pressure as high risk for their business. Their meticulous record-keeping and astute observations eventually spurred scientific investigations focusing on blood pressure reduction. Towards that end, the visionary Dr. Edward Freis threw himself into the drug trial at the Veterans Administration in Washington DC. In a groundbreaking moment, in 1971, his efforts proved medication-induced reduction beneficial for the first time, validating the predictions made by Dr. Frederick Akbar Mahomed a century prior and inspiring further similar trials to follow.

A major credit should also be attributed to Dr. Nicolai Korotkov, without whom the identification and monitoring of hypertension would have been far more cumbersome. In 1905, during the Russo-Japanese War, this young man’s painstaking efforts led to the discovery of the first working sphygmomanometer. He utilized auscultatory sounds, later known as Korotkov sounds, to achieve this breakthrough.

Although both systolic and diastolic blood pressure proved detrimental, treatment was initially instituted only for diastolic hypertension, based more on hunch than concrete evidence. However, numerous drug trials over the years gradually changed this perspective. Yet, this shift didn’t come easily. For decades, the diagnosis excluded the so-called elderly—individuals aged 60 and above. Reluctantly, trial investigators included those above 60 with isolated systolic hypertension and were astonished to find benefits in this age group. This paved the way for trials on individuals above 80, the very elderly, and once again, benefits prevailed across all age spectrum.

Since 1976, the National Heart, Lung, and Blood Institute has been at the forefront of advocating for cardiovascular health, regularly releasing Joint National Committee (JNC) reports. These reports, typically issued every 5 to 7 years, represent a consensus among experts in the field. However, after the 7th JNC report in 2003, the committee faced internal discord, leading to a lack of an official consensus statement for the 8th JNC release. Instead, in 2014, a publication in the Journal of the American Medical Association (JAMA) attempted to fill this void, albeit amidst significant dissent among the authors, particularly concerning the acceptance of a systolic blood pressure target of 150 for individuals aged 60 and above.

In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) stepped in, assuming responsibility for providing guidance on blood pressure management. Their recommendations emphasized more stringent control measures, advocating for lower blood pressure targets (130/80) for all age groups with caveats. While the European Society of Cardiology generally aligns with many of these recommendations, disparities persist, particularly concerning the cutoff for systolic blood pressure levels pertaining to drug therapy (140/90) as well as reduction targets for the elderly (above 65) (not less than 130). Lately, ambulatory blood pressure monitoring and home recordings supersede doctor’s office recordings, taking into consideration the nature of fluctuations and white coat effect, necessitating multiple readings for the diagnosis.

Even though accepting hypertension as a malady faced numerous hurdles, they were insignificant compared to the challenge of identifying its causation. Over time, the cascade of discoveries related to hormones, chemical substances, neural pathways, environmental factors, genetic influences, and the evolving changes in vascular function with aging has revealed the intricate web of interactions among these elements. This complexity has rendered the pursuit of a single unifying theory impossible. However, these individual components have paved the way for drug discovery, ultimately culminating in the success of combination therapy contained within a single pill, which has become increasingly popular in the Western world.

The notion of taking medication is often a bitter pill to swallow. Although there are slight differences, individuals classified as stage 1 according to American guidelines and grade 1 according to European guidelines will typically undergo lifestyle changes for six months before being considered for drug therapy. These lifestyle changes encompass weight reduction, regular exercise, decreased alcohol consumption, smoking cessation, reduced salt intake, and adherence to a diet akin to the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet, in turn, shares similarities with the Mediterranean diet, emphasizing the consumption of ample fruits and vegetables, low saturated fat intake, and a high intake of polyunsaturated and monounsaturated fats, whole grains, fish, legumes, and seeds, all with a low sodium content.

Given the genetic predisposition for heart disease among South Asians, it’s noteworthy that individuals of African descent face a genetic disadvantage in the context of hypertension, often resulting in a higher incidence of kidney failure. Individuals of Sub-Saharan African descent occasionally harbor a mutation in the Apo L1 gene, providing resistance against trypanosomiasis (sleeping sickness) while simultaneously elevating the risk of kidney failure. This mirrors the scenario seen in carriers of the sickle cell trait, who demonstrate resistance to malaria. These instances underscore the concept of natural selection being advantageous during endemic diseases, yet potentially problematic in their absence.

There are occasions when hypertension stubbornly resists treatment, posing a looming threat of severe bodily harm—an occurrence referred to as resistant hypertension. In eras predating the availability of medications, surgical nerve disruptions were implemented with success. Building upon this legacy, contemporary approaches involve less invasive radiofrequency procedures targeting nerve endings around the kidneys. While initial results have shown limited success, ongoing endeavors aim to refine and enhance this technique at present, particularly for this category of resistant hypertension.

We have traversed a circuitous arc of trajectory vis-à-vis high blood pressure: from regarding the condition as benign, to seeing it as a necessary compensatory mechanism, to recognizing it as a symptom of underlying diseases. Now, we predominantly identify it as a standalone condition, termed essential hypertension. Cases linked to other underlying conditions are now categorized as secondary hypertension, representing a small minority and considered only in rare circumstances.