Algorithm for the diagnosis and pharmacotherapy of arterial hypertension, chronic heart failure in patients with newly diagnosed tuberculosis and chronic obstructive pulmonary disease in the the intensive phase of tuberculosis chemotherapy

Abstract

Chronic heart failure (CHF), arterial hypertension (AH), chronic obstructive pulmonary disease (COPD) worsen the prognosis for the cure of newly diagnosed pulmonary tuberculosis (TB), including due to an increase in negative symptoms and a deterioration in the quality of life of patients in the intensive phase of TB treatment. This requires the algorithmic diagnostic actions of a doctor for the subsequent appointment of rational pharmacotherapy with a proven best outcome in the treatment of TB.Objective. To develop an algorithm for the diagnosis and pharmacotherapy of patients with hypertension, CHF and COPD in the intensive phase of chemotherapy for newly diagnosed TB in terms of the best outcome of TB cure.Design and methods. An open, prospective, randomized comparative study included 135 patients who were admitted to a tuberculosis dispensary for the treatment of newly diagnosed TB. Depending on concomitant cardiac pathology, patients were divided into 2 groups: 76 patients with TB, COPD and AH; 59 patients with TB, COPD and CHF. In patients on the background of intensive chemotherapy for newly diagnosed TB, symptoms such as shortness of breath, tachycardia, and increased blood pressure (BP) were first detected or intensified. The selection of treatment regimens was carried out with an assessment of the best tolerability and effectiveness. Duration of follow-up was 6 months with an assessment of the outcomes of TB treatment in comparison with retrospective control (a similar group according to the inclusion and exclusion criteria treated in 2018).Results. During intensive chemotherapy of newly diagnosed TB, increasing symptoms were assessed and analyzed, indicating the appearance or exacerbation of comorbid pathology: AH, CHF and COPD. Based on the results of the study, an algorithm of doctor’s actions was developed for the differential diagnosis of cardiovascular (AH and CHF) and bronchopulmonary (COPD) pathologies with recommendations for prescribing a rational combination of drugs. In patients with TB, hypertension and COPD, the best effect was obtained in reducing the average daily systolic and diastolic BP during therapy with an angiotensin II receptor antagonist and a dihydropyridine calcium antagonist with satisfactory tolerability. For patients with TB, COPD and CHF, an angiotensin-converting enzyme inhibitor (if intolerant, an angiotensin II receptor antagonist) in combination with a mineralocorticoid receptor antagonist and titration of a beta-blocker with the addition of a myocardial cytoprotector to the above therapy showed an optimal effect on the severity of CHF symptoms. These treatment regimens for 3 months led to the achievement of target indicators for BP, heart rate, exercise tolerance in the test with a 6-minute walk, and improvement in echocardiography. Continuation of treatment up to 6 months showed a significant improvement in the outcomes of TB chemotherapy, expressed in an increase in the number of people who achieved cessation of bacterial excretion and closure of decay cavities, without increasing antibiotic therapy.Conclusions. Algorithm of doctor’s diagnostic actions and prescription of rational pharmacotherapy of AH, CHF and COPD in patients with newly diagnosed pulmonary TB leads not only to improved tolerability of TB therapy, but also to the outcomes of curing newly diagnosed TB without intensifying antibiotic therapy.