Perspectives of Ayurveda in Integrative Cardiovascular Chinese Medicine for Patient Compliance: Volume 4 0128175702, 9780128175705

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Perspectives of Ayurveda in Integrative Cardiovascular Chinese Medicine for Patient Compliance

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Integrative Cardiovascular Chinese Medicine Series

Perspectives of Ayurveda in Integrative Cardiovascular Chinese Medicine for Patient Compliance Volume 4

Anika Niambi Al-Shura, BSc, MSOM, PhD Niambi Wellness Institute Integrative Cardiovascular Chinese Medicine St. Petersburg, Florida, USA

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright Ó 2020 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-0-12-817570-5 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Stacy Masucci Acquisition Editor: Katie Chan Editorial Project Manager: Tracy Tufaga Production Project Manager: Poulouse Joseph Cover Designer: Matthew Limbert Typeset by TNQ Technologies

In Memory This textbook is dedicated in memory of my late parents. To Mary A Cummings (1954e2006) who passed away of heart failure and other related diseases, I am continuing to keep my promise of finding out what was wrong with you and what could have been done to prevent some of them. To my father AbdurRahman Qurban Al-Shura (1949e80), I followed what you advised me to do in life, and taught me to always find a way to make it happen.

The writing of this textbook is dedicated to my son, Khaleel Shakeer Ryland, and his son, my grandson Khaleem Qurban Ryland. Your ancestors motivated me to find important solutions that may help some people in this world be relieved of suffering. May this legacy inspire and guide you to do the same in this life and to pass our ways on to future descendants.

Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Dr. Al-Shura biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Part I The homeostasis of body, mind & spirit Chapter 1 The science of personal autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Shad Darshan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The five elements in traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . 5 The five elements in Ayurvedic medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The tridosha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Agni fire as an aspect of the five elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Agni and the individual self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Vatika Hrudyoga in Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Part II Responsibility, awareness & guidance Chapter 2 Heart function and shen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Shen in Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Etiology of shen disturbance and pathology within six cardiovascular disease symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Neurohumoral mechanisms involved in the heart failure process. . . . . . 23 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 3 Tridosha and pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Ayurveda and the body constitution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 The tridosha, foundations of Ayurvedic medicine . . . . . . . . . . . . . . . . . . . . . . 29 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Chapter 4 Agni in digestion and life expression . . . . . . . . . . . . . . . . . . . . . . . 33 Overview of heart function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Functions of agni . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Expression of life: important body sites of the doshas . . . . . . . . . . . . . . . . . 37 Subtypes of vata dosha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Subtypes of pitta dosha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Subtypes of kapha dosha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Srotamsi: meridian system in Ayurvedic medicine . . . . . . . . . . . . . . . . . . . . . 43 Consciousness: prana, tejas, and ojas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Chapter 5 Constitution and pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Constitutional theories in Chinese medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Prakruti as constitution in Ayurvedic medicine . . . . . . . . . . . . . . . . . . . . . . . . . 58 Panchakarma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Part III Strategies of compliant patients Chapter 6 Digestion and nutrition in ayurveda and Chinese

medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

The digestive tract in descending order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Ayurvedic medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Traditional Chinese medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 7 Recovery techniques according to disease stage . . . . . . . . . . . 71 Acute stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Lipidemia/statins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Positive inotropes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Chronic stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

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Common symptoms associated with taking common antiarrhythmic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Beta blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Antithrombotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Atherosclerotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Antiglycemics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Hypertension/beta blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Hypertension/calcium channel blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Positive inotropes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Recovery stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Prevention stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Chapter 8 Utilizing the systems for benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Generally permissible food choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Generally prohibited food choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incompatible food choices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Panchakarma: concise overview of Ayurvedic health care practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods of diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

101 102 103 103 103 104 105

Chapter 9 Characteristics of compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Acute stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recovery stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107 108 112 115 118

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Chapter 10 Partnering with the health care team . . . . . . . . . . . . . . . . . . . . . 121 Medical empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physicianepatient relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

121 122 123 124

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Preface

The Development, Promotion, and Ongoing Research of Integrative Cardiovascular Chinese Medicine Integrative Cardiovascular Chinese Medicine (ICCM) is an area of medical study, research, and education with basic medical sciences, theories, and practices. It was created by Dr. Anika Niambi Al-Shura in 2014 as part of her doctorate degree. Cardiology in Chinese Medicine first became an interest during her early years of study in Chinese hospitals in China in 2004e06. At the time Dr. Al-Shura got a great opportunity to travel to China to work and study. It had dawned on her that before her father died in 1980, he predicted that she would study sciences and travel east to do something important. Dr. Al-Shura decided that she could search for ways to improve on her skills and master’s degree in Oriental Medicine education to help her mother, Mary, suffering from advancing cardiovascular diseases. Before important revelations in medicine and health care became understood in her mission, Mary passed away in her early 50s in 2006. Dr. Al-Shura continued her study and went on to hospital research in China between 2006 and 2014. She was recycling what her father had predicted directly to her word for word, realizing it may have been bigger than finding ways to only help her mother. Realizing that her father’s prediction seemed to be coming true, she used this period to learn and think about how she could have been able to care for Mary and possibly relieved or cured certain cardiovascular disorders had she survived. It became apparent that Mary’s ignored genetic predispositions, lifestyle, and practitioner racial/cultural profiling assumptions about prescribing, maintaining, and prolonging pharmaceutical drug use, and without access to gold star therapies even though the means to afford such therapies were available, were contributors to her advancing condition. Consideration and empathy for these factors from her health-care team and a careful analysis of the condition early on, the method of combining herbal therapy, nutrition, and pharmaceutical drug therapy, had this method been available at the time, may have had a positive impact. Today, Dr. Al-Shura’s work in developing her subject of ICCM is partially in memory of her mother who lived before the dawning of the integrative medicine era. Health-care practitioners, cardiovascular patients, and the public who study from the textbooks in the Integrative Cardiovascular Chinese Medicine series should note the basic medical sciences, theories, and practices which revolve throughout the textbooks, making it necessary to read them first in order then randomly several times. The reader who studies among the integrative cardiovascular Chinese medicine series embarks on a leg of the life

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journey, discovering what small and significant accomplishments one may achieve in their own well-being. Themes which can be found in the textbooks throughout the series are as follows: 1. ICCM acknowledges and integrates the history of the ancient and modern medicine perspectives from cultures around the world. Science and medicine was shared and preserved on some continents while being destroyed or lost on others. 2. ICCM establishes the belief that the human body can be explained through static scientific explanations of anatomy and physiological mechanisms and actions and through dynamic perspectives which brings people together in common and makes each person unique. Personalizing medicine can put analysis and insight into focus and tailor treatment more effectively. 3. ICCM acknowledges that patient autonomy and responsibility is a necessary and primary factor in health and well-being. Patients must enter the health care arena with a clear intention to heal and a detailed narrative that assists in that purpose. They must partner with providers in compliance with what is required to assist health restoration. 4. ICCM establishes the belief in practitioner empathy and the ability to listen, teach, and guide patients. Also, the ability to discern when utilizing one or more than one system of medicine to help a patient who also helps themselves heal. 5. ICCM considers the etiology of diseases as dynamic as the constant changes in modern and urban life. 6. ICCM considers genetic information as crucial as the patient family and personal history. Physical exam and diagnostic methods should involve routine practices of more than one system of medicine. 7. ICCM considers genetic information, innate and seasonal adaptions in body constitution are as crucial as the patient family and personal history. Certain key factors in a patient’s health-care profile make a significant difference when choosing a herbal formula, nutritional supplement, and pharmaceutical drugs singly or in combination in therapy. 8. ICCM establishes the belief that knowledge of herbal constituents in herbs that combine to swiftly restore health are used to make up a single formula or combination of formulations in acute, recovering, and preventive care in cardiology. Knowledge of nutritional deficiencies associated with cardiovascular symptoms helps in dietary planning over a short treatment course or a permanent lifestyle in acute, chronic, recovering, and preventive stages of care. Use of pharmaceutical drugs can assist with acute and chronic conditions where herbs and nutritional intervention is ineffective or the condition has reached a stage of no return to health restoration. Lifestyle modification that helps avoid preventable cardiovascular disorders leads to personal well-being. Chapters in each textbook involve the latest published research from around the world that identifies agreement of theories of principles of ICCM with ongoing research and established protocols of medical science. On of the purposes of exposure of ICCM is to encourage practitioners and patient to adopt our principles when applicable to improve health outcomes and to encourage medical researchers to study our principles and publish

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results in internationally recognized journals. I welcome your constructive comments, suggestions, and ideas which may improve or enhance content for future editions and courses offered for learners. Please write to: Dr. Anika Niambi Al-Shura St. Petersburg, FL, USA

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Dr. Al-Shura biography Dr. Anika Niambi Al-Shura is originally from Louisville, Ky, USA. She has one son, one grandson, and resides in Kentucky and Florida, USA. She enjoys cultivating medicinal plants and formulating medicinal herb recipes, soapmaking, fine art, travelling internationally to meet people for learning new cultures and ways of living, mountain hiking, and relaxing on the beach near the ocean. Dr. Al-Shura has 14 continuous years of formal education involving Traditional Chinese Medicine (TCM) clinical practice, advanced medical study, research and education between the United States, Italy, and China. In 2004, her master’s degree in Oriental Medicine was earned from East West College of Natural Medicine in Florida, USA. In mainland China between 2004 and 2014, she earned hospital study, advanced scholar, and specialty certificates in Chinese medicine, internal medicine, and surgery and cardiology from several university-affiliated hospitals. Those hospitals include Shandong University of Traditional Chinese Medicine, Shandong Provincial Hospital, and Tianjin University of Traditional Chinese Medicine. Her subspecialty training in TCM is in interventional cardiology involving the catherization lab. Dr. Al-Shura earned her PhD in medical education in 2014 through the University Ambrosiana program. Her dissertation on Integrative Cardiovascular Chinese Medicine (ICCM) became her first textbook entitled, Integrative Cardiovascular Chinese Medicine: A Personalized Medicine Perspective. This book was one of 7 textbooks written to introduce the concepts of ICCM. All were published and released together through Elsevier Academic Press in 2014. Those textbooks are utilized for the level 1 program studies in ICCM with continuing medical education (CME) courses. Eight additional textbooks were written on the establishment and development of intermediate ICCM theories and practices. Those textbooks are utilized for the level 2 program CME studies in ICCM. Those 8 textbooks are part of the Integrative Cardiovascular Chinese Medicine series and were published and released together through Elsevier Academic Press in 2019. Dr. Al-Shura is currently a faculty member at Everglades University in Florida, where she teaches medical and healthcare course in the Bachelors of Alternative Medicine program. She also has the Niambi Wellness Institute, based in Florida and Kentucky, where ICCM research and work continues. It includes a natural pharmacy lab and a CME program. The natural pharmacy researches, formulates, manufactures, and distributes various patented and original formulations using TCM herbs. The CME program includes TCM cardiology courses which grant credits towards NCCAOM, state medical board, and state TCM board license renewals in the United States.

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Other Titles by Dr. Anika Niambi Al-Shura • Integrative Cardiovascular Chinese Medicine: A Prevention and Personalized Medicine Perspective • Health Communications in Traditional Chinese Medicine • Integrative Anatomy and Pathophysiology in Traditional Chinese Medicine • Physical Examination in Cardiovascular Chinese Medicine • Diagnosing in cardiovascular Chinese medicine • Essential Treatments in Cardiovascular Chinese Medicine 1: Hyperlipidemia • Advanced Clinical Therapies in Cardiovascular Chinese Medicine

I PART

The homeostasis of body, mind & spirit

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1 The science of personal autonomy Chapter Objectives: 1. Introduce Ayurvedic medicine scientific theories and concepts into integrative cardiovascular Chinese medicine 2. Introduce tenets of body constitution according to Ayurvedic medicine 3. Introduce the tridosha, which includes vata, pitta and kapha as part of the foundation of body constitution in Ayurvedic medicine

The Shad Darshan The Shad Darshan is also called the six truths or six systems of Vedic philosophy. It is associated with six schools of thought inspired by six different sages. The schools in common teach humans cosmic science and its relationship to the soul, reality and illusion, and the purpose of life endeavors and goals and how to attain them. According to the principles of Ayurvedic medicine, humans have control over the course and direction of their lives. The physical body represents the soul, but will debilitate and eventually perish. The soul, which represents the true essence and nature of the individual self, can continue and live on through space and time. Therefore, one should strive through personal habits, social practices, actions in the material world, and spiritual practices to become one with the natural divine order of the universe. When the soul is in opposition to the divine order of the universe, there is a series of debilitating pathologies that take over the body, mind, and spirit. In Chinese medicine and in Ayurvedic medicine, respectively, the heart encompasses the mind as an aspect of spirituality and a principle of Parusha, and yang activity. The blood, as aspect of the material, is a principle of Prakruti and yin activity. When the soul is one with the natural divine order, there is well-being, self-awareness, and a desire for personal autonomy and recovery from cardiovascular disease before the point of chronic debilitation. Perspectives of Ayurveda in Integrative Cardiovascular Chinese Medicine for Patient Compliance. https://doi.org/10.1016/B978-0-12-817570-5.00001-3 Copyright © 2020 Elsevier Inc. All rights reserved.

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Chapter 1 The science of personal autonomy

According to the Shad Darshan, as described among the Vedas: • The individual self acquires and inhabits the physical body through reincarnation under law of karmic action. • The individual self is spiritual and is basically imbued with eternal consciousness. • The individual self experiences suffering spiritually and physically because of being affected by the material world. • The individual self can accomplish purification and selfcontrol by following any of the six Vedas. The goal of each philosophy is to end suffering. The six Vedic truths are discussed next.

Nyaya Darshan This Vedic philosophy was inspired by the sage Gautam. It is based on universal creation and logical reasoning, the endeavor to attain correct knowledge in life as set forth by God, and how to attain it.

Vaishesika Darshan This Vedic philosophy was inspired by the sage Kanad. This philosophy is based on scientific logic, reasoning, and atomic theory of the universe and earthly nature.

Sankhya Darshan This Vedic philosophy was inspired by the sage Kapil. It is based on the dual male and female principles of Parusha and Prakruti as a representation of God. From Parusha, the male (yang) principle representing spirituality, comes the inspiration of Prakruti, the female (yin) principle, the universe itself, who gives birth to all that is material and substance mixed with immaterial and spiritual. The manifestation is represented in yin and yang theory, five elements theory, and qi and blood theory.

Yoga Darshan This Vedic philosophy was inspired by the sage Patanjali. It is based on meditation, renunciation, and self-discipline for the purpose of uniting individual consciousness with God. The schools of yoga are Bhakti, Jnana, Karma, and Ashtanga.

Mimamsa Darshan This philosophy was inspired by the sage Jaimini. It is based on the study of the methodology and practice of the principles of the Vedas. It features performing rituals to help elevate the

Chapter 1 The science of personal autonomy

consciousness/individual soul and to purge or avoid physical urges that weigh the soul down into a lower vibrational existence, such as wealth and sensual pleasure.

Vedanta Darshan This philosophy was inspired by the sage Ved Vyas. It is based on the teachings of transcendental knowledge as one has achieved higher consciousness and is ready to learn the secrets of God and the attainment of absolute bliss.

The five elements in traditional Chinese medicine The five elements, also known as the five phases, are aspects of qi energy. Each element represents aspects seen in the spiritual and physical aspects of the greater universe, in nature, and in humans. • Wood • Fire • Earth • Metal • Water Humans encompass good and bad energetic characteristics of all five elements, yet usually take on the characteristics of one to three based on personal body constitution granted during conception and developed and expressed after birth. The good aspects are reflected through personal habits, social practices, actions in the material world, and spiritual practices to become one with the natural divine order of the universe.

Wood constitution Balanced • Clear life vision and goals with accomplishment • Good at persuasion and negotiating

Unbalanced • • • • • • • •

Indecisive Unstable direction in life Unable to plan and determine personal life purpose Unable to express sentiments and therefore prone to anger Arrogant Controlling Addictive personality Digestive problems

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Fire constitution Balanced • Socially charismatic, inspiring for others, commanding attention and action toward causes

Unbalanced • Socially anxious • Restless and insomniac • Suffers from speech problems: stuttering, talking too much or too rapidly and chuckling nervously while appealing to others in social transactions • Irritable and excitable • Easily stimulated and quick to be overstimulated to excess • Emotionally cold and unfeeling

Earth constitution Balanced • • • •

Nurturing and compassionate Reliable to friends and family Enjoys helping others Enjoys making sure others are happy or comfortable

Unbalanced • • • • • • • •

Worrier Meddles and controls the lives of others Nervous and pensive Overworks/workaholic in studying or career Digestive problems and diarrhea Gains weight easily and loses it with difficulty Tendency to produce excessive mucus everywhere in the body Cloudy thinking, confusion, inability to maintain focus, and a lack of clarity

Metal constitution Balanced • Organized and structured • Self-disciplined

Unbalanced • Afflicted by grief and sadness that cannot be relieved or resolved and becomes part of the personality, resulting in lethargy and laziness • Critical of the lives of others

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• Problems with respiratory functioning, sweating, skin rashes, colds, and allergies • Problems with diarrhea and constipation

Water constitution Balanced • Fearless persevering will to achieve goals and endeavors

Unbalanced • • • • • • • •

Worrier Anxious and fearful Withdrawn, phobic personality Problems with urinary incontinence and water retention Ear ringing Hot flashes, dry skin, and general dryness Cold extremities Declining sexual desire

The five elements in Ayurvedic medicine The five elements in Ayurvedic science are based on the understanding of physiology through universal attributes (gunas) and actions (karmas). The perceived origin of the beginning of the universe was that Consciousness was in an unmanifested state within a subtle vibrational energy, which eventually manifested the sound Om. From Om came the first element, ether. As ether began to move throughout the cosmos, the air element appeared as the action of ether. The friction and movement of air created heat and light, which produced the fire element. Heat began to dissolve ether to form water, which solidified to form the earth. Each element represents aspects seen in the spiritual and physical aspects of the greater universe, in nature, and in humans.

The five elements in Ayurvedic medicine • • • • •

Ether Air Fire Water Earth Humans are considered a microcosm of the universe, encompassing the five basic elements in anatomical structure, physiological functioning, wellness, and disease. The good and bad aspects are part of the basic body constitution, the tridosha: vata, pitta, and kapha. The five elements are influence and are

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reflected through personal habits, social practices, actions in the material world, and spiritual practices to become one with the natural divine order of the universe.

Ether influence Balanced • Ability to negotiate with others, using advanced functioning of hearing perception by understanding and recapping and articulating the understanding through speech • Good at persuasion and negotiating

Unbalanced • • • •

Indecisive Unstable direction in life Unable to plan and determine personal life purpose Unable to connect with others in mutual understanding, positive manifestation, and maintenance of goodwill

Air influence Balanced • Able to perceive problems and solve them in a timely manner and with satisfaction • Calm demeanor and happy disposition • Able to make clear decisions and to act upon them, anticipating favorable results • Able to organize projects and matters of life and to follow through to completion • Able to connect with others in mutual give and take

Unbalanced • Socially anxious • Restless and insomniac • Neurological disorders involving tactile perception, skin sensations, and the sense of touch • Easily stimulated and then overstimulated to excess • Emotionally cold and unfeeling

Fire influence Balanced • Clear and developed thinking and intelligence • Sharp visual perception • Stable body temperature, the basis for all normal body functioning

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• • • • •

Balanced digestion Active metabolic and enzymatic processes Reliable to friends and family Enjoys helping others Enjoys making sure others are happy or comfortable

Unbalanced • • • • • • • • •

Physiological vision problems Problems perceiving reality and consciousness Nervous and pensive Overworks/workaholic in studying or career Digestive problems and diarrhea Gains weight easily and loses it with difficulty Cold limbs Painful lower back and knees Fluid buildup in the lower extremities causing difficulty in walking • A tendency to produce excessive mucus everywhere in the body • Cloudy thinking, confusion, inability to maintain focus, and a lack of clarity

Water influence Balanced • Proper distribution of fluids throughout the cells, tissues, and organs of the body • Proper secretion of digestive fluids for transformation and transportation • Organized and structured • Self-disciplined • Fearless persevering will to achieve goals and endeavors

Unbalanced • • • • • •

Worrier Anxious and fearful Withdrawn, phobic personality Problems with urinary incontinence and water retention Procrastinator Difficulty grasping the qualities of food through taste and transforming such perception into clear spiritual consciousness • Dehydration and dryness • Vomiting and diarrhea • Problems with fertility and procreation

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Earth influence Balanced • • • •

Clear thinking and intelligent Decisive and takes action Full and normal patterned breathing Grounded sense of life purpose and consciousness

Unbalanced • • • •

Muzzy-headed thinker Lethargic and lazy Critical of the lives of others Problems with upper respiratory functioning, with allergies and frequent stuffy cold symptoms • Problems with lower respiratory functioning, with asthma, chronic breathing disorders, and cardiopulmonary diseases • Sweating, skin rashes, colds, and allergies • Problems with diarrhea and constipation

The tridosha The human body encompasses the five elements and consciousness, which work together to form and maintain homeostasis. The human body constitution is made up of three types, called the tridosha. Each dosha includes two main elements.

Dosha

Elements

Vata Pitta Kapha

Air and ether Fire and water Water and earth

Vata constitution • • • •

Involved in breathing and eye movement Motor functioning Cell functioning Easily excited, alert without thinking much before constant action • Thin, light, and flexible body

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Balanced • Personal creativity and accomplishment • Courage

Unbalanced • • • •

Fear, worry, and anxiety Problems with motor functioning, nimbleness, and dexterity Fear of loneliness Boredom

Pitta constitution • Involved in body metabolism • Involved in appetite, food digestion and absorption, transformation and transportation for assimilation of nutrition into the body and dispelling of waste products • Cell functioning • Neurotransmission and neuropeptides in intelligence • Vitality • Learning and understanding theories and concepts • Seldom gains or loses weight nor has weight fluctuations • Disciplined leaders

Balanced • Intelligence and understanding

Unbalanced • • • •

Anger, hatred, and jealousy Perfectionism Judgmental and critical Problems with inflammation leading to chronic disorders and heart diseases

Kapha constitution • Involved in body structure and the stability of the structure • Involved in water metabolism and fluid distribution throughout the body • Lubricates cells, tissues, joints, and organs • Cell functioning • Chubby shape • Retention of knowledge for memory

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Balanced • • • • • •

Expressions of love and compassion Faith and devotion Melodious voice and speech patterns Longevity in life Feelings of calmness Forgiveness and benevolence

Unbalanced • Addictions and unhealthy attachments to things, substances, and people • Calculating greed and ruthlessness • Disorders involving the congestion of fluids trapped in various places within the body • Slow digestion and weight gain • Cravings for sweet and salty food • Idleness • Long periods of sleeping

Agni fire as an aspect of the five elements Agni is a Sanskrit word that means fire. It is used extensively in Buddhism, Hinduism, and Jainism to describe many rites of passages, aspects and characteristics of life, and attributes and habits of the gods of Hinduism. It is also considered one of the five elements as also described in traditional Chinese medicine. The concept of Mahabhuta was expanded upon by the sages Kanada and Kapila as part of the body constitution. Thought to predate the traditional Chinese medicine five elements, in Ayurvedic medicine, the five elements are described as akasha (ether, space), vayu (air), ap (water), prithvi (earth), and agni (fire). The various contexts of agni: • Body temperature stable at 98.6 F • Fire in the stomach that digests food for material sustenance for life and nutritional well-being that leads to spiritual consciousness • The cooking fire in a home • The sacrificial fire on an altar • The fire of rebirth • The fire of death • The fire of the sun Agni was originally conceptualized as one of the holy trinity, the triad. It was considered the ultimate source of the “creatore maintaineredestroyer” Agni was a god, with a twin brother

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named Indra, who ruled the atmosphere as the god of storm, rain, and war. Surya, the third, ruled the sky and heavens. The Upanishads are a post-Vedic literature that describes agni as a metaphor, knowledge that illuminates with enlightenment in the state of darkness and ignorance. Agni is also considered a metaphor for the immortal soul, which in itself represents the light of spiritual consciousness.

Agni and the individual self Agni has distinct characteristics and therefore qualities in the body. It is subtle, luminous, and clear in appearance and radiation; hot in temperature; and sharp in movement (spikes upward) and spreads outward. There are four varieties of agni that are associated with the tridoshas: Sama agni: balanced Vishama agni: irregular, vata dosha Tikshna agni: sharp, pitta dosha Manda agni: slow, kapha dosha Jathara agni is a major type of agni that sits in the stomach and represents the fire that governs the digestion and assimilation of nutrition of food throughout the body. It is the catalyst for the functioning of the nine other major agnis for body systems and their 40 subtypes for physiological functioning in the body. There is agni of cellular memory in DNA, other cells, tissues, and organs that also governs sensory perception, a function of spiritual attainment, and the nutrition of specific tissues, a means of well-being that permits spiritual attainment. Important aspects of agni: • The gatekeeper of life, the force of intelligence within each cell, tissue, and body system • Controls and regulates cellular stasis • The mingmen fire in traditional Chinese medicine, which warms the body and vitalizes, nourishes, and serves as the root of vitality and health • Death follows extinguished agni as well as mingmen fire • Impaired agni is at the root of all imbalances and diseases Agni governs: • Digestive enzymes, digestion, absorption, and assimilation of nutrition into the cells, tissues, and organ systems of the body • Basal body temperature • Stable blood pressure • Sufficient sleep patterns • All metabolic activities

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• • • • • • • • • • • • • • • •

Strength and vitality Joy, laughter, love, and contentment The production of ojas, tejas, and prana Skin color, complexion, glow, and luster Intelligence, mental clarity, discrimination, logic, and reasoning Sensory perception, which is the gateway to consciousness, especially the visual Courage and confidence to meet the demands of life Agni imbalance: Low energy, fatigue, and weakness Emotional disturbances, anxiety, and depression Procrastination Indifference and inconsideration to oneself and others Indigestion, nausea, gas, bloating, acid indigestion Upper respiratory congestion Feeling tired or heavy body Mental fogginess Constipation and loose stools

Seven types of tissue (dhatu) in Ayurvedic medicine The structural, supporting, and tissue structures in Ayurvedic sciences are called dhatu. Dhatu agni collectively pertains to the body tissues and each tissue has its own individual agni. Food is the precursor of all tissue production and maintenance, and the metabolic process involved in the generation of tissues creates its own mala, or waste products. Waste products include stool, urine, sweat, saliva, tears, etc. 1. Rasa dhatu: plasma fluids 2. Rakta dhatu: blood 3. Mamsa dhatu: muscular tissue 4. Meda dhatu: adipose tissue 5. Asthi dhatu: bony tissue 6. Majja dhatu: bone marrow and nervous tissue 7. Shukra dhatu: reproductive organs of males and females

Vatika Hrudyoga in Cardiology The three main sectors of cardiology according to Ayurvedic medicine: • Acute myocardial infection • Ischemic heart disease • Cardiomyopathies

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Vatika Hrudyoga involves disorders directly affecting the heart and vascular system. Key symptoms include: • palpitations; • chest pain in the heart area with a heavy or empty feeling, and sensations of squeezing and crushing; • sudden loss of consciousness. In Ayurvedic medicine, treatment is called panchakarmas. Panchakarmas include: • virechna (purgation); • basti (medicated enemas): internally ingested herbal decoctions such as ajmoda, vishatinduka, and bold; • hridebasti, a treatment using substances forming a pool or paste on the sternum of the body, including: • the application of oils; • decoctions of herbs and fruits.

Further reading Rastogi S. What is needed to keep Ayurveda growing? An interview with Prof. R H Singh. J Ayurveda Integr Med. 2018;9(4):316e318. https://doi.org/10.1016/ j.jaim.2018.06.003. Kumar A, Aswal S, Chauhan A, Semwal RB, Kumar A, Semwal DK. Ethnomedicinal investigation of medicinal plants of Chakrata region (Uttarakhand) used in the traditional medicine for diabetes by Jaunsari tribe. Nat Prod Bioprospect. 2019;9(3):175e200. https://doi.org/10.1007/s13659-0190202-5. Patwardhan K, Prasad BS, Aftab A, Raghunath More V, Savrikar SS. Research orientation in Ayurveda educational institutions: challenges and the way forward. J Ayurveda Integr Med. 2019;10(1):45e49. https://doi.org/10.1016/ j.jaim.2018.12.001. Kim K, Park KI. A Review of antiplatelet activity of traditional medicinal herbs on integrative medicine studies. Evid Based Complement Alternat Med. 2019; 2019:7125162. https://doi.org/10.1155/2019/7125162. Published 2019 Jan 3. Mutalik G, Tillu G, Patwardhan B. AyurYoga, the confluence of healing sciences: a call for global action. J Ayurveda Integr Med. 2019;10(2):79e80. https:// doi.org/10.1016/j.jaim.2019.06.001. Muthiah K, Ganesan K, Ponnaiah M, Parameswaran S. Concepts of body constitution in traditional Siddha texts: a literature review. J Ayurveda Integr Med. 2019;10(2):131e134. https://doi.org/10.1016/j.jaim.2019.04.002. Menon M, Shukla A. Understanding hypertension in the light of Ayurveda. J Ayurveda Integr Med. 2018;9(4):302e307. https://doi.org/10.1016/ j.jaim.2017.10.004. Chinthala R, Kamble S, Baghel AS, Bhagavathi NNL. Significance of Shringagrahika Nyaya (maxim) in understanding Charaka Samhita in context to commentary of Chakrapani. Ayu. 2018;39(3):121e126. https://doi.org/ 10.4103/ayu.AYU_47_18. Jain J, Pai S, Sunil S. Standardization of in vitro assays to evaluate the activity of polyherbal siddha formulations against Chikungunya virus infection. Virusdisease. 2018;29(1):32e39. https://doi.org/10.1007/s13337-018-0421-0.

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II PART

Responsibility, awareness & guidance

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2 Heart function and shen Chapter Objectives: 1. Introduce the concept of Shen, well known in traditional Chinese medicine and explained as part of clinical signs 2. Introduce shen as seen as part of the pathological signs of coronary artery disease, edema, heart failure, hypertension, hypotension and peripheral artery disease

Shen in Chinese medicine Shen in traditional Chinese medicine translates closely to physical health and vitality, mental function, and consciousness. It is part of the three treasures, which represent the three radiant aspects of life:

Heaven Human Earth

Heart and vascular system Spleen and stomach Kidneys and endocrine system

Shen Qi Jing

Immaterial vitality, which resides in the heart and vascular system Energy and function created in the stomach as food, in the spleen and lungs inhaled as oxygen Material essence of life; prenatal is stored in the kidneys and postnatal is dependent upon nutritional factors

In traditional Chinese medicine, shen is part of the cardiovascular system and moves within the blood vessels. The amount and quality can be seen in the function of the heart and the emotional factors of the mind. Blood and qi are also formed from the postnatal jing derived from food and fluids. Therefore, the quality and nourishment of shen is dependent on the state of qi and jing inherited from parents. Shen can be seen in the eyes, which will appear bright, shining, and vital. Perspectives of Ayurveda in Integrative Cardiovascular Chinese Medicine for Patient Compliance. https://doi.org/10.1016/B978-0-12-817570-5.00002-5 Copyright © 2020 Elsevier Inc. All rights reserved.

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In traditional Chinese medicine pathology, deficient qi and blood will fail to nourish the shen, and too much internal heat from any organ or organ system will disturb the shen. The eyes of disturbed shen appear dull and lifeless, like doll eyes. This is seen in those with psychosis, with emotional problems, or in shock. The physiological functions and pathology of the heart and vascular system involve the disturbance of shen in traditional Chinese medicine.

Etiology of shen disturbance and pathology within six cardiovascular disease symptoms The six cardiovascular diseases described in the chapter are as follows: coronary artery disease edema heart failure hypertension hypotension peripheral artery disease

Coronary artery disease Healthy coronary arteries: • supply blood flow to the heart; • provide adequate oxygenation of the myocardium. The disease process includes: • abnormal deposition of lipids in the vessel wall; • plaque formation; • leukocyte infiltration; • vascular inflammation; • thickening of the vessel wall, which stenoses the lumen, thus restricting blood flow; dysfunction in the endothelial cells, leading to: imbalance of nitric oxide and prostacyclin for coronary function coronary vasospasm formation of blood clots restriction of blood flow to the myocardium, leading to: reduction in oxygen supply/demand ratio, which leads to hypoxia ischemia angina (chest pain) arrhythmia heart failure

Chapter 2 Heart function and shen

Edema Edema is a problem with capillary filtration and reabsorption and lymph nodal drainage, leading to an excessive accumulation of fluid within the tissue. It can include the entire body, a section of the body, specific organs, an entire limb, or a small localized area. The factors of edema are: • elevation of venous pressure by gravitational forces, marking an increase in hydrostatic pressure; • malnutrition and hypoproteinemia, marking a decrease in plasma oncotic pressure; • histamine and bradykinin, which are proinflammatory mediators that cause an increase in capillary permeability and therefore make them leak; • obstruction of the lymphatic system, which is the result of tissue injury and parasite infestation such as in filariasis.

Fluid balance ¼ filtration ¼ reabsorption þ lymphatic flow Capillaries: • Filtration is the movement of fluid out of capillaries. • Reabsorption is the movement of fluid back into the capillary. • Around 1% of plasma fluid accumulates within the interstitium over time. • The lymphatic system removes excess fluid from the interstitium and returns it back to the intravascular compartment. When net capillary filtration exceeds lymphatic filtration abilities, the interstitium swells with fluid, causing edema.

Intravascular and extravascular compartments There are two body compartments where fluid and electrolytes move and are exchanged: Intravascular compartment Blood flows within the: chambers of the heart vascular system of the body Extravascular system This is a specialized system that contains cerebrospinal fluid. It is made up of many subcompartments: cellular interstitial lymphatic

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Hydrostatic and oncotic forces move fluid in a balanced fashion between the two compartments for the kidney functions of constant excretion of sodium and water. In pathology, especially with kidney failure, the fluid volume may increase in one compartment and decrease in another, or increase in both compartments. • Ascites in the interstitial compartment causes it to increase in size, leading to tissue swelling within the peritoneal space. • Pulmonary edema occurs when congestion from left atrial pressure increases and blood backs up in the pulmonary circulation.

Heart failure Coronary artery disease and myocardial infarction both are a reduction in myocardial coronary blood flow and oxygen delivery leading to hypoxia and diminished electrical activity due to tissue death. The rest of the heart must compensate for the reduction in or total loss of function, thus contributing to the continuing debilitation. Heart failure is an acute and chronic clinical syndrome originating from excessive demand contributing to intrinsic or external heart pathology. Intrinsic pathology: Dilated and hypertrophic cardiomyopathy External pathology: • Hypertension • Increased stroke volume • Hormonal disorders Acute heart failure: • Rapid development • Life threatening due to inability of the heart to compensate as it does in chronic conditions over time Results of acute situations: • Sepsis • Myocardial infarction • Cardiopulmonary surgery • Bypass surgery • Arrhythmia • Valvular dysfunctions Chronic heart failure:

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Takes many months and years, due to constant heart compensatory adaptations with contributing factors from certain diseases: • Idiopathic • Arrhythmia (brady/tachy) • Valvular disease • Congenital defects • Cardiomyopathies that are bacterial or viral

Neurohumoral mechanisms involved in the heart failure process

Cardiac

Humoral

Autonomic

- Frankestarling mechanism - Chronic ventricular dilation or hypertrophy - Tachycardia

- Renineangiotensinealdosterone system - Vasopressin (antidiuretic hormone) - Circulating catecholamines - Natriuretic peptides

- Increased sympathetic adrenergic activity - Reduced vagal activity to heart

Neurohumoral responses are compensatory mechanisms: They increase ventricular load and debilitate the patient toward heart failure, causing pulmonary or systemic congestion and therefore edema by: increasing ventricular preload increasing ventricular afterload Venous constriction increases venous pressure Arterial vasoconstriction helps maintain arterial pressure Increased nitric oxide and endothelin in heart failure contribute to its pathogenesis and further development Increased blood volume increases ventricular filling

Vascular compensation The vascular role in reduced cardiac output (CO) is seen in hypertensive systolic and diastolic blood pressure readings and changes in blood volume and venous pressures. It involves

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feedback mechanisms that manage arterial pressure by constricting the arteries. Humoral contribution: • Vasopressin (antidiuretic hormone) • RAAS (renineangiotensinealdosterone system) • Increased venous pressure • Arterial barioreception • Activation of the sympathetic adrenergic nervous system • Increased systemic vascular resistance (SVR) • Increased afterload of the left ventricle and decreased CO

Blood volume compensation Edema develops through a systemic imbalance between the heart, kidneys, humoral control, fluid filtration, and blood volume. Blood volume increases to compensate for increases in ventricular preload and stroke volume; the result is a reduction in renal perfusion evidenced by retention of fluids and no output of urine. Increased blood volume influences: compensatory maintenance of CO elevation of venous pressure with pulmonary edema (dyspnea) systemic or lower body edema reduced renal perfusion humoral activation, leading to increase in antidiuretic hormone (arginine vasopressin) and RAAS

Hypertension Regardless of the origin of hypertension, the actual increase in arterial blood pressure is caused by either an increase in SVR or an increase in CO. The former is determined by the vascular tone (i.e., state of constriction) of systemic resistance vessels, whereas the latter is determined by heart rate and stroke volume. Therefore, to understand how arterial blood pressure can become elevated, it is necessary to understand the mechanisms that regulate both SVR and CO. Primary (or essential) hypertension: Ninety to ninety-five percent of adult patient cases are of unknown origin Vascular constriction causes increase in vascular SVR Increase in stroke volume and heart rate increases CO Secondary hypertension:

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Five to ten percent of adult patient cases result from a known origin, usually diseases of the renal and endocrine systems Vascular constriction causes increase in vascular SVR Increase in stroke volume and heart rate increases CO The guidelines of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) in effect at this writing lower the threshold for stage 1 hypertension by 10 mm Hg. Generally, the worldwide incidence of hypertension has increased. Considerations for lifestyle modifications should include alternative forms of herbal treatments, diet, treatment and prophylaxis against microbial infections and reduction of negative stressors. With these considerations as part of regular life practices, it may be possible to monitor progress for reducing or eliminating the necessity of pharmaceutical drugs, non-invasive or invasive interventional therapy.

JNC 7

Blood pressure guidelines for adults Category

Systolic (mm Hg)

Diastolic (mm Hg)

Normal Prehypertension Stage 1 hypertension Stage 2 hypertension