A young patient burdened with many diseases with a very high cardiovascular risk; a therapeutic challenge not only for the doctor

Abstract

A 39-year-old patient with hypertension and a 28-year history of type 1 diabetes with numerous complications in the form of microangiopathy and macroangiopathy was admitted to the Cardiology Clinic due to recurrent angina pectoris accompanied by the intensification of ischemic electrocardiographic (ECG) changes and symptoms of heart failure. In addition, a history of hyperlipidemia, chronic kidney disease, Graves’ disease at euthyroid stage. On admission, the patient hemodynamically stable, arterial pressure — 129/75 mm Hg, regular heart rate, without signs of losses in the pulmonary circulation, visible swelling of the lower limbs and trophic changes on the lower shink. In laboratory tests, mildly impaired renal function (glomerular filtration 56 ml/min), high blood glucose values (up to 350 mg/dL), glycated hemoglobin 8.7%, hypercholesterolemia. The echocardiographic study showed a worsening of the left ventricular systolic function compared to the previous assessment — a decrease in ejection fraction from 46 to 35%, on ECG — left anterior hemiblock, features of past and anterior wall infarction. During hospitalization, the therapy of coronary heart disease, hypertension (ramipril, bisoprolol, spironolactone, and furosemide), diabetes (insulin initially used at a variable flow pump, followed by intensive insulin therapy and hyperlipidemia was modified), obtaining satisfactory results in relation to the initial ones. Extended release nitrates were included, and antiplatelet treatment with ticagrelor was continued. Due to elevated cholesterol, the dose of atorvastatin was increased. In case of therapy failure, the PCSK9 inhibitor (evolucumab) and family diagnosis of hypercholesterolemia were considered. Despite the treatment, angina ailments increased, the ECG performed during the pain revealed ischemic lesions. By decision of the Heart Team, the patient was qualified for accelerated surgery for myocardial revascularization.