Abstract
It's evident that neither all people become hypertensive nor all hypertensive patients are suffering from left ventricular impairment as well as from other well-known hypertension-dependent complications, regardless of environmental conditions. Indeed, the existence of biophysical-semeiotic hypertensive constitution accounts for the reason that only some individuals are hypertensive, and among them, only those with real risk in well defined biological system, are involve by myocardial failure or by other known hypertension complications. In the article, bedside diagnosis of both biophysical-semeiotic hypertensive constitution and hypertension complication real risk is fully described.
Key Words.
Biophysical-Semeiotics. Hypertensive Constitution. Hypertension. Clinical Microcirculation.
Introduction.
In the primary prevention of arterial hypertension, based on the pre-morbid, pre-metabolic stage (See: Arteriosclerotic Constitution in the website http://www.semeioticabiofisica.it, and particularly the URL
http://www.semeioticabiofisica.it/semeioticabiofisica/Documenti/Eng/Costituzione%20ipertensiv%), we have to devote a particular discussion to pre-hypertensive state of arterial hypertension (AH), component of pre-metabolic, and obviously, metabolic syndrome, classic and “variant”, often associated to other human Congenital Acidosic Enzyme-Metabolic Histangiopathy-a (CAEMH-a) -dependent diseases. CAEMH-a is a singular, functional mitochondrial cytopathy, inherited almost always by mother (1-3). For further information See above-cited website and Bibliography.
Really, the pre-hypertensive state allowed me to define clinically the hypertensive constitution, discussed in this article.
In order to understand such as topic usefully, we must remember that the primary function of blood circulation as well as of complex mechanisms, which rule pressure values (i.e., cardiac out-put, peripheral arteriolar resistance, blood volume, arterial compliance), is represented by physiological tissue supply of material-information-energy (O2, various metabolites, enzymes, hormones, a.s.o.), and by catabolites removal, in particular CO2 and produkts of tissue secretion.
Possible pH tissue variations bring about necessarily haemodinamic-haemorheological modificatioms, aiming to maintain metabolic “homeostasis” or, more exactly speaking, to keep in the normal ranges the physiological condition of deterministic chaos, both microvascular and parechymal, according to my Angiobiopathy theory (4).
Notoriously, blood circulation influences cellular metabolism, which, in turn, interferes on the regulation of blood pressure complex mechanisms, as prostaglandyns synthesis, thromboxane, radical NO, vasoactive amines, neurotransmitters, a.s.o., beside pH oscillations, axones reflexes and baro-receptorial mechanisms.
Our research data have, published in 1990, we demonstrated that Congenital Acidosic Enzyme-Metabolic Hystangiopaty-a (CAEMH-a) represents the conditio sine qua non “also” of essential arterial hypertension, as we suggested for a lot of years, on the base od clinical evidence (1-4).
On the other hand, all authors agree on the fundamental role played by “genetic factor” on the onset of arterial hypertension (4, 20-24).
Analogously to diabetes mellitus, arteriosclerosis, malignancies, and all other severe human diseases, also in arterial hypertension it is possible to observe an early, first stage, clinically silent, although initial tissue hypoxic disorder, particularly in skeletric muscle, which we suggested to term pre-hypertensive stage (4), on the analogy of what we wrote in the introductory article on Quantum-Biophysical-Semeiotic Constitutions (5, 9).
All individuals, which have suffered over the last years from an episode of the so-called “white-cloth” arterial hypertension (or have had arterial hypertension in the past, but now are normotensive) are under this condition, that takes a part of the so-called Grey Zone, namely the site of primary prevention.
However, nowadays, doctors belittle real significance of such hypertensive episodes, considered mainly as trivial and transitory consequence of commonplace neuro-hormonal reaction to stress situations, while they really represent the peak of an ice-berg, to which we have to pay all our attention and devote an accurate biophysical-semeiotic evaluation.
In fact, in individuals CAEMH-a positive of great intensity, particularly if localized in microvascular, e.g., muscular tissue, the reaction of smooth muscle cells of resistance vessels (i.e., small arteries and arterioles, according to Hammersen) to vasomotor physiological stimuli appears clearly exceeding, as we will say later (4, 15, 32).
In “initial” stage, however, such abnormal reaction can be still counterbalanced by vasodilation upward, i.e. in the vasa publica, according to Ratschow, and by blood re-distribution in various destricts, especially in the splancnic territory.
In other words, in pre-clinical, initial, pre-hypertensive stage, as well as in hypertensive constitution, blood pressure does not result increased at all – a part from episode of sympathetic hypertonus and/or Renine-Angiotensin-Aldosterone System (RAAS) – but peripheral blood supply is slightly “reduced”, causing tissue disorder, due to acidosis, as consequence of increased peripheral arteriolar resistances (PAR), which bring about elastic vessels dilation and opening of Arterio-Venous Anastomoses, functionally speaking, in always CAEM-a-positive individuals (5, 9, 10).
With the aid of Biophysical Semeiotics doctor can quickly recognize bedside such as special microcirculatory situation, e.g., in skeletric muscles by the method of the preconditioning.
In healthy, at basal line, latency time of biceps muscle-gastric aspecific reflex (= in the stomach, both fundus and body dilate, while antral-pyloric junction contracts), when digital pressure stimulation is “mean-intense, results 8 sec., and it lasts for <> (= parameter value of paramount importance, duew to the fact that it is inversely correlated with Microcirculatory Functional Reserve), while at second evaluation, performed after 5 sec. exactly, latency time increases to ³ 12 sec.
On the contrary, in a subject with hypertensive constitution under identical experimental condition, basal latency time appears normal (NN = 8 sec.), but the duration results 4 sec. or more, and it does not ameliorate or sometimes lowers in the second evaluation, pathogical preconditioning, in relation to the severity of hypertensive “real risk” itself, as a consequence of impaired Microcirculatory Functional Reserve (9) (For further technical information, See
http://www.semeioticabiofisica.it/microangiologia).
In the pre-hypertensive state, which can last clinically silent years or decades, and, then, very difficult to recognize by physical orthodox semeiotics (21, 26, in 4), doctor observes the typical microcirculatory metabolic abnormalities in post-absorptive state, i.e. at least 4 hours after meels, characterized by AL + PL duration (= duration of microcirculatory wave oscillation, which parallel ureteral reflexes) of pancreatic vasomotion (for instance, more easy to detect, duration of pancreatic body inferior margin lowering: see Technical Page 5, in above-cited website) lasting more than those of muscular, hepatic and adipose tissues, evaluated by means of upper (vasomotility) and lower (vasomotion) reflex oscillations, during “light” stimulation of related trigger-points (Fig 1).
.
Fig.1
The figure shows physiological vasomotion of all biological systems, assessed directly (e.g., as values of pancreas periodic, deterministic chaotic oscillations: lowering of inferior pancreatic margin) or indirectly as ureteral reflexes fluctuations, upper – vasomotility – and lower – vasomotion – brought about by “light” stimulation of related trigger-points, e.g., muscular and central, adipose tissue.
In other words, there is dissociation between insulin secretive-metabolic activity and that of “peripheral” tissues, indicating, in a refined biophysical-semeiotic manner, hyperinsulinaemia-insulinresistance: “classic” metabolic syndrome (5, 6, 10, 11, 12).
On the contrary, in the “variant” metabolic syndrome, the AL + PL Phase of liver vaso-dynamics, under identical condition, i. e., in the post-absorptive state, results lower than those of adipose tissue, musculare tissue, and above all of pancreas, which is the most instense (AL + PL) of all .
In other words, in case of “variant” metabolic syndrome, exclusively hepatic insulin receptors are normally sensitive to the hormone, and, under the above-mentioned circumstance, i.e., after at least 4 hours after meels, insulin normally controls hepatic glucose secretion, but not the lipidic secretion from “central” adipose tissue (13, 14).
At this point, it is necessary to underline that insulin secretion activity, if not properly ameliorated by diet, etymologically speaking, and/or histangioprotective drugs, such as coniugated melatonine can go on slowly towards progressive its insufficiency (6), characterized by gradual, before limited, and after widespread, changing of pancreatic beta-cell insulin activity from type I, associated, (in which both vasomotility and vasomotion are intense: active hyperaemia), to type II, intermediate (origin of IGT) and, finally, to type III, dyssociated (first stage of microcirculatory insufficiency), when pancreatic tissue acidosis is highest (real begin of DM). (See also Diabetic Constitution and Diabetes Mellitus in Practical Applications, in above-cited website and in the website www.indmedica.org, 2 Cyber Lectures: Diabetic and Dyslipidaemic constitutions).
Starting from this stage, pancreatic interstitium becomes more large than the normally, mainly due to amyloid deposit, as formerly demostrated: pancreatic-“in toto” ureteral reflex results ³ 1 cm. (NN < 1 cm.) (See Diabetes mellitus, in http://www.semeioticabiofisica.it, Practical Applications, URL
http://www.semeioticabiofisica.it/semeioticabiofisica/Documenti/Eng/Diagnosis%20DM,%20amyloid.doc).
At this point, we can finally understand more clearly the really frequent association between arterial hypertension and DM, which appears “always” on the common base of a congenital inherite factor, i.e. CAEMH-a., particularly intense in both Langherans’s pancreatic isles and skeletric muscle arteriols, i.e, resitance vessel wall-
For the first time it is possible to speak of real beginning of diabetes mellitus, a term until now used without scientific support, namely in acritical manner, despite the progress of sophysticated instrumental semeiotics.
At a large number of congresses I have showed the misuse of such termin in front of well-known diabetologists, who appeared without exception surprised, annoyed and totally unable to falsify our statement (7).
DM type II, so-called NIDDM, – more than 94% of all cases – from biophysical-semeiotic viewpoint shows a precise, clear-cut beginning, which corresponds to the first onset of pancreatic isles microcirculatory activation type II, intermediate, in individuals involved by dyslipidaemic “and” diabetic constitutions, causing histangic acidosis anf further, pancreatic amyloyd deposit, and reduction of local insulin receptors sensitivity, essential factor in the self-regulation of hormone secretion.
In a few words, such characteristic microcirculatory condition parallels the activation of “only” vasomotility, evaluated at the bed-side as fluctuations of upper ureteral reflex, during “light” stimulation of pancreatic trigger-points: AL + PL, i.e. duration of oscillation wave (Fig.1), is 7-8 sec. (NN = 6 sec.), whereas vasomotion, i.e. the fluctuations of lower ureteral reflex, shows a AL + PL duration unchanged (6 sec.), due to impairment of loca AVA and especially of Endoarteriolar Blocking Devices (EBD).
From the haemoreological-microcirculatory view-point, that indicates an impairment of Microcirculatory Functional Reserve, and consequently initial abnormality of insulin secretion, according to Angiobiopathy theory.
In addition, it has to be considered that elastic artery dilation, evaluated clinically by means of Biophysical Semeiotics, as it will be once more illustrated in following, aims to counterbalance the dangers of increased peripheral artery resistance. However, repeated and acute dilation, e.g. during stresses, brings about initial alterations of endothels (denuding) and smooth muscle cells endo-reduplication, with subsequent arterial wall structural abnormalities, as intimal thikening (4, 25, 26).
At this point, we briefly remember the contemporaneous alterations of local vasa-vasorum, caused mainly by wall dilation, which brings about, in turn, further impairment of related microcirculation and consequently arterial wall damage.
In biophysical semeiotic detecting pre-hypertensive state, i.e. hypertensive constitution and hyrtension real risk, beside muscular preconditioning, illustrated above, to which we will return later, a primary role is played by the diagram of finger-pulp tissue microvascular unit, in which Phase A is reduced (gastric aspecific reflex < 1 cm.) and disappearing time of tGC results prolonged, after rapid interruption of digital pressure: Oxygen Recovery Time < 1 cm. (O2RT) (15-17).
Interestingly, O2RT (NN £ 2 sec.) is in relation to the recovery of normal tissue oxygenation, after interruption of jatrogenetically induced histangic acidosis, “aerobic” glycolisis restoration, H+ washing, and, then, post-ischaemic reactive hyperaemia, strictly related to Microcirculatory Functional Reserve, always altered also in the pre-hypertensive state, as clinical and experimental evidence shows: O2RT (NN = 2 sec.) > 2 sec., directly related to the seriousness of hypertensive constitution.
Unavoidable to evaluate pre-hypertensive state, it proved to be ausculatory percussory outlining of common femoral artery, which can be performed with the bell-piece of stethoscope, properly localized on this arterial vessel at the groin, or, in a practical way, immediately under umbelicus, at right or at left.
At this point, auscultatory percussion has to be applied, directly and “gently” from right to left and viceverse, right below umbelicus as far as hypophonetic and intense sound is perceived, indicating the cutaneous projection area of common femoral artery: if the individual, which is examined, performes boxer’s test or, apnea test or Restano’s manoeuvre (contemporaneously, he performes the two tests), in healthy, the artery dilates clearly; on the contrary, in hypertensive state as well as in hypertensive patients, of course, the vessel dilate just a little or does not dilate at all (70).
By recognizing the pre-clinical condition, pre-hypertensive stage or hypertensive constitution, as well as hypertension real risk, which may evolve to arterial hypertension, doctor has to consider accurately a lot of parameters, really different in bed-side evaluation difficulty.
1) Systolic arterial pressure (SAP).
2) Diastolic arterial pressure (DAP)
3) Mean arterial pressure (MAP = SAP – DAP/3 + DAP)
4) Heart rate (HR).
5) Systo-diastolic oscillations of left ventricle at rest and during boxer’s test (NN = 1 and, respectively, 2 cm.): this paramter may be overlooked, although it is really interesting.
6) Tissue pH, evaluated as latency time of Critical Point (CP) of 5 cm. in tissue-microvascular-unit diagram. In healthy young, CP is generally absent (Fig. 2).
7) O2 Recovery Time (O2 RT), assessed as latency time of tGC disappearing (NN = 2 ± 0,5 sec.) .
8) Arterial peripheral resistance (APR = MAP/10 x O2 RT); normal value £ 20.
9) Basal arterial diameter (BAD), evaluated, e.g., as diameter of cutaneous projection of common iliac artery in a relaxed patient (NN £ 2 cm.).
10) Dilation index (DI = Max AD/BAD; NN ³ 2 cm.); artery diameter is assessed at basal line and, then, during boxer’s test, for instance.
11) Arterial compliance (Co = DI x 10 / O2RT; NN = 8-17).
12) Skeletal muscle preconditioning.
In practice, the preconditioning can be performed at the level of biceps muscle (or other muscle, of course). It is a simple, and reliable manoeuvre, which permits rapidly by itself to diagnose hypertensive constitution: in healthy, in supine position and psycho-physically relaxed with open eyes to avoid melatonin secretion, doctor evaluates basal lt of biceps muscle-gastric aspecific reflex and/or caecal reflex by mean of “mean-intense” pressure (NN = 8 sec.).
After 5 sec. “exactly” – preconditioning – the same parameter is evaluated for the second time: in healthy, latency time appears prolonged significantly, while in the individual with hypertensive constitution, and, of course, in hypertensive patient, latency time is either unchanged or lowered, in inverse relation to the seriousness of arterial hypertension.
Without going on in the pathophysiology discussion, in which we are not concern at this moment, this method allows doctor to “quantify” peripheral arterial resistance. In a 50-year-long well established experience, the method proved to be reliable in 100% of cases.
It is easy to understnd that DI is related directly to distension ability of arterial wall, i.e., to arterial wall elasticity, impoortant factor of arterial compliance, evaluated by a different, more refined method (12-14).
In individuals under 60 years of age, DI is ³ 2 cm., when evaluated as cutaneous projection area of vessel, while over 60 years DI appears reduced to less than 2 cm.
Clinical and experimental evidence suggests that O2RT is related to PAR, as we demonstrated in an our research: r = + 0,84; tr = 4,378; p <>
Generally, Co is assessed by Bramwell and Hill’s formula, which consider the speed of wave puls and vascular elasticity, observed with sophysticated methods.
However, at the bed-side it proved reliable the datum obtained by this formula, opportunely modified, using DI, which gives information about common iliac artery elasticity ( or, of course, of other artery) and O2RT inversely related to blood-flow in tisssue-microvascular unit, during the phase of post-ischaemic hyperaemia (exclusively because of calculation reasons, DI is multiplied for 10). In aging, over 60 years, Co results <>
At this point, it is possible clinically to face the aethiopathogenetic problems of AI in a new way, i.e., trying to define pre-hypertensive state, which shows a particular hypertensive constitution, analogously at what we described as regards the diabetic, migraine constitution rheumatic arteriosclerotic constitution, and other constitution, such the oncological terrain.
Exclusively in this way it is possible to bed-side recognize pre-clinic stage of arterial hypertension, whose knowledge is essential for the primary prevention of hypertension.
Among young individuals, CAEH-a positive, with blood pressure in normal ranges, it is relatively easy to regognize those with increased PAR (> 20), even during stress test, DI < 2 cm., O2RT > 2 sec. and Co < style=""> physiological conditions.
Biophysical-Semeiotic Evaluation of Natriuretic Peptides.
From practical view-point, I advice such as “easy” evaluation of NP, offering a lot of usefull and interesting information on NP biological activity, particularly as hypertensive constitution is concerned.
In fact, individuals with hypertensive consitution (pre-hypertensive state) as well as overt hypertension, show a significantly decreased renal biological activity of natriuretic peptides, as patients involved by CAD, when down-regulation of renal specific receptors is caused by high levels of NP.
As a consequence, the impaired biological renal activity of natriuretic peptides plays a paramount role in bedside detecting hypertensive biophysical-semeiotic constitution. (For further technical information, See in above-mentioned website, the URL
http://www.semeioticabiofisica.it/semeioticabiofisica/Documenti/Eng/BNP%20engl.doc .
In following, an easy way reliable in such evaluation is described: in healthy, lying down in supine position, “intense”, sub-occlusive digital pressure is applied upon phemoral artery at the groin (or on another great muscular artery); the subsequent artery dilation upstrem brings about left cardiac atrial and left ventrical dilation, and then NPs secretion. After about 15 sec., kidney does not fluctuates as usually, showing congestion for 30 sec. exactly.
On the contrary, in individuals with hypertesive constitution and obviously overt hypertension, kidney congestion lasts for a time varying between 20 sec. and less than 30 sec., in relation to the severity of underlying disorder.
Hypertensive Constitution PAR > 20 DI < 2 cm. O2RT > 2 sec. Co <> Muscolar Preconditioning pathologic Evaluation of Natriuretic Peptides |
Getting rid of abnormalities of pre-clinical, pre-metabolic stage, we can hpefully prevent the serious diseases, which otherwise can onset, and, mainly the well-known complications in different biological systems.
On the contrary, we must rely only on treatments of high arterial pressure, often apparently efficacious, due to the fact that complication are already present and therapeutic monitoring is based exclusively upon lowered pressure values, gathered by the aid of a sphygmomanometer, which nothing are able to say about what really happen in target organs and tissue.
Actually, at the beginning of third millennium, doctors, for the fist time, agree with those few colleagues, who over years state that arterial hypertension, evaluated untill now at the level of vasa publica in a large variety of ways, is not significant as regards what really happens in tissue-microvascular-units under the same conditions.
In other words, the urgency of assessing organs damage begins to play the deserving role, also in the mind of those with scarse ability of criticism and creative imagination.
Really, since the descovery of CAEMH I stated without success that our colleagues would pay a great deal of attention to this mitochondrial cytopathology, overlooked for too long time, since I have realized that the war against the most serious human diseases, including arterial hypertension, can obtain the best results only in case of a prompt selection of individuals at “real risk” for them, so that they undergo “clincal” tests, reliable in “quantifying” such as risk, initiating rapidly the correct diet, etymologically speaking, that normalizes the muscular reactions, pathological at the beginning during boxer’s test, simulated stress test, “sucking simulation test, in which rythmic mamma palpation physiologically brings about – by nervous reflex, inhibiting dopamine neurons of TIDA – increase of PRL secretion, which enhances peripheral arteriolar resistance as well as insulin secretion, and negative consequences, we previously described (4, 10).
It is worth for saying that primary prevention of AH allows doctors to prevent contemporaneously also disorders and syndromes (ATS, DM, gout, malignancies, in indivuals, of course, with “oncological terrain”, a.s.o.) with favorable influences, both individual and social (20-22).
In fact, clinical evidence demonstrates that, beside AH, in the same patient there are frequently other serious disorders, cause of morbidity and mortality, based upon the commom genetic factor, i.e. CAEMH
The authors agree generally on both exsistence and importance of “genetic factor” of arterial hypertension, which has to explain following facts:
1) sympatethic hypertonus;
2) “intense and rapid “ response of a-adrenergic receptors, present in fifferent way in arterial and venous districts;
3) “rapid and intense” response of the vessels, which dilate;
4) “rapid and intense” congestion and subsequent similar decongestion of splancin organs, a part from intestine.
In hypertensive state, in fact, in a previous research performed on 249 individuals CAEMH-a, negative for AH, in the age between 15-80 years, the duration of kidney congestion during boxer’s test, resulted 4-5 sec., while in 467 individuals, comparable to age, CAEMH-a positive, among them 175 hypertensive (37,5%), and the other normotensive, but with family history positive for AH (292; 62,5%), kidney congestion duration was <>
CAEMH-a – as we demonstrated previously (2-4, 9, 10, 11, 14, 18, 19) – represents the conditio sine qua non of ATS, migraine, DM, autimmune disorders, incuding Acute Benigne Variant Polymyalgya Rheumatica (18, 19), tumours (10), solid and liquid, : “all” hypertensive individuals, we observed over the last 50 years, are or were involved by the mitochondrial cytopathology, I described, as allows us to state also the clinical evidence: digital pressure, applied on a nail-fold, e.g. of the big toe, of a young CAEMH-a negative, causes temporary dilation of homolateral common iliac artery (0,5 cm.), while both aorta and controlateral common iliac artery “practically” show unchanged diameters.
On the contrary, in the young CAEMH-a positive homolateral iliac artery shows a dilation ³ 1 cm. and, simultaneously, both aorta and controlateral common iliac artery dilate clearly and significantly, permitting thus pressure values to be normal.
Really, CAEMH-a is the genetic factor, clinically “quantifiable”, at the base of various formes of neuro-vegetative dystonia (8), of particular a2-receptors overactivity, as in case of alexytimia, frequently associated to AH (4, 28). The incapacity for speaking correctly and describe emotions by Autonomous Nervous System, due to internal tensions, plays a primary role in the pathogenesis of AH associated with this nervous disorder.
From the above remarks, in order to prevent efficaciously AH we have to be considered, in “healthy subjects, i.e. without AH or other clinical phenomenology, but CAEMH-a positive, the possibility of assessing hemoreological-haemodynamic as well as metabolic-biochemical modifications (post-absorptive state with abnormalities in central and peripheral vessels dynamics), even caused by numerous tests: boxer’s test, simulated stress, apnea test, sucking simulated test, Restano’s manoeuvre, a.s.o.
We must consider interesting the data collected, as usually, by tissue-microvascular-unit of finger-pulp or nail-foild, in which A Phase is characteristically of small intensity and O2RT is > 2 sec.
Beside the family history, the results of this evaluation allow to recognize promptly individuals at “real” risk for arterial hypertension, starting from the initial stage, we suggested to term pre-hypertensive state of AH, in which tissue pH appears to be lowered, O2RT prolonged, PAR increased, DI abnormal, arterial Co pathological, according to the values, illustrated above in the scheme.
These individuals show metabolic-biochemical conditions, characteristic of pre-morbid state, in which is present hyperinsulinaemia-insulinresistance,observable, the first, by specific renal test (brief kidney congestion and prolonged decongestion; NN 4-5 sec. and, respectively, 10 sec.) and by suprarenal glands evaluation (reduced microvascular activity since the third fluctuation), during insulinaemic acute pick secretion, due to the phenomenon of down-regulation of kidneys insulin receptors as well as insulin “vasocostriction” action caused by functional dysendotelization, as we observe as regards acethyl-choline
In conclusion, by a large number of biophysical semeiotic methods, of different difficulty and refinement (we illustrated above some among the less difficult methods, although reliable and practically easy to perform) nowadays is possible to recognize individual at risk for AH, since the first two decades of life, in a “quantitative” manner, due to the severity of their hypertensive constitution.
Consequently, now we can perform fortunately the primary prevention of this widespread and dangerous disease, notoriously complicated, if diagnosed to late, by morbidity and mortality, which can nowadays be prevented, because we can detect the disease in its pre-morbid stage, before complications onset, clinically, and, therefore, on very large scale.
* Sergio Stagnaro MD
Via Erasmo Piaggio 23/8, CP. 42
16039 Riva Trigoso (Genoa) Europe
Founder of Quantum Biophysical Semeiotics
Who's Who in the World (and America)
since 1996 to 2009
Ph 0039-0185-42315
Cell. 3338631439
www.semeioticabiofisica.it
dottsergio@semeioticabiofisica.it
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