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ACCELERATED ILLNESSES
OP KAPOOR
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
The word `accelerated' was first used in clinical medicine in patients having angina pectoris. If a patient of angina experiences the pain more than three times a day, he is labelled as a case of `accelerated angina'. What is the significance of this to a family physician? This patient should be considered as a case of unstable angina, which includes any patient having angina at rest, new onset angina (2 months after first attack), angina at low work-load and post-myocardial infarct angina. The significance of this label is that such patients must have a coronary angiography done because, most of them will either need an interventional procedure like angioplasty or CABG surgery. Otherwise, the mortality rate in such patients is very high.
In my opinion, "accelerated" hypertension is very common in private practice. But the entity of `malignant hypertension' has hardly ever been seen by me during the last 20-30 years and is not likely to be seen in future, because most of the family physicians start drug treatment for hypertension very early.
`Resistant hypertension' is an entity where a number of patients do not respond to medicines.
`Secondary hypertension' is an entity where the treatment of the primary cause, if possible, is important.
`Multi-drug resistant (MDR) hypertension' is my label, for patients who often need a combination of two to three or more drugs to control hypertension. In fact, in modern days, 30-50% patients of hypertension need more than one drug.
The word `accelerated hypertension' has a different meaning than all the ones mentioned above. A patient, who is very well controlled on a certain dose of a tablet, for a long time, starts showing very high levels of blood pressure, for no apparent reason. This patient has not become a heavy alcoholic, has not started consuming heavy tobacco, has not developed renal artery stenosis, or chronic renal failure (CRF), which can also raise the BP. These are the patients who should be labelled as having `accelerated hypertension'. They should be given additional drugs and in high doses to control their BP. The patient's question (why did I develop such a high blood pressure, in spite of taking regular treatment for years together?) should be answered by quoting that such `accelerated' phase is known to occur in patients of hypertension.
I will now go a stage further and say that in private practice, I see three other diseases, which can develop an `accelerated phase'. How does it help the physician by giving this label to such patients? The three illnesses are:
1. Migraine; 2. Bronchial Asthma; 3. Diabetes Mellitus
Quite often, I find migraine patients having frequent attacks when the patient may need the help of additional drugs like anti-hypertensives, anti-epileptics, drugs for anxiety and depression, in addition to usual treatment. This phase lasts for a few weeks, sometimes.
Some patients of bronchial asthma start getting very frequent attacks, for no apparent cause. They will now need larger doses of drugs for some time.
Finally, I have often seen diabetic patients, who are well motivated and very compliant and have very well controlled diabetes on insulin or tablets. Then, at some stage, without having any infection or a precipitating factor, they suddenly develop an `accelerated phase', when larger doses of medicines are required for a few weeks or months, before they again settle down to their original doses.
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