Scientific advisers: ass. prof. T. A. Derienko, prof. M. I. YabluchanskyClinical case

Ajewole, O. Michael

Aroyewun, O. Taofeek

Eran, Ammar

Central Scientific Library

Medical Support of the Cardiovascular and Metabolic Diseased Patient with Cardiac Pacemaker at the Annual Stage of Observation

Електронного архіву Харківського національного університету імені В.Н.Каразіна (Electronic Archive V.N. Karazin Kharkiv National University)

V. N. KARAZIN KHARKIV NATIONAL UNIVERSITYINTERNAL MEDICINE DEPARTMENTSpeaker: Eran Ammar BA-504Aroyewun Opeyemi Taofeek BA-510Ajewole Olamide Michael  BA-510 Medical support of the cardiovascular and metabolic diseased patient with cardiac pacemaker at the annual stage of observationScientific advisers: ass. prof. Derienko T.A.Head of department: prof. Yabluchansky M. I.INTRODUCTION • The proportion of cardiovascular disease (CVD) in the structure of mortality is about 56% of all cases, of which almost 90% of cases take death from coronary heart disease (CHD)• Hypertension is often associated with CHD as a major cause of left ventricular hypertrophy and diffuse myocardiosclerosis -remodeling of the heart muscle, which in turn contributes to different, sometimes fatal, arrhythmias and conduction disorders of the heart.• Obesity - the most common metabolic disease, which is one of the important risk factor of developing CVD.• Implantation of a permanent pacemaker is effective method of treatment resistant to medical therapy life-threatening cardiac arrhythmias and bradysystiolic arrhythmia, however, it does not eliminate the problem of support. AH is one of the most important clinical syndromes requiring therapeutic support. • AV-block is the most common indication for the implantation of pacemakerT. Derienko CLINICAL FEATURES OF PATIENTS WITH PERMANENT PACEMAKERS DEPENDING ON THE STAGE OF ARTERIAL HYPERTENSION/T. Derienko, D. Volkov// The Journal of V. N. Karazin Kharkiv National University, series "Medicine. -2015. - №30- p.5-8OUR PATIENT• Male• Age:55 y.o.• Factory Worker• Townsman• Admitted to our polyclinic 10/12/2016COMPLAINTS• Dyspnea, during physical activity, absent at rest• Fatigue• Chest pain, behind the breastbone during physical activity(400m)MEDICAL HISTORY 1.1• 1978 – myocarditis(not confirmed by medical records), then diagnosed full right bundle branch block.• 2011 – hypertension (max 170/100 mmHg, usual BP 140/90 mmHg(with drugs))• 2011 – chest pain behind the breastbone during ordinary  physical activity absent at rest (refused to do coronary angiography)• 2011 – during stress test first diagnosed transient atrioventricularblock stage 2  Mobitz II• 2014 – atherosclerosis of coronary arteries• Sinse 2014 diagnosis: IHD:STABLE ANGINA.AH II STAGE, 2 DEGREE. FULL RBBB. TRANSIENT AV BLOCK STAGE 2, MOBITZ 2. HF I.• 2005 - peptic ulcer disease and GERDMEDICAL HISTORY 1.2STRESS TEST ECG X/X/2011Conclusion:transient AV block stage 2 Mobiz 2MEDICAL HISTORY 1.3CORONARY ANGIOGRAPHY 17/04/2014Conclusion:Right descending artery atherosclerosis 20-30%, atherosclerotic plaque mouth diagonal artery 40%, atherosclerotic lesions of the circumflex artery and the right coronary artery 20-30%MEDICAL HISTORY 2.226/10/2015 – during usual physical activity felt dizziness, weakness, tinnitus, nausea, loss of consciousness was not noted, on the ECG recorded complete atrioventricular block.Conclusion: rhytm regular, heart rate 35bpm , signs of left ventricularhypertrophy, full RBBB,  transient AV-block 3 degree.INDICATIONS FOR THE IMPLANTATION OF CARDIAC PACEMAKER Class I1. Third-degree AV block at any anatomic level associated with any one of the following conditions: a. Bradycardia with symptoms presumed to be due to AV block. (Level of evidence: C)b. Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia. (Level of evidence: C)c. Documented periods of asystole ≥3.0 seconds or any escape rate <40 beats per minute (bpm) in awake, symptom-free patients. (Level of evidence: B, C)d. After catheter ablation of the AV junction. (Level of evidence: B, C) There are no trials to assess outcome without pacing, and pacing is virtually always planned in this situation unless the operative procedure is AV junction modification. e. Postoperative AV block that is not expected to resolve. (Level of evidence: C)f. Neuromuscular diseases with AV block such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb’s dystrophy (limb-girdle), and peroneal muscular atrophy. (Level of evidence: B)2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy/ [M. Brignole, A. Auricchio, B. Gonzalo et.al.]. // European Heart Journal. – 2013..MEDICAL HISTORY 2.327/10/15 – ESPRITE DDR (Dual Chamber Ventricular  pacemaker), mode of stimulation DDD:• HR-60bpm, stimulation threshold-0,75V, impedance-350OmConclusion: sinus rhythm, regular, heart rate 76bpm , full RBBB, signs of left ventricular hypertrophyPATIENT’S MEDICAL TREATMENT FOR THE LAST YEAR• Perindopril 4 mg• Amlodipin 5 mg• Atorvastatin 40 mg• Aspirin 75 mgLIFE/SOCIAL HISTORY• Married• Smoking History: 15 Pack years (1/2 pack for 30 years)(quit smoking two years ago)• Father died from ventricular rupture. • Mother died from stroke secondary to Long standing hypertensionOBJECTIVE SUBJECT 1.2.• The general condition is satisfactory, consciousness is clear, emotionally stable, optimistic mood• Hypersthenic, Height = 176 cm, Weight = 115 kg, BMI= 37.1 (Obese)• Skin, visible mucous membranes are pale pink andclean• Peripheral lymph nodes are not palpable• The thyroid is not palpable • Signs of eyelid retraction, periorbital edema, proptosis are absentOBJECTIVE SUBJECT 2.2. Respiratory System:• pulmonary percussion –normal• auscultation - weakened vesicular breathing, no adventitious sounds Cardiovascular system:• heart borders extended to the left on 1,5 cm of mid clavicular line, HR =78 bpm, regular.• no pulse deficiency; heart sounds are muted Blood Pressure left hand = 145/100 mmHg (on the background of antihypertensive therapy), Blood Pressure of right hand = 140/90 mmHg Gastrointestinal system:• abdomen is soft, painless, symmetrical, no discrepancies of the abdominal muscles, no visible peristalsis• liver edge is smooth, painless , palpated 0.5 cm below the costal archspleen and pancreas are not palpablePRESCRIBED EXAMINATIONS Complete blood test General urine test Biochemical blood test  Liver function test (ALT, AST, AP) Blood lipid spectrum ECG EchocardiogramCOMPLETE BLOOD COUNT 10/12/2016INDEX RESULT NORMALErythrocyte 4.23 3.9-4.7Hematocrit 41.1% 36-42%Hemoglobin 135 g/l 120-140g/lThrombocyte 313 g/l 160-320 g/lLeukocyte 7.7 g/l 4-9.0 g/lLymphocyte 22% 19-37%ESR 3 mm/hr 2-15 mm/hrConclusion: normalURINALYSIS 10/12/2016INDEX RESULT NORMALSpecific Gravity 1.011 1.000 – 1.030Glucose Negative NegativeProtein Negative NegativeLeucocyte 4.7 0-5 WBC/hpfConclusion: normalBIOCHEMICAL BLOOD TEST 10/12/2016INDEX RESULT NORMALBilirubin 15.6 μmol/l 2-20 μmol/lCreatinine 113 μmol/l 60-123 μmol/lUrea 6 μmol/l 2.5-7 μmol/lBlood Sugar 5.8 μmol/l ≤ 6.1 μmol/lAST 30 8-38 U/LALT 38 8-40 U/LConclusion: normalBLOOD LIPID SPECTRUM10/12/2016INDEX RESULT NORMALCholesterol 4.65 < 5.2 mmol/lVLDL 0.6120 < 1.0 mmol/lLDL 2.9680 < 3.5 mmol/lHDL 1.07 > 0.9 mmol/lTriglycerides 1.36 ≤ 2.3 mmol/lConclusion: normalECHOCARDIOGRAPHY 1.1INDEX RESULT NORMALAorta 36.0 20-37mmAortic valve 19.0 17-26mmMitral valve 32.0 26-35mmLeft atrium 33.0mm To 38 mmEnd Diastolic velocity 100 50-180 cm/sEnd Systolic volume 50.0 35-55mmLeft Ventricular 14.1 6-11mmEjection Fraction 69% 55-78%Left Ventricule amplitude 9.9 mm 7-13mmIntraventricular septum 13.0 mm 6-11mmRight atrial diameter 34.0mm ≤45mmRight Ventricular diameter 23.0 mm 9-26mmConclusion:Atherosclerosis of aorta andaortic valves mild degree,hypertrophy of the left ventricle. Dyssynergicareas were not identified.BASIC CLINICAL SYNDROMES• Atherosclerosis (sclerotic changes of aorta and aortic valve)• Ischemia (Stable Angina)• Arterial hypertension• Conduct disorder• Heart failure• Obesity• Duodenum Ulcer (2005)THE CLINICAL DIAGNOSISACCORDINGTO CURRENT CLASSIFICATIONSCLASSIFICATION OF CHD(ON THE RECOMMENDATIONS OF THE EUROPEAN SOCIETY OF CARDIOLOGY ESC, 2013)2. Angina2.1.1. Stable angina (indicating the functional classes (FC).2.1.2. Stable angina with angiographically intact vessels (coronary syndrome X).2.2. Vazospastichna angina (angiospastic, spontaneous, variant, Printsmetalla).2.3 Mixed angina2.4 Unstable angina (up to 28 days)2.4.1. Angina, which appeared for the first time to 28 days (angina that occurred for the first time, with transient ECG changes - rest).2.4.2. Progressive angina (angina at rest or the appearance of night attacks in a patient with angina pectoris, angina change, progressive decrease in exercisetolerance, transient ECG changes - rest).2.3.3. Early post-infarction angina (from 3 to 28 days).CLASSIFICATION OF HYPERTENSION ACCORDING TO THE LEVEL OF BLOOD PRESSURE(RECOMMENDATIONS BY THE UKRAINIAN ASSOCIATION OF CARDIOLOGISTS PREVENTION ANDTREATMENT OF HYPERTENSION, 2008)DiastolicSystolicCategory<80and<120Optimal80-84and/or120-129Normal85-89and/or130-139High normal90-99and/or140-159Grade 1 hypertension100-109and/or160-179Grade 2 hypertension>110and/or>180Grade 3 hypertension<90or>140Isolated systolic hypertensionhttp://emedicine.medscape.com/article/241381-overviewCLASSIFICATION OF HYPERTENSION STAGES (RECOMMENDATIONS OF THE ASSOCIATION OF CARDIOLOGISTS OF UKRAINE 2008)Stage The degree of target organ damageI Objective changes in the target organs are absentII There is objective evidence of target organ damage without symptoms with their hand or dysfunction:Left ventricular hypertrophy (on ECG, ultrasound, Ro)Generalized narrowing of retinal arteries Microalbuminuria and / or a small increasein serum creatinine (y m. - 115 - 133 mmol / L at x. -107 - 124 mmol / l) Carotid artery disease - a thickening of the intima-media> 0.9 mm or the presence of atherosclerotic plaques.III There is objective evidence of target organ damage with symptoms from their side and impaired heart - myocardial infarction, heart failure II A - III stage;brain - stroke, transient ischemic attack, acute hypertensive encephalopathy,vascular dementia; fundus - hemorrhage and retinal exudates with papilledema the optic nerve or without;kidney - concentration of plasma creatinine in males> 133 umol / L, y Women> 124;vessels - dissecting aortic aneurysm; peripheral arterial occlusionhttp://www.mif-ua.com/education/symposium/arterialnaya-gipertenziya-v-2014-g-klassifikacii-diagnostika-lechenie#test_endHYPERTENSION RISK FACTORS http://www.brainandspine.com.hk/en/stroke/stroke-in-depthCARDIOVASCULAR RISK STRATIFICATION CHART WITH RECOMMENDED FOLLOW-UP FREQUENCY FOR EACH CATEGORY2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration withEACTSTHE NEW YORK HEART ASSOCIATION (NYHA)FUNCTIONAL CLASSIFICATION (FUNCTIONAL CAPACITY)OF CHRONIC HEART FAILUREhttp://www.intechopen.com/books/primary-care-in-practice-integration-is-needed/integrated-care-for-heart-failure-in-primary-careAMERICAN HEART ASSOCIATIONHEART FAILURE STAGESClass Objective AssessmentA No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.B Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).C Objective evidence of moderately severe cardiovascular disease. Markedlimitation in activity due to symptoms, even during less-than-ordinary activity.Comfortable only at rest.D Objective evidence of severe cardiovascular disease. Severe limitations.Experiences symptoms even while at rest.http://www.sunshineheart.com/patients/classification-of-heart-failureDEFINITION OF HEART FAILURE WITH PRESERVED (HFPEF),MID-RANGE (HFMREF) AND REDUCED EJECTION FRACTION (HFREF)2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failureCLASSIFICATION OF OVERWEIGHT AND OBESITY BMI CLASSIFICATIONClassification BMI Category(kg/m2)Risk of developinghealth problemsUnderweight <18.5 IncreasedNormal Weight 18.5 - 24.9 LeastOverweight 25.0 - 29.9 IncreasedObese class I 30.0 - 34.9 HighObese class II 35.0 - 39.9 Very highObese class III >= 40.0 Extremely highhttp://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/bmi_chart_java-graph_imc_java-eng.phpCOMPLETE MAIN DIAGNOSIS OF OUR PATIENT Ischemic heart disease Stable angina, II FC Essential arterial hypertension II stage, 2 degree, hypertensive heart (LVH) Full RBBB Full AV-block Condition after the implantation of cardiac pacemaker ESPRIT DR, mode of stimulation DDD Heart failure with preserved ejection fraction, II FC, stage BCO-MORBIDITY OF OUR PATIENT Obesity II class Peptic ulcer disease and GERDTREATMENTLIFESTYLE MODIFICATION Intensive weight reduction DASH diet Control of compliance to medical recommendationsPHARMACOLOGICAL TREATMENT IN STABLE FORMS OF IHDhttp://eurheartj.oxfordjournals.org/content/ehj/34/38/2949.full.pdfSUMMARY OF RECOMMENDATIONS AND TREATMENT STRATEGIES IN PATIENTS WITH AH2013 ESH/ESC Guidelines for themanagement of arterial hypertensionSUMMARY OF RECOMMENDATIONS ON THERAPEUTIC STRATEGIES IN HYPERTENSIVE PATIENTS WITH HEARTDISEASE2013 ESH/ESC Guidelines for themanagement of arterial hypertensionRECOMMENDATIONS FOR TREATMENT OF PATIENTS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTIONhttp://eurheartj.oxfordjournals.org/content/37/27/2129OUR RECOMMENDED TREATMENT Β-blocker: bisoprolol 5 mg in the morning ACE-inhibitor: enalapril 5 mg in the evening Statin: rosuvastatin 20 mg in the eveningPROGNOSIS▶ Prognosis for life - non-compliance to doctor's appointments – non-satisfactory▶ The prognosis for recovery – an unfavorableCONCLUSIONS Cardiac pacing in the presence of possible solutions to the problem of arrhythmias and HF it does not cancel, but modifies the medical support of patients Reliability and quality of modern devices that are based on science and technology, gives confidence to physicians and patients that the number of people who live fully life with pacemaker (ECS) will continue to grow up.Ponomarenko V. B. Results of treatment in patients with atrioventricular blockade (retrospective data analysis)/V. B. Ponomarenko. Vestnik Arrhythmology. -2001. -№ 22. -P. 5-12

http://dspace.univer.kharkov.ua/bitstream/123456789/12703/2/Klin_razbor_terapia_Cardiovascular_and_Metabolic_Diseased_Patient_with_Cardiac_Pacemaker%20.pdf

Medical Support of the Cardiovascular and Metabolic Diseased Patient with Cardiac Pacemaker at the Annual Stage of Observation

Abstract

Similar works

Full text

Available Versions

Central Scientific Library

Електронного архіву Харківського національного університету імені В.Н.Каразіна (Electronic Archive V.N. Karazin Kharkiv National University)