uchch raktachaap

uchch raktachaap
vargeekaran evam baahya saadhan
Grade 1 hypertension.jpg
svachaalitbhuja raktachaapamaapi, jismein sistolik raktachaap 158mmHg, daayastolik raktachaap 99 mmHg evam hrudaya-gati 80prati minute darshit hai.
aaiseedi-9 401.x
oemaaaiem 145500
dijeej-deebi 6330
medalaain plas 000468
imedisin med/1106 ped/1097 emerg/267
M.iesaech D006973

(HTN) haaiparateinshan ya uchch raktachaap, jise kabhi kabhi dhamani uchch raktachaap bhi kehte hain, ek puraani chikitseeya sthiti hai jismein dhamaniyon mein rakt ka dabaav badh jaata hai. dabaav ki is vruddhi ke kaaran, rakt ki dhamaniyon mein rakt ka pravaah banaaye rakhane ke liye dil ko saamaanya se adhik kaam karne ki aavashyakta padti hai. raktachaap mein do maap shaamil hoti hain, sistolik aur daayastolik, jo is baat par nirbhar karti hai ki hrudaya ki maansapeshiyon mein sankuchan (sistol) ho raha hai ya dhadkanon ke beech mein tanaav muktata (daayastol) ho rahi hai. aaraam ke samay par saamaanya raktachaap 100-140 mmHg sistolik (uchchatam-reeding) aur 60-90 mmHg daayastolik (nichli-reeding) ki seema ke bheetar hota hai. uchch raktachaap tab upasthit hota hai yadi yeh 90/140 mmHg par ya iske oopar lagaataar bana rahata hai.

haaiparateinshan praathamik (moolabhoot) uchch raktachaap tatha dviteeyak uchch raktachaap ke roop mein vargeekrut kiya jaata hai. 90-95% maamale "praathamik uchch raktachaap" ke roop mein vargeekrut kiye jaate hain, jiska arth hai spasht antarnihit chikitseeya kaaran ke bina uchch raktachaap.[1] anya paristhitiyaan jo gurde, dhamaniyon, dil, ya ant:sraavi pranaali ko prabhaavit karti hain, shesh 5-10% maamalon (dviteeyak uchch raktachaap) ka kaaran hoteen hain.

haaiparateinshan stroke, maayokaardiyl rodhagalan (dil ke daure), dil ki vifalta, dhamaniyon ki dhamani visfaar (udaaharan ke liye, mahaadhamani dhamani visfaar), paridheeya dhamani rog jaise jokhimon ka kaarak hai aur puraane kidni rog ka ek kaaran hai. dhamaniyon se rakt ke dabaav mein madhyam darje ki vruddhi bhi jeevan pratyaasha mein kami ke saath judi hui hai. aahaar aur jeevan shaili mein parivartan raktachaap niyantran mein sudhaar aur sambandhit svaasthya jatiltaaon ke jokhim ko kam kar sakte hain. haalaanki, dava ke maadhyam se upachaar aksar un logon ke liye jaroori ho jaata hai jinmein jeevan shaili mein parivartan aprabhaavi ya aparyaapt hain.

anukram

vargeekaran

vargeekaran (JNC7)[2] sistolik dabaav daayastolik dabaav
mmHg kPa mmHg kPa
saamaanya 90–119 12–15.9 60–79 8.0–10.5
haaiparateinshan-poorv 120–139 16.0–18.5 80–89 10.7–11.9
charan 1 haaiparateainshan 140–159 18.7–21.2 90–99 12.0–13.2
charan 2 haaiparateinshan ≥a160 ≥a21.3 ≥a100 ≥a13.3
pruthak sistolik
haaiparateinshan
≥a140 ≥a18.7 <90 <12.0

vayask

18 varsh ya puraane aayu varg ke logon mein uchch raktachaap ko, sveekrut saamaanya maan se sistolik aur/ya daayastolik raktachaap maap se lagaataar uchch rahane se (vartamaan mein 139 mmHg sistolik, 89 mmHg daayastolik: taalika dekhein - vargeekaran (JNC7)) se paribhaashit kiya jaata hai. yadi maapaank 24 ghante embyuleins ya ghar ki nigraani se liye gaye hain, to kam seemaantar (135 mmHg sistolik ya 85 mmHg daayastolik) ka upayog kiya jaata hai.[3] saamaanya seema mein uchch raktachaap ke saath jokhim ke saatatya ko darshaane ke liye, haal hi mein antarraashtreeya uchch raktachaap dishaanirdesh banaaye gaye hain jo uchch raktachaap seema ke neeche banaaye gaye hain. JNC7 (2003)[2] haaiparateinshan shabd ko 120-139 mmHg sistolik aur/ya 80-89 mmHg daayastolik raktachaap ki paraas ke liye upayog karta hai, jabki 140 mmHg sistolik aur 90 mmHg daayastolik dabaav ko pratibhaag karne ke liye ESH - ECS (2007) ke disha nirdeshon[4] aur BHS IV (2004)[5] ishtatam, saamaanya aur uchch saamaanya shreniyon ka upayog karta hai. uchch raktachaap ko nimn roop mein bhi upavargeekrut karte hain: JNC7 uchch raktachaap charan I, uchch raktachaap charan II aur pruthak sistolik raktachaap ke roop mein bhed karta hai. pruthak sistolik raktachaap saamaanya daayastolik dabaav ke saath oonche sistolik dabaav ke roop mein jaana jaata hai aur bujurgon mein aam hai.[2] ESH - ESC (2007) ke disha nirdesh[4] aur BHS IV (2004),[5] un logon ke liye ek teesare charan (charan III) ka nirdhaaran karte hain jinka sistolik raktachaap 179mmHg ya daayastolik dabaav 109 mmHg hota hai. agar davaaen raktachaap ko kam karke saamaanya star tak naheen laati hain to uchch raktachaap "pratirodhi" ke roop mein vargeekrut kiya jaata hai.[2]

navajaat shishu tatha shishu

navajaat shishuon mein uchch raktachaap durlabh hai aur yeh 0.2 se 3% tak navajaat shishuon mein hota hai. svasth navajaat mein raktachaap niyamit roop se naheen maapa jaata hai.[6] uchch raktachaap, uchch jokhim vaale navajaat shishuon mein adhik aam hai. gestiteshanal umr, postakaunsepshanal umr aur janm ke samay vajan jaise kaarakon ko dhyaan mein rakh kar yeh tay kiya jaata hai ki kisi navajaat shishu mein raktachaap saamaanya hai athva naheen.[6]

bachche aur kishor

bachchon aur kishoron (umr, ling aur jaateeyata ke aadhaar par 2-9%) mein uchch raktachaap kaafi saamaanya roop mein hota hai[7] tatha kharaab svaasthya ki lambi avadhi ke jokhim ke saath juda hua hota hai.[8] ab yeh sifaarish ki jaati hai ki teen saal ki umr se adhik bachchon mein niyamit chikitsa dekhbhaal ke samay raktachaap ki jaanch ki jaani chaahiye. kai dauron ke pashchaat is baat ki pushti ki jaati hai ki kisi bachche mein uchch raktachaap ke lakshan hain.[8] bachapan mein umr ke saath raktachaap badh jaata hai aur bachchon mein uchch raktachaap ko ausat sistolik ya daayastolik raktachaap ki teen ya chaar baar ki maap ke ausat ke hisaab se tatha bachche ke ling, umr va oonchaai ke liye upayukt maan ki 95 pratishtata ke baraabar ya uchchatar nirdhaarit kiya jaata hai. bachchon mein poorv-haaiparateinshan ko sistolik ya daayastolik raktachaap ki 90 pratishtata ke baraabar ya adhik lekin 95 pratishtata se kam par maana jaata hai.[8] kishoron mein, aam taur par uchch raktachaap aur poorv-uchcharaktachaap ka nidaan vayask maapdand ka upayog kar vargeekrut kiya jaata hain.[8]

sanket evam lakshan

uchch raktachaap shaayad hi kabhi koi lakshan dikhaata hai aur aamtaur par iski pehchaan screening ke maadhyam se hoti hai ya jab isse asanbandhit svaasthya samasya ke liye dekhbhaal jaroorat padti hai. uchch raktachaap se peedit kuchh log sirdard (vishesh roop se sir ke pichhle hisse mein aur subah) tatha saath hi chakkar aane ki, vartigo tinits (kaan mein goonj ya fusafusaahat ki aavaaj), drushti parivartan tatha behoshi ki shikaayat karte hain.[9]

shaareerik pareekshan mein, uchch raktachaap ka shak tab hota hai jab opthelmoskopi ka upayog karte huye aankhon ke peechhe ki or optik fandas ki jaanch ke samay haaiparateinsiv retinopaithi ka pata chalta hai.[10] pratishthit roop se, uchch raktachaap se grast retinopaithi mein parivartan ki gambheerta ko I se IV tak ki shreni mein vargeekrut kiya jaata hai, haalaanki iske adhik halke prakaaron ka ek doosare se bhed karna mushkil ho sakta hai.[10] opthelmoskopi ke nishkarsh yeh sanket bhi de sakte hain ki koi vyakti kitne lambe samay tak uchch raktachaap se grasit raha hai.[9]

dvitiyk uchch-raktachaap

kuchh atirikt sanket aur lakshan dvitiyk uchch-raktachaap, ka sanket de sakte hain jo kisi pehchaan yogya kaaranon jaise gurde ki beemaariyon ya ant:sraavi rog ke ke kaaran hone wala uchch-raktachaap hai. udaaharan ke liye, chhaati aur pet ka foolana, glookoj asahishnuta, chaaaind mukhaakruti, "bafailo hanp" aur baingani dhaariyaan kushing sindrom ka sanket dete hain.[11] thaayaraaid rog aur atikaayata bhi uchch raktachaap ka kaaran ho sakte hain aur inke vishisht lakshan aur sanket hote hain.[11] pet ki aavaaj vrukk dhamani ka rog (gurde ki aapoorti dhamaniyon ka sankuchan) ka sanket ho sakta hai. pairon mein raktachaap mein kami ya jaangh ki dhamaniyon ke spandan mein vilamb ya anupasthiti, mahaadhamani nisankuchan (hrudaya se baahar nikalte hi mahaadhamani ka sankuchan) ka sanket ho sakti hai. vah uchch raktachaap jo sir dard, dhukadhuki, peelaapan aur paseene ke saath vyaapak roop se ghatata badhta hai fiyokromosaaitoma (adhivrukk granthi ke ek sanvahani tyoomar) ke sandeh ka sanket maana jaana chaahiye.[11]

uchch raktachaap sambandhit sankat

gambhir roop se uchch raktachaap (180 sistolik ya 110 daayaastolik ke baraabar ya adhik, kabhi kabhi ghaatak ya tvarit uchch raktachaap kaha jaata hai) "uchch raktachaap sambandhi sankat" ke roop mein sandarbhit kiya jaata hai. in staron se oopar ka raktachaap, jatiltaaon ke uchch jokhim ka sanket deta hai. is shreni mein raktachaap se grasit logon ke saath koi lakshan naheen bhi ho sakta hai, lekin aise logon ko sirdard (22% maamalo mein)[12] ya chakkar aane ki shikaayat kiye jaane ki sambhaavana aam logon se adhik hoti hai.[9] uchch raktachaap se grast sankat ke anya lakshanon mein, dekhne ki kshamata mein giraavat ya hrudaya ki vifalta ke kaaran saanso ka foolana ya gurde ki vifalta ke kaaran saamaanya bechaini ka ehsaas shaamil ho sakte hain.[11] uchch raktachaap se grast sankat se grast adhikaansh logon ka raktachaap ooncha hota hai, lekin achaanak vruddhi ke liye atirikt kaaran bhi ho sakte hain.[13]

"uchch raktachaap sambandhi aapaat sthiti", jisko pehle "ghaatak uchch raktachaap" kaha jaata tha, tab hoti hai jab gambhir roop se oonche raktachaap ke parinaam svaroop ek ya ek se adhik angon mein pratyaksh kshati ke pramaan milte hain. is kshati mein mastishk mein soojan aur shithilta ke kaaran hone wala uchch raktachaap se grast ensefolopethi, shaamil ho sakta hai jo sir dard aur chetna ke parivrtit star dvaara ise pahachaana jaata hai. retina ke paapelodema aur budhn sambandhi hemarej aur dheema sraav lakshya ang kshati ke anya sanket hain. seene mein dard hrudaya ki maansapesheeya kshati (jo rodhagalan ko badhaava de sakta hai) ya kabhi-kabhi mahaadhamani vichhedan, mahaadhamani ki bheetari deevaar mein fatan ka sanket ho sakta hai. shvaas ki kami, khaaainsi, kaf aur khoon se sane huye thook ki samasya fefade ki edeema ke lakshan hain. yeh sthiti, dil ke baaen veintrikl ki akshamata ke kaaran fefade ke ootakon mein soojan ki hai jo hrudaya ke baaen veintrikl dvaara fefadon se dhamaniyon ki pranaali mein paryaapt roop se rakt panp karne ki akshamata hai.[13] gurde ki kaarya pranaali mein teji se hraas (gurde ki teevr chot) aur maaikroenjiyopaithik heemolitik eneemiya (rakt koshikaaon ka vinaash) bhi ho sakti hai.[13] in sthitiyon mein, angon ki kshati ko rokane ke liye raktachaap mein teji se kami aavashyak hoti hai.[13] iske vipreet, is baat ka koi saboot naheen hai ki uchch raktachaap sambandhi atyaavashkataaon mein jahaan par lakshit angon mein kshati ke koi saakshya na mile hon vahaan par raktachaap ko teji se kam karne ki aavashyakta hoti hai. raktachaap ki kami mein ati-aakraamakata kisi jokhim ke bina naheen hoti hai.[11] uchch raktachaap se sambandhit atyaavashkataaon mein munh se khaayi jaane waali davaaon ke upayog se raktachaap ko 24 se 48 ghante mein dheere-dheere kam karne ki vakaalat ki jaati hai.[13]

garbhaavastha

garbhadhaaran ke lagbhag 8-10% maamalon mein uchch raktachaap ki samasya hoti hai.[11] garbhaavastha mein uchch raktachaap ki samasya waali mahilaaon mein praathamik uchch raktachaap pehle se maujood hota hai. garbhaavastha mein uchch raktachaap poorv-eklanpashiya, ka pehla sanket ho sakta hai jo ki garbhaavastha ki doosare aadhe bhaag ki tatha prasav ke kuchh hafto baad ki gambhir sthiti hai.[11] poorv eklanpashiya ke nidaan mein badha raktachaap tatha mootr mein proteen ki upasthiti shaamil hai.[11] poorv-eklanpashiya garbhadhaaran ke lagbhag 5% maamalon mein hota hai aur vishv star par sabhi maatru mrutyu ke lagbhag 16% maamalon ke liye jimmedaar hota hai.[11] poorv-eklanpashiya bachchon ki mrutyu ka bhi khatra doguna kar deta hai.[11] aamtaur par poorv-eklanpashiya ka koi lakshan naheen hota hain aur yeh niyamit jaanch se hi pata chalta hai. jab poorv-eklanpashiya ke lakshan hote hain to unamein sabse aam sirdard, drushyata sambandhi gadbadi (aksar "chamakati roshani"), ulti, adhijthar (pet ke oopari-madhya bhaag mein) dard aur edema (soojan) hain. poorv-eklanpashiya kabhi-kabhi jeevan ke liye ek khatarnaak sthiti eklanpashiya tak pahunch jaati hai. eklanpashiya ek uchch raktachaap se sambandhit aapaat sthiti hai ismein kai gambhir jatiltaaen shaamil hain. in jatiltaaon mein drushti ka khona, mastishk mein soojan daure ya kanpakapi, gurde ki vifalta, fefade ka edema aur ek ya adhik rakt vaahikaaon mein khoon ka jamana (rakt ke thakke ka vikaar) shaamil hain.[11][14]

shishu aur bachche

navajaat shishuon aur yuva shishuon mein badhat mein kami, daure, chidchidaapan, oorja mein kami aur saaains lene mein kathinaai[15] ko uchch raktachaap ke saath jod kar dekha ja sakta hai. bade shishuon aur bachchon mein, uchch raktachaap, sirdard, aspasht chidchidaapan, thakaan, badhat mein kami dhundhali drushti, nakaseer footana, aur chehare ka pakshaaghaat ho sakta hai.[6][15]

jatiltaaen

deerghasthaayi uchch raktachaap ki mukhya jatiltaaon ko darshaata chitr.

duniya bhar mein uchch raktachaap, samay se poorv mrutyu hetu, roka ja sakane wala sabse mahatvapoorn jokhim kaarak hai.[16] yeh iskemik hrudaya rog[17] stroke,[11] paridheeya sanvahani rog,[18] aur anya hrudaya rogon jismein dil ki vifalta, mahaadhamani dhamaneevisfaar, dfyoos ethaerausaklirauses aur fuffuseeya ant: shalyata shaamil hai, ke jokhim ko badhaava deta hai.[11] uchch raktachaap sanjnyaaanaatmak haani, paagalapan aur jatil kidni rog ke liye ek jokhim kaarak hai.[11] anya jatiltaaon mein shaamil hain:

  • uchch raktachaapagrast drushti patal vikruti
  • uchch raktachaap se grast apavrukkata[19]

kaaran

praathamik uchch raktachaap

praathamik (aavashyak) uchch raktachaap, uchch raktachaap ka sabse aam roop hai, uchch raktachaap ke sabhi maamalon mein 90-95% yahi hota hai.[1] lagbhag sabhi samakaaleen samaajon mein, umr badhne ke saath raktachaap badhta hai tatha baad ke jeevan mein uchch raktachaap se grast hone ka khatra kaafi badh jaata hai.[20] jeen aur paryaavaraneeya kaarakon ke ek jatil milaap se uchch raktachaap hota hai. raktachaap par halka prabhaav daalne waali kai aam jeenon ki pehchaan ki gayi hai[21] saath hi raktachaap par adhik prabhaav daalne waali kuchh durlabh jeen bhi pata chali hain[22] lekin uchch raktachaap ka aanuvanshik aadhaar abhi bhi behad kam samjha gaya hai. kai paryaavaraneeya kaarak raktachaap ko prabhaavit karte hain. jeevan shaili se sambandhit kuchh kaarak hain jo raktachaap kam karte hain jinmein aahaar mein namak ki maatra kam karna,[23] fal aur kam vasa vaale utpaadon ko aahaar mein badhaana (uchch raktachaap ko rokane ke liye aahaar sambandhi drushtikon (DASH aahaar) shaamil hain. vyaayaam,[24] vajan ghataana[25] aur sharaab ka kam sevan bhi raktachaap kam karne mein madad karte hain.[26] anya kaarakon jaise tanaav,[24] kaifeen ki khapat,[27] aur vitaamin di ki kami[28] ki sambhaavit bhoomika, kam spasht hai. insulin pratirodh, jo motaape mein aam hai aur sindrom ex (ya upaapachayi sindrom) ka ek ghatak hai, bhi uchch raktachaap ke liye yogadaan dene wala maana jaata hai.[29] haal ke adhyayanon se yeh bhi pata chala hai ki praarambhik jeevan ki ghatnaaen (udaaharan ke liye, janm ke samay kam vajan, dhoomrapaan karne waali maaain tatha stanapaan ki kami) aavashyak uchch-raktachaap ke liye jokhim kaarak hoti hain.[30] haalaanki, in jokhimon ko vayaskon mein uchch raktachaap ki samasya se jodne vaale tantr aspasht hain.[30]

dviteeyak uchch-raktachaap

dviteeyak uchch raktachaap kisi pahachaane ja sakane vaale kaaran ka parinaam hai. gurde ka rog uchch raktachaap ke dviteeyak kaaranon mein sabse aam hai.[11] uchch raktachaap, ant:sraavi sthitiyon jaise kushing sindrom, haaiparathaayaraadijm (atiglagranthita), haaipothaayaraadijm(alpagalagranthita), ekromigeli, kaun sindrom (atikaayata) ya haaiparaeldostaronijm (rakt mein eldostaron haarmon ki adhikta) tatha haaiparapairaathaayaraairaudijm (atiprajeevita) ya fiyokromosaaitoma (epaafraain ke atisraav ke kaaran satat uchch raktachaap) ke kaaran bhi ho sakta hai.[11][31] dviteeyak uchch raktachaap ke anya kaaranon mein motaapa, neend ke samay alpashvasan, garbhaavastha, mahaadhamani ka nisankuchan, atyadhik likoris khapat aur kuchh parche waali davaaen, harbal upachaar aur avaidh davaaen shaamil hain.[11][32]

paithofijiyolauji (rog ke kaaran paida hue kriyaatmak parivartan)

dhamaneeya daab ko prabhaavit karne vaale kaarakon ko darshaata chitr.

sthaapit moolabhoot uchch raktachaap (praathamik) vaale jyaadaatar logon mein, kaardiyk aautaput saamaanya rahate huye rakt pravaah ka badha hua pratirodh (kul paridheeya pratirodh) uchch dabaav ke liye jimmedaar hota hai.[33] is baat ke saakshya hai ki poorv-uchcharaktachaap ya "seemaavarti uchch raktachaap vaale kuchh yuva logon ko uchch kaardiyk aautaput, uchch hrudaya gati dar aur saamaanya paridheeya pratirodh hota hai. is sthiti ko haaiparakaainetik seemaavarti uchch raktachaap kaha jaata hai.[34] in vyaktiyon ke baad ke jeevan mein sthaapit moolabhoot uchch raktachaap ke vishisht lakshanon ka vikaas ho jaata hai kyonki umr ke badhne ke saath unka kaardiyk aautaput gir jaata hai tatha paridheeya pratirodh badh jaata hai.[34] yeh vivaad ka vishay hai ki yeh paitarn un sabhi logon par laagoo hota hai naheen jinmein antat: uchch raktachaap ka vikaas ho jaata hai.[35] sthaapit uchch raktachaap mein badha hua paridheeya pratirodh mukhya roop se chhoti dhamaniyon aur dhamanikaaon ke sanrachanaatmak sankuchan ke kaaran hota hai.[36] keshikaaon ki sankhya ya ghanatv mein kami bhi paridheeya pratirodh mein yogadaan kar sakti hai.[37] uchch raktachaap paridheeya nason mein lacheelepan ki kami ke saath bhi juda hua hai,[38]jo hrudaya mein rakt ki vaapasi ko badhaane, hrudaya preelod mein vruddhi kar sakta hai aur antat: daayastolik asamaanyata ka kaaran ban sakta hai. rakt vaahikaaon ka sakriya sankuchan sthaapit moolabhoot uchch raktachaap mein bhoomika nibhaata hai ya naheen yeh spasht naheen hai.[39]

naadi dabaav (sistolik aur daayastolik raktachaap ke beech antar) uchch raktachaap vaale bujurgon mein aksar badh jaata hai. is sthiti mein aisa sistolik dabaav ho sakta hai jo ki asaamaanya roop se uchch ho, lekin daayastolik dabaav saamaanya ya kam ho sakta hai. is sthiti ko pruthak sistolik raktachaap kaha jaata hai.[40] bujurg logon mein uchch raktachaap ya pruthak sistolik uchch raktachaap ke saath uchch naadi dabaav ko badhi huyi dhamaneeya kathorata dvaara samjha ja sakta hai jo aam taur par umr badhne ke saath juda hua hai aur uchch raktachaap ke dvaara aur bigad sakta hai.[41]

uchch raktachaap mein dhamaniyon ki pranaali ke bheetar dekhe gaye pratirodh mein vruddhi ke liye kai tantron ko prastaavik kiya gaya hai. adhikaansh saakshya in kaaranon mein se ek ya donon ki or ishaara karte hain:

  • gurde dvaara namak aur paani se nipatne mein aniyamitata, vishesh roop se ant: gurda renin - enjiyotenasin pranaali ki gadbadiyaan.[42]
  • sahaanubhooti tantrika tantr ki aniymittaaen[43]

ye tantr paraspar ananya naheen hain aur yeh sambhaavana hai ki moolabhoot uchch raktachaap ke jyaadaatar maamalon mein donon kuchh had tak jimmedaar hon. yeh bhi sujhaaya gaya hai ki endotheliyl asamaanyata (rakt vaahikaaon ke astar ki shithilta) aur sanvahani soojan bhi badhe huye paridheeya pratirodh aur uchch raktachaap mein sanvahani kshati ke liye yogadaan kar sakte hain.[44][45]

rog ke lakshan

uchch raktachaap mein kiye jaane vaale aam pareekshan
pranaali pareekshan
gurde sambandhi sookshm mootr vishleshan, (proteenuriya) proteenameh, seeram BUN (rakt yooriya naaitrojan) aur/ya kretanaain
ant: sraav (endokraain) seeram sodiym, poteshiym, kailshiym, TSH (thaayaraaid-uttejak haurmon).
metaabolik (chayaapachayi) niraahaar rakt glookoj, kul kolestraul, HDL aur LDL kolestraul, traaiglisraaids
anya hemaataukrit, ilektrokaardiyograam aur chhaati ka rediyograaf
sootr: aantarik chikitsa ke hairisn ke siddhaant[46] anya[47][48][49][50][51]

uchch raktachaap ka nidaan tab hota hai jab rogi lagaataar uchch raktachaap se peedit hota hai. paramparaagat roop se,[3] nidaan ke liye ek maheene ke antaraal par teen alag raktadaabamaapi maap ki aavashyakta hoti hai.[52] uchch raktachaap se grast mareejon ke praarambhik moolyaankan mein poorn itihaas aur shaareerik pareeksha shaamil hai. 24 ghante chal raktachaap mauneetar aur ghar par raktachaap naapane waali masheenon ki upalabdhata ke saath, white kot uchch raktachaap (white kot sindrom) vaale rogiyon ke galat nidaan se bachane ke mahatva ne protokaul mein parivartan kar diya hai. United Kingdom mein, vartamaan mein sabse achha abhyaas chal maap ke saath ekal kleenik pathan ka fauloap hai. saat din ki avadhi mein ghar par raktachaap naapane waali masheenon ke maadhyam se bhi kam aadarsh roop se fauloap ka paalan kiya ja sakta hai.[3]

jab ek baar uchch raktachaap ka nidaan nishchit ho jaata hai, to chikitsak, yadi upasthit ho to jokhim vaale kaarakon aur anya lakshanon ke aadhaar par antarnihit kaaran ki pehchaan karne ka prayaas karte hain. kishoraavastha se poorv bachchon mein aamtaur dviteeyak uchch raktachaap adhik hota hai tatha adhiktar maamale gurde ki beemaariyon se sambandhit hote hain. kishoron mein praathamik ya moolabhoot uchch raktachaap adhik aam hai iske kai kaarak hai jinmein motaapa aur uchcharaktachaap ka paarivaarik itihaas shaamil hain.[53] dviteeyak uchch raktachaap ke sambhaavit kaaranon ki pehchaan karne ke liye tatha yeh nirdhaarit karne ke liye ki kya uchch raktachaap ne hrudaya, aaainkhon tatha gurde ko kshati pahunchaayi hai, prayogashaala pareekshan bhi kiye ja sakte hain. madhumeh aur uchch kolestraul star ke liye atirikt pareekshan kiye jaate hain kyonki ye sthitiyaan hrudaya rog ke vikaas ke jokhim ka kaarak hain aur inke upachaar ki aavashyakta ho sakti hai.[1]

seeram kretanaain ki maap gurde ki beemaari ki upasthiti ka aankalan karne ke liye ki jaati hai, jo ya to uchch raktachaap ka kaaran ya parinaam ho sakta hai. seeram kretanaain akele hi glomeroolar chhanan dar ko vaastavikta se adhik kar sakta hain. haal ke disha nirdesh glomeroolar chhanan dar (eGFR) ke aankalan ke liye gurda rog mein khuraak mein sanshodhan (MDRD) sootr jaise bhavishyasoochak sameekaranon ke upayog ki vakaalat karte hain.[2] eGFR gurde ke prakaarya ki ek aisi aadhaarbhoot maap pradaan kar sakta hai jise gurde ke prakaarya par kuchh uchcharaktachaaparodhi davaaon ke dushprabhaavon par najar rakhane ke liye istemaal kiya ja sakta hai. proteen ke liye mootr ke namoonon ka pareekshan bhi gurde ki beemaari ke ek dviteeyak soochak ke roop mein prayog kiya jaata hai. ilektrokaardiyograam pareekshan (EKG/ECG) is saakshya ko praapt karne ke liye kiya jaata hai ki hrudaya, uchch raktachaap ke kaaran tanaav mein hai. yeh hrudaya ki maansapeshi (baaen nilya mein ativruddhi) ka mota hona bhi dikha sakta hain ya yeh bata sakta hai ki kya hrudaya ko pehle koi maamooli gadbadi jaise mook dil ka daura hua hai. hrudaya ki vruddhi ya hrudaya ki kshati dekhne ke liye chhaati ka ex-re ya ikokaardiyograam kiya ja sakta hai.[11]

rokathaam

bahut se log uchch raktachaap se grast hain, lekin unako iska ehsaas naheen hai.[54] poori janasankhya ke uchch raktachaap ke parinaamon ko kam karne ke liye tatha uchcharaktachaaparodhi dava chikitsa ki aavashyakta ko kam karne ke liye upaayon par dhyaan dene ki jaroorat hai. raktachaap kam karne ke liye, davaaon ke maadhyam se upachaar shuroo karne se pehle jeevan shaili mein parivartan ki sifaarish ki jaati hain. uchcharaktachaap ki praathamik rokathaam ke liye, british uchch raktachaap society ke 2004 ke dishaanirdesh[54] nimnalikhit jeevan shaili ka prastaav karte hain jo ki 2002 mein America ke national haai beepi shiksha kaaryakram ke dvaara ullikhit nirdeshon ke anuroop hai:[55]

  • shareer ke vajan ko maamaanya banaaye rakhein (udaaharan ke liye, shareer vajan soochakaank 20-25 kigra/meter2).
  • aahaar mein shaamil sodiym ki maatra <100 mmol / din tak seemit rakhein (<6 gram sodiym kloraaid ya <2.6 gram sodiym prati din).
  • erobik shaareerik gatividhi jaise tej chalana (≥ 30 minute prati din, saptaah mein jyaadaatar dinon mein) niyamit roop se apanaayein.
  • sharaab ki khapat seemit karein, purushon ke liye adhiktam 3 ikaai/din aur mahilaaon ke liye adhiktam 2 ikaai/din.
  • aahaar falon aur sabjiyon ko adhik se adhik shaamil karein (jaise, prati din kam se kam paanch bhaag).

prabhaavi jeevan shaili sanshodhan bhi raktachaap ko utana hi kam kar sakti hai jitni ki koi raktachaaparodhi dava. do ya do se adhik jeevan shaili sanshodhanon ke sanyojan bhi behtar parinaam de sakte hain.[54]

prabandhan

jeevan shaili mein sanshodhan

uchch raktachaap ke liye ilaaj ka pehla prakaar anumodit bachaav jeevan shaili parivrtanon ke samaan hi hain[56] tatha inmein aahaar sambandhi parivartan[57], shaareerik vyaayaam tatha vajn mein kameen shaamil hain. in parivrtanon ne uchch raktachaap se peedit logon mein mahatvapoorn tareeke se uchch raktachaap ko kam karke dikhaaya hai.[58] agar uchch raktachaap itna adhik hai ki aushadh upachaar turant karna sahi hoga, to bhi jeevanashaili mein parivartan anumodit hai. uchch raktachaap ko kam karne ke liye baayofeedabaik, tanaav mukti ya dhyaan jaise manovaigyaanik tanaav ko kam karne ke liye design kiye gaye vibhinn kaaryakramon ka vigyaapan kiya jaata hai. haalaanki, aam taur par vaigyaanik adhyayan, inke prabhaav ka samarthan naheen karte hain kyonki adhyayan aamtaur par kam gunavatta vaale hain.[59][60][61]

aahaar parivartan jaise kam sodiym aahaar laabhadaayak hai. uchch raktachaap vaale logon mein aur saamaanya raktachaap vaale logon mein kaukeshiyns mein ek lambi avadhi (4 chaar saptaah se adhik) tak kam sodiym aahaar raktachaap ko kam karne mein prabhaavi hai.[62] iske alaava, DASH aahaar, ek aahaar jo baadaam aadi, saabut anaaj, machhali, anda, fal aur sabjiyon se bharpoor hai, jise raashtreeya hrudaya, fefade aur rakt sansthaan dvaara protsaahit kiya jaata hai raktachaap kam karta hai. yojana ki ek pramukh visheshata sodiym ki maatra seemit karna hai, haalaanki aahaar poteshiym, maigneeshiym, kailshiym aur proteen mein bhi samruddh hai.[63]

aushadhiyaan

davaaon ke kai varg, jinko saamoohik roop se uchcharaktachaaparodhi dava ke roop mein jaana jaata hai, vartamaan mein uchch raktachaap ke ilaaj ke liye upalabdh hain. vyakti ke hrudaya sambandhi (rodhagalan aur stroke ke khatre sahit) jokhim aur raktachaap paath ka dhyaan rakhate huye davaaen likhi jaati hai.[64] yadi dava se upachaar shuroo kiya jaata hai, to raashtreeya hrudaya, fefade aur rakt sansthaan ke saatavein uchch raktachaap (JNC-7) par sanyukt raashtreeya samiti[2] ki sifaarish hai ki chikitsak upachaar ki pratikriya par nigraani rakhe tatha davaaon se hone vaale pratikool prabhaavon ka aankalan karein. 5 mmHg raktachaap ki kami daure ke khatre ko 34% se kam kar deti hai tatha iskemik hrudaya rog ke jokhim ko 21% tak kam kar deta hai. raktachaap mein kami paagalapan, dil ki vifalta aur hrudaya rog se mrutyu ki sambhaavana ko kam kar sakti hain.[65] adhiktar logon ke liye upachaar ka uddeshya raktachaap ko 140/90 mmHg se kam karne ka hona chaahiye tatha madhumeh ya gurde ki beemaari se peedit logon ke liye aur kam hona chaahiye. kuchh chikitsa peshevar staron ko 120/80 mmHg ke neeche rakhane ki salaah dete hain.[64][66] yadi raktachaap lakshya naheen haasil ho paate hain to aur adhik upachaar ki jaroorat hoti hai.[67]

vibhinn upasamoohon ke liye dava ke chayan tatha upachaar ke sarvashreshth nirdhaaran par dishaanirdesh samay ke saath tatha deshon ke aadhaar par badle hain. sarvashreshth dava par visheshagyon mein sahamati naheen hai.[68] aaranbhik upachaar ke liye kaukran sahayog, vishv svaasthya sangathan aur sanyukt raajya America ke disha nirdesh ek kam-khuraak waali thiyaajaaid aadhaarit daayooretik ko behtar maanate hain.[68][69] Britain ke dishaanirdesh 55 ya adhik umr ke logon ke liye ya tatha afreeki ya caribbean mool ke liye kailshiym channel blaukar (CCB) par jor dete hain. ye dishaanirdesh enjiyotenasin - parivrti enjaaim avarodh (ACEI) ko yuvaaon ke liye vareeya praarambhik upachaar ke roop mein upayog kiye jaane ki salaah dete hain.[70] Japan mein, shuruaat mein nimn davaaon ke chhah vargon mein se kisi ek ke saath: CCB, ACEI/ARB, thiyaajid daaiyooretiks, beeta blaukars aur alfa blaukars ko uchit samjha jaata hai. Canada mein, pehle sambhav vikalp ke roop mein alfa blaukars ko chhodkar in sabhi davaaon ki sifaarish ki gayi hain.[68]

davaaon ke sanyojan

bahut se logon ko unke uchch raktachaap ko niyantrit karne ke liye ek se adhik dava ki aavashyakta hoti hai. JNC7[2] aur ESH-ESC disha nirdesh[4], do davaaon ke saath ilaaj shuroo karne ki vakaalat tab karte hain jab raktachaap sistolik 20 mmHg se adhik ya daayastolik lakshya se 10 mmHg se adhik hai. pasandeeda sanyojan renin - enjiyotenasin pranaali avarodhak tatha kailshiym channel blaukars, ya renin - enjiyotenasin pranaali pratirodhak aur daaiyooretiks ke hain.[71] sveekaarya sanyojan mein nimnalikhit shaamil hain:

  • kailshiym channel blaukars tatha daaiyooretiks
  • beeta blaukars tatha daaiyooretiks
  • daaihaaidropaairidaain kailshiym channel blaukars aur beeta blaukars
  • veraapemil ya dilshiyaajem saath daaihaaidropaairidaain kailshiym channel blaukars

asveekaarya sanyojan nimnalikhit hain:

  • gair-daaihaaidropaairidaain kailshiym (jaise veraapemil ya dilshiyaajem) blaukars tatha beeta blaukars
  • dohari renin enjiyotenasin-pranaali (jaise, enjaaim pratirodh roopaantaran karne vaale enjiyotenasin + enjiyotenasin riseptar blaukars)
  • renin - enjiyotenasin pranaali blaukars aur beeta blaukars
  • beeta blaukars aur edreenarjik-virodhi davaaen.[71]

gurde ki gambhir vifalta ke ek uchch jokhim ki sambhaavana ke kaaran, ACE avarodhak ya enjiyotenasin II riseptar pratipkshi, ek daaiyooretik aur ek NSAID (chayanaatmak COX -2 pratirodhak tatha gair-nirdhaarit davaaen jaise aaibyooprofen sahit) ke sanyojan se bachein. Australiaee svaasthya saahitya mein is sanyojan ko bolachaal ki bhaasha mein "tripl vhaimi" ke roop mein jaana jaata hai.[56] davaaon ke do vargon ke nishchit sanyojanon se yukt goliyaaain upalabdh hain. jabki ve suvidhaajanak hain, ve un logon ke liye sabse achhi tarah se aarakshit hain jo log vyaktigat ghatakon par sthaapit kiye jaate hain.[72]

bujurg

60 aur puraane ke aayu varg ke logon mein madhyam se gambhir uchch raktachaap ka ilaaj mrutyu dar aur hrudaya sambandhi dushprabhaavon ko kam karta hai.[73] 80 saal se adhik umr ke logon mein upachaar sampoorn mrutyu dar ko mahatvapoorn roop se kam naheen prakat karta hai, lekin hrudaya rog ka khatra kam kar deta hai.[73] amareeka mein thiyaajid daaiyooret pasandeeda dava hai tatha anushansit rakt daab lakshya 140/90 mimi Hg se kam hai.[74] sanshodhit british disha nirdeshon mein, kailshiym channel blaukar pasandeeda upachaar hai jismein lakshya kleenik reeding 150/90 mmHg se kam athva chal ya ghar raktachaap ki nigraani mein 145/85 mmHg se kam hai.[70]

pratirodhi uchch raktachaap

pratirodhi uchch raktachaap vah uchch raktachaap hai jo ki ek saath bhinn uchcharaktachaaparodhi dava vargon se sambandhit teen uchcharaktachaaparodhi agenton ke upayog ke baavajood lakshit rakt daab ke oopar bana rahata hai. pratirodhi uchch raktachaap ke ilaaj ke liye dishaanirdesh Britain[75] aur America[76] mein prakaashit kiya gaya hai.

sambhaavana

san 2000 mein, lagbhag ek arab logon ko ya duniya ki vayask aabaadi ke lagbhag 26% logon ko uchch raktachaap tha.[77] yeh viksit (333 million) aur aviksit (639 karod) donon prakaar ke deshon mein aam tha.[77] haalaanki, kshetron ke saath iski dar bhinn hai jaise graameen Bhaarat mein mein 3.4% (purush) aur 6.8% (mahilaaen) ki dar ke saath nyoonatam aur Poland mein 68.9% (purush) aur 72.5% (mahilaaen) ki dar ke saath adhiktam hai.[78]

san 1995 mein yeh anumaan lagaaya gaya tha ki sanyukt raajya America mein 43 lakh logon ko uchch raktachaap tha ya ve uchcharaktachaaparodhi dava le rahe the. yeh aankada lagbhag 24 pratishat vayask ameriki aabaadi ka pratinidhitv karta hai.[79] sanyukt raajya America mein uchch raktachaap ki darein badh raheen theen aur 2004 mein 29% tak pahunch gayeen.[80][81] san 2006 mein uchch raktachaap ne 76 million Amreeki vayaskon (janasankhya ka 34%) ko prabhaavit kiya hua tha tatha afreeki ameriki vayaskon ke 44% par uchch raktachaap duniya mein uchchatam daron mein se hai.[82] yeh sthaaneeya amereekiyon mein aam aur gore tatha maiksikn amareekiyon mein kam aam hai. darein umr ke saath badh rahi hain aur dakshinpoorvi amareeka mein adhik hain. uchch raktachaap mahilaaon tatha kamjor saamaajik aarthik sthiti vaalon ki tulana mein purushon mein adhik aam hai (haalaanki rajonivrutti is antar ko kam karti hai).[1]

bachche

bachchon mein uchch raktachaap ki dar badh rahi hai.[83] vishesh roop se kishoraavastha se pehle ke bachapan ke uchcharaktachaap dviteeyak hote hain, jo ek antarnihit vikaar ke kaaran hua karte hain. bachchon mein uchch raktachaap ka sabse aam (60-70%) kaaran motaapa, gurde ki beemaari hai. kishoron mein aamtaur par praathamik ya moolabhoot uchch raktachaap hota hai, jo kul maamalon ka 85-95% ke liye jimmedaar hai.[84]

itihaas

Harvey's Exercitatio anatomica de motu cordis et sanguinis in animalibus se nason ki chhavi ("praaniyon mein dil aur rakt ki gati par ek shaareerik abhyaas")

hrudaya pranaali ki aadhunik samajh chikitsak William haarve (1578-1657) ke kaam ke saath shuroo huyi. haarve ne apni pustak De motu cordis ("dil aur rakt ki gati par") mein rakt ke parisancharan ka varnan kiya hai. angrej paadari Stefan hels ne 1733 mein pehli baar raktachaap ki maap ko taiyaar kiya tatha prakaashit kiya.[85][86] uchch raktachaap ka beemaari ke roop mein varnan anya logon ke saath, 1808 mein Thomas yang tatha 1836 mein richrd braait ne kiya tha.[85] gurde ki beemaari ke saakshya ke bina kisi vyakti mein uchch raktachaap ki pehli report mein fredarik Akbar maahomed (1849-1884) dvaara banaayi gayi thi.[87] haalaanki, ek naidaanik ikaai ke roop mein uchch raktachaap 1896 mein astitv mein aaya jab reeva - rokki skipyone dvaara kaf aadhaarit raktadaabamaapi ka 1896 mein aavishkaar kiya gaya tha.[88] is aavishkaar ne raktachaap ko klinik mein maapane mein saksham kiya tha. san 1905 mein, nikolaai koraatakauf ne koraatakauf dhvaniyon ki vyaakhya karke is takaneek ko behtar kiya, ye dhvaniyaan ve hain jinko dhamani mein stethoskop saath us samay parishravit kiya gaya tha, jabki raktadaabamaapi kaf pichkaakar rakha gaya tha.[86]

aitihaasik roop se "kathin naadi rog" kahe jaane vaale rog ke upachaar mein jonkon ke maadhyam se rakt ki maatra nikaal kar rakt ko kam kiya jaata tha.[85] cheen ke peele samraat, kuraneliyus selsas, gailen aur hippokrets ne rakt nikaale jaane ki vakaalat ki.[85] 19 veen aur 20 veen shataabdiyon mein, uchch raktachaap ke liye prabhaavi aushadheeya upachaar ke sambhav hone se pehle, teen upachaar taur tareekon ko kai dushprabhaavon ke saath istemaal kiya jaata tha. in taur tareekon mein sakht sodiym pratibandh (udaaharan ke liye, chaaval aahaar[85]), simpethektaumi (sahaanubhooti tantrika tantr ke kuchh hisson ka shalya kriya dvaara hataana) aur jvarotpaadak chikitsa (kisi aise padaarth ko shareer mein daakhil karna jo jvar paida kare, apratyaksh roop se rakt dabaav ko kam karna) shaamil hai.[85][89] uchch raktachaap ke liye pehla rasaayan, sodiym thaayosaainet, 1900 mein istemaal kiya gaya tha, lekin iske kai dushprabhaav the aur yeh alokapriya tha.[85] dviteeya vishv yuddh ke baad kai anya agent viksit kiye gaye. tetraamethaailaamoniym kloraaid aur uske vyutpann heksaamethoniym, haaidraalajaain aur resarapaain (aushadheeya paudhe Rauwolfia serpentina se praapt) sabse lokapriya aur yathochit roop se prabhaavi the. sabse pehle aur achhi tarah se sahan karne yogya upalabdh maukhik agenton ki khoj ke saath ek badi safalta haasil huyi thi. inmein klorothiyaajaaid, pehli thi, pehli thiyaajaaid daaiyooret, jo enteebaayotik salfenilaamaaid se viksit ki gayi thi aur 1958 mein upalabdh ho gayi thi.[85][90] yeh namak utsarjan mein vruddhi ke saath drav sanchaya ko rokane mein saksham thi. anubhavi prashaasan dvaara ek yaadruchhik niyantrit pareekshan praayojit kiya gaya jisne haaidroklorothiyaajaaid ke saath resarapaain tatha haaidraalajaain banaam plaasebo ki tulana ki gayi. adhyayan jaldi band kar diya gaya tha kyonki ek uchch raktachaap samooh jo upachaar naheen praapt kar raha tha usamein upachaar praapt kar rahe rogiyon ki tulana mein kai jatiltaaon ka vikaas ho gaya tha aur yeh unke upachaar ko roka jaana anaitik samjha gaya tha. yeh adhyayan kam raktachaap vaale logon ke saath jaari rakha gaya pata chala ki ilaaj se kam uchch raktachaap vaale logon mein bhi hrudaya sambandhi kaaranon se maut ka khatre mein aadhe se adhik ki katauti huyi.[91] 1975 mein, us team ko laskar vishesh lok svaasthya puraskaar diya gaya tha jisne klorothiyaajaaid viksit kiya tha.[89] in adhyayanon ke parinaam ne uchch raktachaap ke baare mein janta mein jaagrukta badhaane ke liye aur uchch raktachaap ke maap aur ilaaj ko badhaava dene ke liye saarvajanik svaasthya abhiyaanon ke liye prerit kiya. in upaayon ne kam se kam tukadon mein hi sahi lekin yogadaan diya aur 1972 aur 1994 ke beech stroke aur hrudaya rog mein 50% giraavat dikhaayi di.[89]

samaaj aur sanskruti

jaagrukta

NHANES ke chaar adhyayanon ke madhya jaagrukta, ilaaj aur uchch raktachaap ke niyantran ki prabalata ka pradarshanamoolak rekhaachitr &lt;ref name="pmid7607734"&gt;[454]&lt;/ref&gt;

vishv svaasthya sangathan ne uchch raktachaap ko hrudaya sambandhi mrutyu ke liye mukhya roop se jimmedaar maana hai. vishv uchch raktachaap league (WHL) jo ki 85 raashtreeya uchch raktachaap samaajon aur leegon ka ek sangheeya sangathan hai, is baat ko maanyata pradaan karta hai ki poori duniya ke 50% se adhik uchch rakt chaap se peedit log unki sthiti se anajaan hain.[92] is samasya ke samaadhaan ke liye, WHL ne 2005 mein uchch raktachaap par ek vaishvik jaagrukta abhiyaan shuroo kiya aur pratyek varsh 17 May ko vishv uchch raktachaap diwas (WHD) manaaya jaana nirdhaarit kiya. pichhle teen varshon mein, WHD mein aur bhi kai raashtreeya society shaamil huin aur logon tak sandesh pahunchaane ki gatividhiyon mein unhonne Abhinav prayaas kiye hain. 2007 mein, WHL mein 47 sadasya deshon ki record bhaageedaari thi. WHD ke saptaah ke dauraan, kai media aur saarvajanik railiyon ke maadhyam se uchch raktachaap ke baare mein jaagrukta ko badhaava dene ke liye in sabhi deshon ki sthaaneeya sarkaaron, peshevar samaajon, gair sarkaari sangathanon aur niji udyogon ke saath bhaageedaari ki thi. Internet aur television jaise jan maadhyamon ke upayog se 250 million se adhik logon tak yeh sandesh pahunchaaya gaya. varsh dar varsh jaise jaise gati badh rahi hai, WHL ko vishvaas hai ki lagbhag anumaanit uchch raktachaap se peedit sabhi 1.5 arab logon tak pahuaincha ja sakta hai.[93]

arthashaastr

uchch raktachaap sabse aam puraani chikitsa samasya hai jo sanyukt raajya America mein praathamik svaasthya dekhbhaal pradaataaon ke paas jaane ka kaaran hai. American heart association ke anumaan ke anusaar 2010 mein uchch raktachaap ki pratyaksh aur apratyaksh laagat 76.6 arab dollar thi.[82] sanyukt raajya America mein, uchch raktachaap vaale logon mein se 80% apni sthiti ke jaankaar hain aur 71% koi na koi uchcharaktachaaparodhi dava le rahe hain. haalaanki, jaanane vaalon mein se keval 48% log uchch raktachaap par paryaapt roop se apni sthiti par niyantran rakhate hain.[82] nidaan, upachaar ya uchch raktachaap ke niyantran mein aparyaaptata uchch raktachaap ke prabandhan ke saath samjhauta kar sakti hai.[94] svaasthya dekhbhaal pradaata raktachaap par niyantran praapt karne mein kai baadhaaon ka saamana karte hain jinmein raktachaap lakshya ko haasil karne ke liye kai davaaeain lene mein pratirodh shaamil hai. logon ko dava sambandhi samay-saarani ka paalan karne aur jeevanashaili mein parivartan ki chunautiyon ka saamana karna padta hai. baharahaal, raktachaap lakshyon ki praapti sambhav hai. raktachaap kam karna unnat chikitsa dekhbhaal ke saath judi laagat ko mahatvapoorn roop se kam kar deta hai.[95][96]

sandarbh

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