CC BY
18
UDC 616.1:616.06-08-039.35-089
MULTIMORBID AND POLYPHARMACY IN CLINICAL CARDIOLOGY IN TERMS OF THE CLINICAL CASE
Radchenko A. O.1, Makienko N. V.1, Vodyanitska N. A.1'2
1 V. N. Karazin Kharkiv National University, Kharkiv, Ukraine
2 Kharkiv Railway Clinical Hospital № 1 of the branch «Center of Healthcare» of public JSC «Ukrainian Railway», Kharkiv, Ukraine
In this article is raised the topic of multimorbidity and polypharmacy on the example of a clinical case with the main diagnosis of Ischemic Heart Disease: Systemic atherosclerosis with predominance of coronary arteries sclerosis. Stable angina class III. Hypertensive heart disease III stage 3rd degree. Aortocoronary bypass. Sick sinus syndrome, tachy-brady form. Constant form of atrial fibrillation-flutter. AV node catheter ablation with pacemaker implantation. Infarction pneumonia of the lingual segments of the upper lobe of the right lung. CHF II-B stage with preserved systolic function of the left ventricle (EF LV 53 %). Very high additional cardiovascular risk. Concomitant conditions: Chronic obstructive pulmonary disease: Chronic obstructive bronchitis 2 degrees severity. Chronic pulmonary insufficiency III degree. Obesity III degree. Diabetes mellitus type 2, medium severity, decompensated. Chronic renal failure, III stage. The ongoing therapy is discussed and recommendations are given to minimize it in order to avoid polypharmacy.
KEY WORDS: multimorbidity, cardiovascular diseases, drug therapy, polypharmacy
МУЛЬТИМОРБВДШСТЬ I ПОЛ1ПРАГМАЗ1Я В КЛШ1ЧНШ КАРДЮЛОГП НА ПРИКЛАД1
КЛ1Н1ЧНОГО ВИПАДКУ
Радченко А. О.1, Макжнко Н. В.1, Водяницька Н. А.1'2
1 Харювський нацюнальний ушверситет iMeHi В. Н. Каразша, м. Харюв, Украша
2 Харювська ктшчна лжарня на залiзничному транспорт № 1 фшп «Центр охорони здоров'я» ПАТ
«Украшська залiзниця», м. Харюв, Украша
У статп розглянута тема мультиморбщност i полшрагмазп на прикладi клшчного випадку з основним дiагнозом хвороба серця: Системний атеросклероз з переважанням склерозу
коронарних артерш. Стабшьна стенокардш напруги III функцюнальний клас. Ппертошчна хвороба III стадп 3 ступеня. Аортокоронарне шунтування. Синдром слабкосл синусового вузла, тахi-брадi форма. Постшна форма фiбриляцii-трiпотiння передсердь. Катетерная аблящя АВ-з'еднання з iмплантацieю електрокардiостимулятора. Iнфаркт-пневмонiя язичкових сегментiв верхньоi частки правоi легенi. Хронiчна серцева недостатнють II-Б стадii зi збереженою систолiчною функцieю лiвого шлуночка (ФВ ЛШ 53%). Дуже високий додатковий кардюваскулярний ризик. Супутнi стани: Хрошчне обструктивне захворювання легень: Хронiчний обструктивний бронхи 2 ступеня тяжкостг Хрошчна легенева недостатнiсть III ст. Ожиршня III ст. Цукровий дiабет 2 тип, середньоi тяжкосл, декомпенсований. Хрошчна ниркова недостатнють, III ст. Обговорюеться що проводилася терапiя i даються рекомендацii щодо ii мiнiмiзацii з метою уникнення полшрагмазп.
КЛЮЧОВ1 СЛОВА: мультиморбщшсть, серцево-судинш захворювання, лiкарська тератя, полiпрагмазiя
МУЛЬТИМОРБИДНОСТЬ И ПОЛИПРАГМАЗИЯ В КЛИНИЧЕСКОЙ КАРДИОЛОГИИ НА
ПРИМЕРЕ КЛИНИЧЕСКОГО СЛУЧАЯ
Радченко А. О.1, Макиенко Н. В.1, Водяницкая Н. А.1'2
1 Харьковский национальный университет имени В. Н. Каразина, г. Харьков, Украина
2 Харьковская клиническая больница на железнодорожном транспорте № 1 филиала «Центр
здравоохранения» ПАО «Украинская железная дорога», г. Харьков, Украина
© Radchenko A. O., Makienko N. V., Vodyanitska N. A., 2017
В статье поднята тема мультиморбидности и полипрагмазии на примере клинического случая с основным диагнозом ИБС: Системный атеросклероз с преобладанием склероза коронарных артерий Стабильная стенокардия напряжения III функциональный класс. Гипертоническая болезнь III стадии 3 степени. Аорто-коронарное шунтирование. Синдром слабости синусового узла, тахи-бради форма. Постоянная форма фибрилляции-трепетания предсердий. Катетерная абляция АВ-соединения с имплантацией ЭКС. Инфаркт-пневмония язычковых сегментов верхней доли правого легкого. Хроническая сердечная недостаточность II-Б стадии с сохраненной систолической функцией левого желудочка (ФВ ЛЖ 53 %). Очень высокий дополнительный кардиоваскулярный риск. Сопутствующие состояния: Хроническое обструктивное заболевание легких: Хронический обструктивный бронхит 2 степени тяжести. Хроническая легочная недостаточность III ст. Ожирение III ст. Сахарный диабет 2 тип, средней тяжести, декомпенсированный. Хроническая почечная недостаточность, III ст. Обсуждается проводившаяся терапия и даются рекомендации по ее минимизации для избегания полипрагмазии.
КЛЮЧЕВЫЕ СЛОВА: мультиморбидность, сердечно-сосудистые заболевания, лекарственная терапия, полипрагмазия
INTRODUCTION
The topic of multimorbidity and progression of the cardiovascular pathology has been relevant and is being fully investigated [1-2]. The most frequent combinations of multimorbidity in clinical practice are Ischemic Heart Disease (IHD), Arterial Hypertension (AH), atherosclerotic dyscirculatory encephalopathy (ADE), atherosclerosis of mesenteric vessels, intestinal ischemia and other conditions [3-6].
Multimorbidity results in polypharmacy [7] that is when the number of medications simultaneously prescribed to the patient is significantly higher than the reasonable limits and when the probability and severity of their cumulative side effects are increasing catastrophically. In this regard, the physician is faced with the task of controlling prescriptions, the solution of which is not simple.
The clinical case demonstrates the problem and its possible solution.
CLINICAL CASE
57 year old man, resident of the city, transport retiree, disabled of the 2nd group.
COMPLAINTS
Patient E., born in 1959, was hospitalized with complaints on chest pains of a pressing character during moderate physical exertion, and at rest (go away at rest). These attacks are accompanied by dyspnea, palpitations. Feeling of suffocation at night. Shortness of breath decreases in the sitting position. Frequent remote dry wheezing. Transient increases in blood pressure to 230/130 mm Hg are accompanied by headache, dizziness. Dyspnea
accretion while minimal physical exertion. Weakness. Fast fatigability.
ANAMNESIS
Hypertensive disease since 1984 with a maximum level of blood pressure of 230/130 mm Hg. The usual blood pressure of 140/90 mm Hg. In 2004, radiofrequency ablation and pacemaker implantation because of atrial fibrillation were performed. Subsequently, ablation was repeated twice. 22.10.2010, pacemaker reimplantation. 22.10.2010, the pacemaker was replaced to Baikal in the VVI mode due to depletion. In August 2011 patient suffered pulmonary embolism. 15.04.2013, coronary angiography was performed, multivessel lesion was revealed, and Coronary artery bypass grafting (CABG) was recommended. 23.10.2013, CABG - 2 shunts were performed. During the last 5 days, blood pressure began to increase more often, pain attacks increased and dyspnea became worse at rest. 11.09.2016 on the background of significance increases of blood pressure to 220/110 mm Hg the patient experienced severe shortness of breath, chest pain. Ambulance was called out, first aid was rendered, and patient was hospitalized in Kharkiv railway clinical hospital № 1 of the branch «Center of healthcare» of public JSC «Ukrainian Railway».
MEDICATIONS TAKEN:
Warfarin, Acetylsalicylic acid, Valsartan, Nifedipine, Rosuvastatin, Torasemide, Spironolactone, Dapagliflozin, Metformin, Nitroglycerin situationally in the presence of chest pains, Captopril / Nifedipine in case of
significance increase in blood pressure. There is indisputable presence of polipharmacy.
LABORATORY TESTS
Complete Blood Count: WBC count 7,5 109/L, band neutrophils 7 %, segmented 79 %, eosinophils 2 %, lymphocytes 10 %, monocytes 2 %, RBC count 4,21012/L, platelet count 388 109/L, hemoglobin 122 g/L, hematocrit 39 %, ESR 27 mm/h, color index 0,87.
Chemistry Panel: glucose 13.52 ^mol/L, urea 9.6 ^mol/L, creatinine 119 ^mol/L, total protein ratio g/L, AST 14 U/L, ALT 17 U/L, total bilirubin 5,2 ^mol/L.
Coagulation Test: prothrombin complex according to Quique 78,1 %, soluble fibrin-monomer complexes 14 mg/100 mL, fibrinogen 3,77 g/L.
Urinalysis Test: color light yellow, clear, specific gravity 1010, pH 7,0, protein ratio 0,14 g/L, leukocyte 0-1, glucose -24,12 mmol/L, ketone bodies were not detected.
Activity of serum enzymes: CK-83,6 U/L, CK-MB 16,47 U/L.
INSTRUMENTAL TESTS
ECG: Pacemaker rhythm with stimulation frequency = 65 beats / min on the background of atrial fibrillation, the form of the QRS complex is constant.
Echocardiography: Eccentric type of left ventricular hypertrophy. Sclerotic changes in the walls of the aorta, flaps of the aortic and mitral valves. Dilatation of all heart cavities. Left ventricular diastolic dysfunction type 2. Left ventricular myocardial contractility was reduced (Fractional shortening = 28 %, ejection fraction (EF) = 53 %).Tricuspid valve regurgitation of the 3rd-4th degrees, 1st degree regurgitation of the pulmonary artery valve, signs of the 1st degree pulmonary hypertension. Pacemaker electrode is fixed in the right heart cavities.
Ultrasonography of the lower extremities arteries: Atherosclerosis of the main arteries of lower extremities, occlusion of the left superficial femoral artery, multiple stenosis of the right superficial femoral artery up to 65 %
Chest X-ray: eED 0.3 mSv, focal and infiltrative changes in the lungs were not detected. The roots are structural, not enlarged. Sinuses are free. Aperture clearly delineated. The median shadow is widened in diameter; the heart is widened to the left. Pacemaker is on the
left, dislocations and damages of the electrode were not revealed. Condition after sternotomy.
DIAGNOSIS
The underlying disease: Ischemic Heart Disease: Stable angina class III. Hypertensive heart disease III stage 3rd degree. Hypertensive heart (LVMH). Complicated hypertensive crisis (11.09.2016 Acute left ventricular failure: cardiac asthma). Atherosclerosis of coronary arteries (coronary angiography 15.04.2013). CABG - 2 shunts (23.10.2013). Sick sinus syndrome, tachy-brady form. Constant form of atrial fibrillation-flutter. AV node catheter ablation with pacemaker implantation (16.04.2004). Reoperation - AV node destruction (08.11.2004). Pacemaker reimplantation (22.10.10) in the VVI mode. The stimulation frequency 65. Pulmonary artery thromboembolism (16.08.2011). Infarction pneumonia of the lingual segments of the upper lobe of the right lung (2011). CHF II-B stage with preserved systolic function of the left ventricle (EF LV 53 %).
Very high additional cardiovascular risk.
Comorbid conditions: Cardio-cerebral syndrome on the background of vascular encephalopathy II stage. Cerebral atherosclerosis. Chronic obstructive pulmonary disease: Chronic obstructive bronchitis 2 degrees severity. Chronic pulmonary insufficiency III degree. Metabolic syndrome. Obesity III degree. Diabetes mellitus type 2, medium severity, decompensated. Chronic renal failure, III stage. Urolithiasis, asymptomatic form. Mixed nephropathy. Obliterating atherosclerosis of the lower extremities arteries. Hemodynamically significant stenosis of the arteries of the lower extremities on both sides. Diabetic antipathy of the lower extremities. Chronic ischemia of the 2nd degree.
CLINICAL TREATMENT
Warfarin 3.75 mg at 5 pm, Valsartan 80 mg 2 times a day, morning and evening, Rosuvastatin 20 mg in the evening, Spironolactone 50 mg in the morning, Acetylsalicylic acid 75 mg in the evening, Nifedipine 40 mg, Torasemide 50 mg in the morning in a day, Metformin 500 mg 2 times a day, Aminophylline 2 % - 5.0 intravenously jet-like 2 times a day + Dexamethasone 8 mg + saline intravenously drip-like, Salmeterol 100 ^g + Fluticasone 500 ^g 2 times a day, Ipratropium bromide 40 ^g + Fenoterol
hydrobromide 100 ^g in case of threat of respiratory failure, Tiotropium bromide 22.5 ^g once a day, soda 4 % - 200.0 intravenously drip-like.
RECOMMENDED REDUCED DRUG TREATMENT
Lisinopril 10 mg 2 times a day, Nebivolol 5 mg under the control of blood pressure and pulse, Nitrates as needed, Rivaroxaban 10 mg once a day, Rosuvastatin 10 mg once a day, Metformin 500 mg 2 times a day, Salbutamol
2 inhalations as needed, Salmeterol 25 ^g 2 times a day.
CONCLUSIONS
Multimorbidity and polypharmacy take place in the clinical case. The solution of the problem is not simple, but the doctor should always monitor the prescribed combinations of drugs in order to minimize their number and choose the most suitable combination to get the best result with the least risk of side effects.
REFERENCES
1. Cardiovascular multimorbidity, emerging coalescence of the integrated panvascular approach [Electronic resource] / [P. Lanzer, H. Zühlke, P. Jehle et al.] // Z Kardiol. - 2004. - Access to resource: http://doi.org/10.1007/s00392-004-0062-8.
2. Multimorbidity and risk among patients with established cardiovascular disease: A cohort study [Electronic resource] / [L. G. Glynn, B. Buckley, D. Reddan, J. Newell, J. Hinde, S. F. Dinneen, et al.] // Br J Gen Pract. - 2008. - Access to resource: http://doi.org/10.3399/bjgp08X319459.
3. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany [Electronic resource] / [H. van den Bussche, D. Koller, T. Kolonko et al.] // BMC Public Health. - 2011. - Access to resource: http://doi.org/10.1186/1471-2458-11-101.
4. Vascular multimorbidity in patients with a documented coronary artery disease [Electronic resource] / [P. Lanzer] // Z Kardiol. - 2003. - Access to resource: http://doi.org/10.1007/s00392-003-0954-z.
5. Diagnosis and choice of the management strategy in patient with cardiac resynchronization therapy in case of chronic heart failure with multimorbidity / D. G. Drokin, I. V. Shanina, D. E. Volkov, A. O. Parfonova, N. V. Lysenko // The Journal of V. N. Karazin Kharkiv National University. Series: Medicine. - 2013. -№ 1090, Issue 26. - P. 61-65.
6. Clinical case of persistent atrial flutter in patient with comorbid pathology / O. V. Gavrilyuk, Y. Y. Boeva, I. Ch. Anyasi, M. S. Maltseva, D. E. Volkov // The Journal of V. N. Karazin Kharkiv National University. Series: Medicine. - 2013. - № 1090, Issue 26. - P. 66-70.
7. Comorbidity study on type 2 diabetes mellitus using data minind / J. Korean, H. S. Kim, A. M. Shin [et al.] // Intern. Med. - 2012. - № 27 (2). - P. 197-202.
