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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 140-143

A case study on geriatric patient with coronary artery disease-associated diabetic foot ulcer: A clinical pharmacist management care


1 Department of Pharmacy Practice, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India
2 Department of Pharmaceutics, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India
3 Department of Cardiology, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India
4 Department of Cardiology, Gleneagles Global Health City, Kancheepuram, Tamil Nadu, India

Date of Submission02-Aug-2019
Date of Decision20-Jan-2020
Date of Acceptance28-Jan-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. M S Umashankar
Department of Pharmaceutics, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur - 603 203, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_117_19

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  Abstract 


A 66-year-old male patient was presented to the cardiology ward with complaints of chest pain for couple of days, breathlessness, sweating, and cough. He had complaints of loss of sensation over foot. He had past medical history of type 2 diabetes mellitus with hypertension. He had a history of ulcer with right big toe gangrene and trauma to right big toe before 20 days. Following with this condition, he developed a small ulcer. He has previous history of wound debridement. His echocardiogram detected moderate left ventricular systolic function and left ventricular ejection fraction was 38% which confirmed the presence of coronary artery disease. He underwent coronary angiogram which showed the presence of calcific coronary artery disease with triple vessel disease. The patient was diagnosed with diabetic foot ulcer with coronary artery disease. He was continuously monitored for a week and prescribed with medications. The patient was found stable and he was discharged from the hospital with advise of scheduled Physician's follow-up. The patient was forwarded to a clinical pharmacist counseling services for medication usage, foot care, wound care, lifestyle modifications' advices, physical exercise, stress management strict medication adherence, dietary intake suggestions, and disease-based information to alleviate the progress of disease complications. The medications advice by clinical pharmacist services in such complex disease association management is an imperative need in clinical practice. The clinical pharmacist intervention was proved to be an implementation to effective therapeutic outcomes in the patient.

Keywords: Clinical pharmacist counseling services, coronary artery disease, diabetic foot ulcer, hypertension


How to cite this article:
Kumar A B, Umashankar M S, Sriram V, Kumar G B. A case study on geriatric patient with coronary artery disease-associated diabetic foot ulcer: A clinical pharmacist management care. J Datta Meghe Inst Med Sci Univ 2020;15:140-3

How to cite this URL:
Kumar A B, Umashankar M S, Sriram V, Kumar G B. A case study on geriatric patient with coronary artery disease-associated diabetic foot ulcer: A clinical pharmacist management care. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 31];15:140-3. Available from: http://www.journaldmims.com/text.asp?2020/15/1/140/297962




  Introduction Top


The diabetes mellitus prevalence is steadily increasing worldwide. The international diabetes federation estimated that diabetic incidence may even rise to 592 million by the year 2035. World diabetes  Atlas More Details predict around 51 million population got affected with diabetes mellitus in India. The study exhibited that the urban population had poor knowledge on diabetes mellitus as compared to rural population. The International diabetes federation had predicted that the Indian population around 74 million was affected with diabetes in comparison with other countries in the world.[1] The uncontrolled levels of type 2 diabetes mellitus drastically increase the progression of diabetic complications such as retinopathy, renal failure, neuropathy, foot ulcer and amputations, cerebrovascular disease, and also rising the higher incidences of mortality due to coronary artery diseases. Diabetic foot ulcer is allied with formation of ulcer in the foot with neuropathy symptoms with different grades of infection. It shows a long-term complication of diabetes mellitus, which leads to leg amputations and further reduces the health status of the individual patients. The presence of neuropathy, trauma, deformity, hyperglycemia, high plantar pressures, peripheral arterial disease, and poor ischemic levels reduce the defense mechanism which increases the risk of occurring diabetic foot ulcer. The diabetic foot ulcer patients were represented with potential risk of infection, ulceration, destruction of deep tissues, and neuropathic abnormalities in the lower limb.[2] Coronary artery disease is a chronic burden of the cardiovascular disease which needs long-term treatment care for effective management of the disease complications among diabetic patients. Diabetes mellitus can increase two–four folds of coronary artery disease risk. The effective prescribing of statins and oral hypoglycemic agents is the practice of treatment for the coronary artery disease among the diabetic patients. The altered lifestyle practices increase the alarming incidences of coronary artery disease burden among diabetic patients. The well-known triggering factors such as smoking, dyslipidemia, obesity, diabetes, and hypertension can greatly influence the development of cardiovascular diseases. Henceforth effective diagnostic strategies and treatment options is to be thrived for a better management of cardiovascular complications among diabetic foot ulcer affected patients.[3]


  Case Report Top


A 66-year-old male was presented with chest pain, breathlessness, sweating and cough with complaints of numbness in his left foot.

Family history

His family history showed that his father and mother both were diabetics and suffered with coronary artery disease, and father had died with coronary artery disease.

Personal and social history

He is professionally a car driver with usual habit of smoking periodically around5–8 cigarettes per day since 10 years. He regularly eats meat, sea foods, and pickles.

Past medical history

He had previous medical history of type 2 diabetes mellitus with hypertension. He had a history of ulcer with right big toe gangrene and trauma to right big toe before 20 days. Following with this condition, he developed a foot ulcer. He also had previous history of wound debridement.

Past medication history

He takes drugs of antidiabetic medications, antihyperlipidemic drugs, antihypertensives, diuretics, neuropathic drugs, antibiotics, antiplatelets, and proton pump inhibitors.

Diagnosis

The patient's clinical and laboratory test characteristics demonstrated that he was suffering with diabetic foot ulcer and coronary artery disease.

General examination reports

The patient was conscious, oriented, and afebrile, with heart rate of 80 bpm. His blood pressure was 150/90 mmHg; the cardiovascular sounds S1 and S2 were normal and respiratory sounds (B/L AE) were normal. His ankle brachial index was 0.85 which detected mild peripheral artery disease. His electrocardiogram demonstrated sinus arrhythmia, depressed ST segment in L1, LII, and LIII. The echocardiogram of the patient confirmed the presence of coronary artery disease, moderate left ventricular systolic function, mild dilated left ventricle, left ventricular ejection fraction of 38% with left ventricular grade III. He underwent coronary angiogram which showed the presence of calcific coronary artery disease with triple-vessel disease.

Hematology laboratory examinations exhibited hemoglobin 13.2 g/dl, packed cell volume 39%, white blood cells 8360/cum, neutrophils 81%, eosinophils 5%, basophils 1%, lymphocytes 9%, monocytes 36%, red blood cells 4.7 × 106/mm3, erythrocyte sedimentation rate 41/h, mean corpuscular volume 87 fl, mean corpuscular hemoglobin 32 pg/cell, mean corpuscular hemoglobin concentration 38 g/dl, and platelets 189,000 cells/cum. Serum electrolyte value as follows Na+ =135 meq/L (Hyponatremia), K+ =3.6 meq/L. cl− =93 meq/L and HCO3= 21 meq/L. Blood sugar test showed fasting blood sugar 210 mg/dl, post prandial blood sugar level 309 mg/dl, HbA1c 6.6 (%), and eAG 143 (mg/dl).

Liver function test report showed alkaline phosphatase 51 IU/L, total bilirubin 0.3 mg/dl, direct bilirubin 0.4 mg/dl, albumin 1.9 g/dl, globulin 0.9 g/dl, total protein 4.3 g/dl, Gamma-glutamyl transferase: 32, aspartate aminotransferase: 15 U/L, and alanine aminotransferase: 21 U/L. Renal function test revealed serum creatinine 1.0 mg/dl, serum urea 16 mg/dl, blood urea nitrogen 11 mg/dl, and uric acid 8.3 mg/dl. His cardiac enzyme test showed creatine kinase 71 U/L and creatine kinase–MB 18 IU/L. His serum cholesterol was 142 mg/dl, high-density lipoprotein was 43 mg/ dl, serum triglyceride was 97 mg/dl, very low-density lipoprotein cholesterol was 29 mg/dl and low-density lipoprotein cholesterol was 114 mg/dl etc.

Medications

He was found asymptomatic and treated with oral hypoglycemic agents, anti hypertensives, proton pump inhibitors, diuretic drugs, antibiotics, antiplatelets, and statins, and the details were summarized in [Table 1]. He was discharged after a week stay in the hospital with continuous treatment monitoring by the healthcare team. The patient was advised to attend clinical pharmacist counseling sessions on medication usage, medication compliance, lifestyle modifications advices, physical exercise, stress management and dietary intake suggestions and disease-based information to reduce the cardiovascular complications promoting diabetic foot ulcer patients.
Table 1: Patient Medications Chart

Click here to view



  Discussion Top


Atherosclerosis is more common in diabetic patients, and its burden negatively impacts the health of affected population. The aggregation of lipid lesions in the vascular path can contribute the advancement of cardiovascular disease events such as heart failure and myocardial infarction. The hyperglycemia, hyperlipidemia, smoking, and excessive pressure in the blood stream can alter the functioning of the vascular cells. The injury to the endothelial cells causes decrease in the release of endothelial nitric oxide synthase, which leads to vasoconstriction in the blood vessels. Hypercholesterolemia increases superoxide free radicals production in the vessels which causes the release of inflammatory cells such as IL-1β and TNF, interferon-gamma inhibits the matrix synthesis which causes proliferation of smooth muscles in blood vessels leads to formation of plaques and ultimately increase the risk of coronary artery disease. Previous studies suggested that regular cardiovascular disease and diabetic screening test can identify the future risk of cardiovascular abnormalities. American college of cardiology strongly recommends that the coronary artery disease screening test should be performed to summarize the risk profile characteristics of the diseased patients as an event of health care.

The pathological association between diabetes mellitus and cardiovascular disease is multifactorial which includes abnormal molecular mechanisms causing insulin resistance and hyperglycemia which ensues cardiovascular complications. The formation of atheromatous plaque-associated hardening of coronary artery with common mechanism of endothelial cell injury, smooth muscle cell proliferation, inflammatory reactivity, and plaque deposition leads to development of coronary artery disease.

The hyperglycemia levels are associated with various biochemical mechanisms which lead to converts the nicotinamide adenine dinucleotide to nicotinamide adenine dinucleotide hydrogen by cellular oxidation and form the uridine diphosphate Nacetyl glucosamine and increase the risk of metabolic abnormalities in the body. The glycosylation of proteins in the arterial wall of the heart is responsible for the development of atherosclerotic cardiovascular diseases in diabetes mellitus.[4] Diabetic foot ulcer pathogenesis is associated with multiple etiological factors. Higher glycemic levels results in the development of more oxidative stress on nerve cells are responsible for the occurrence of neuropathic problems. Hyperglycaemia and dyslipidaemia activates advanced glycation end product and polyol pathways and lowers the nerve function and thickening of hyalinization of the walls of small blood vessels causes impairment of endothelial dysfunction and reduces blood supply to the nerve cells increase the risk of nerve problems. These cellular changes show motor, autonomic, and sensory components of neuropathic diabetic foot ulcers. The persistent hyperglycemia alters the functions of the endothelial cells and increase the thromboxane A2 levels leads to vasoconstriction in the blood vessels that can enhance the risk of plasma hypercoagulability.

The injury to motor neurons in the foot muscles imbalance foot movements that can increase the risk of diabetic foot ulcer. The lower levels of blood supply to the wounds can increase the risk of chronic foot ulcers. The changes in the immune system reduce the wound healing. The increased levels of T lymphocytes and cellular apoptosis mechanisms can lower the wound-healing rate and induces the risk of diabetic foot ulcers. A study by Miteku Andualem Limenih et al. demonstrated that early recommendation of foot ulcer preventive measures and regular patient follow-up care services and patient education about foot ulcer management practices can decrease the incidences of foot ulcer.[5],[6] The proper foot care, maintaining controlled glycemic levels, dressing of wounds, foot surgery, and antibiotic therapy can reduce the mortality and also reduce progress of risk of foot infections in diabetic patients. Regular health screening pr ogrammes can be initiated at hospitals by the health care team to identify the patients with high a risk of diabetic foot infections and to prevent them from diabetic foot ulcer complications among coronary artery disease patients. Eating low fatty foods, adherence to diabetic diet with antidiabetic mediations and maintaining controlled levels of blood sugar, lipid, and blood pressure can help in the prevention of coronary artery disease complications with diabetes.[7] The prevention of diabetic foot ulcer through early initiation of clinical pharmacist interventions on lifestyle modifications, medication adherence and dietary intake and healthcare team-based effective treatment modalities can reduce the lower-extremity amputations and improves the ulcer healing duration. Educating the patients about routine monitoring of foot hygiene, proper wearing of footwear, and early treatment options can reduce the development of wound infections.[8]


  Conclusion Top


Diabetes mellitus is a complex endocrine disorder which is characterized by persistent glycemic levels associated with various macrovascular and microvascular complications. Diabetic foot ulcer is a complication of diabetes mellitus and seems to affect both groups of patients equally. Early assessment of risk factors, clinical features of the diseased patients, understating the etiopathogenesis of the coronary artery disease, novel cardiovascular diagnostic tools, and therapeutic approaches can pave the way for better management of coronary artery disease among diabetic foot ulcer patients.[9]

The effective glycemic control, lipid control and blood pressure levels and forceful treatment of coronary artery disease risk reduction strategies can improve the therapeutic outcomes among diabetic foot ulcer patients. Quick amalgamation of preventive measures and foot care and physical examination of the foot by the podiatrist are recommended to the diabetic patients and to stop the progress of further infections. Reinforcement of newer treatment guidelines by the physician and successful implementation of clinical pharmacist services in the clinical practice can lower the risk incidences of diabetic foot infections and also the healthcare cost among coronary artery disease patients.[10] Early amalgamation of clinical pharmacist interventions with the health care team on lifestyle changes such as medication adherence, eating low fat foods, physical exercises, and termination of smoking and alcohol practices, stress management can ultimately improve the health outcomes of coronary artery disease associated with diabetic complications.

Acknowledgment

We thank Dr. K.S. Lakshmi, Dean, SRM College of Pharmacy, SRM Institute of Science and Technology, for her encouragement and support.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014;371:818-27.  Back to cited text no. 1
    
2.
Prabhakaran D, Jeemon P, Roy A. Cardiovascular diseases in India: Current epidemiology and future directions. Circulation 2016;133:1605-20.  Back to cited text no. 2
    
3.
Lipsky BA, Berendt AR. Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes Metab Res Rev 2000;16:42-6.  Back to cited text no. 3
    
4.
Vaidya V, Gangan N, Sheehan J. Impact of cardiovascular complications among patients with Type 2 diabetes mellitus: A systematic review. Expert Rev Pharmacoecon Outcomes Res 2015;15:487-97.  Back to cited text no. 4
    
5.
Mariam TG, Alemayehu A, Tesfaye E, Mequannt W, Temesgen K, Yetwale F, et al. Prevalence of diabetic foot ulcer and associated factors among adult diabetic patients who attend the diabetic follow-up clinic at the university of Gondar referral hospital, North West Ethiopia, 2016: Institutional-Based Cross-Sectional Study. J Diabetes Res 2017;2017:2879249.  Back to cited text no. 5
    
6.
Deepa R, Arvind K, Mohan V. Diabetes and risk factors for coronary artery disease. Curr Sci 2002;83:1497-505.  Back to cited text no. 6
    
7.
Gjelsvik B, Tran AT, Berg TJ, Bakke Š, Mdala I, Nøkleby K, et al. Exploring the relationship between coronary heart disease and type 2 diabetes: A crosssectional study of secondary prevention among diabetes patients. BJGP Open 2019;3:1-11.  Back to cited text no. 7
    
8.
Omboni S, Caserini M. Effectiveness of pharmacist's intervention in the management of cardiovascular diseases. Open Heart 2018;5:e000687.  Back to cited text no. 8
    
9.
Swieczkowski D, Merks P, Gruchala M, Jaguszewski MJ. The role of the pharmacist in the care of patients with cardiovascular diseases. Kardiol Pol 2016;74:1319-26.  Back to cited text no. 9
    
10.
Porselvi A, Uma Shankar MS, Lakshmi KS, Bharath Kumar A. Comprehensive review on diabetic foot ulcer – A brief guide to pharmacists. In J Chem Tech Res 2017;10:843-51.  Back to cited text no. 10
    



 
 
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