EVALUATION OF THE EFFECTIVENESS OF DAPAGLIFLOZIN

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Relevance. CHF is a syndrome that develops as a result of a violation of the heart's ability to fill and/or empty, occurring in conditions of an imbalance of vasoconstrictor and vasodilating neurohormonal systems, accompanied by insufficient perfusion of organs and systems and manifested by complaints: shortness of breath, weakness, palpitations and increased fatigue and, with progression, edematous syndrome [2]. The main causes of CHF are arterial hypertension and coronary heart disease (CHD).According to epidemiological data, the prevalence of CHF in Russia for 2020 was 7% (on average 10 million people) of the general population, including clinically pronounced – 4.5%, while there is a tendency to increase the growth of patients with this pathology by 0.3% in the age group from 20 to 29 years to 70% in individuals older age [2].Every year, new drugs are being developed aimed at relieving the symptoms that occur with CHF. One of these drugs is dapagliflozin. It belongs to type 2 sodium-glucose cotransporter inhibitors with indications for the treatment of adult patients with CHF (with a low ejection fraction) with persistent symptoms of HF despite standard therapy with other drugs in order to reduce the risk of cardiovascular death and hospitalization for this reason.

Aim.To evaluate the effectiveness of the drug dapagliflozin in the treatment of chronic heart failure on the example of a clinical case.

Materials and methods. The object of the study is the medical documentation of a patient of the Orenburg city polyclinic.The research method was the analysis of the medical record, evaluation of the results of examination and treatment.

Results. Patient K., male, 67 years old, profession driver.

When examining complaints of shortness of breath during normal exercise, climbing the stairs to the 2-3 floor, there is no shortness of breath at rest, a feeling of irregular heartbeat, periodically discomfort in the heart area, heaviness behind the sternum during normal exercise, relieves rest, weakness, fatigue, headache, dizziness, instability when walking.

From anamnesis – AP does not measure, IM, ACVA denies it.

Deterioration of the condition since August 2021, when shortness of breath and swelling of the legs began to increase. In September 2021, I turned to a therapist. The therapist sent for computed tomography of the chest organs (CT OGK): convincing CT data for infiltrative changes of viral genesis in the lungs were not obtained; CT-signs of congestion in the lungs, bilateral pleurisy. Cardiomegaly.

According to the results of echocardiography (Echo-KG) atherosclerosis of the aorta, aortic valves. Dilatation of all parts of the heart. Mitral valve insufficiency of the 2nd degree. Tricuspid insufficiency of 2-3 degrees. Indefinite movement of the LV walls. Global contractility is reduced. Increased pressure in the LA (pulmonary artery).

In September 2021, for the first time, I turned to a cardiologist with complaints of irregular heartbeat, paroxysm of atrial fibrillation (AF), tachysystolic variant was registered. Taking into account the first paroxysm of AF, the patient was sent for hospitalization to the Orenburg Regional Hospital (ORH). In the conditions of the ORH, CT of the OGC was repeated, where CT signs of bilateral hydrothorax with partial compression atelectasis of the lower lobes of both lungs were detected. He received inpatient treatment, after which he was discharged for outpatient treatment with a permanent form of AF.

In October, he was consulted by a cardiologist of the SAHI "ORCH", where an Echo-KG was performed, which showed a decrease in global contractility of the left ventricle (LV).Objectively: the state of moderate severity, clear consciousness. The position is active. Oriented in space, time. The skin is clean, physiologically colored, pasty feet. Height 182 cm . Weight 72 kg. BMI is 21.7 kg/m2. Breathing through the nose, free, the number of respiratory movements is 17. In the lungs, auscultation – hard breathing. Blood pressure (BP) 90/50 mmHg. Pulse 100 beats per minute, heart rate 110. The heart tones are muted, arrhythmic. Rhythm atrial fibrillation. The boundaries of the heart are expanded in both directions. The tongue is overlaid with plaque; the pharynx is symmetrical; swallowing is preserved; the abdomen is soft, not swollen; the liver is not enlarged. Pasternatsky's symptom is negative; urination is normal. Neurological status without pathology.

The following studies were performed:

Total blood count: hemoglobin -116 g/l, erythrocytes - 5.09 x1012 l, leukocytes -7.33 x 109 l, platelets - 166 x109 l, ESR - 8 mm/h.

Biochemical analysis of the cut: ALAT - 12.3 units /l, ASAT - 20 units /l, total bilirubin - 10.1 mmol/l, creatinine - 89 mmol/l, glucose - 4.97 mmol/l.

ECG from 10/25/2021 - Atrial flutter with CHS 84-116 per minute, irregular shape, PMV 270 per minute. EOS to the left. Blockade of the anterior branch of the left leg of the Gis bundle. Focal changes of the anterior-septum region rSV2V3. Violations of the processes of repolarization of the apex, side wall.

Echo-KG from 10/25/2021 - LV: CDR 6.5 cm, CSR 5.2 cm, KDO 219 ml, CSR 133 ml, UO 86 ml, FV 39%. Atherosclerosis of the aorta, aortic valve, grade I aortic insufficiency, enlargement of the ascending aorta, enlargement of all parts of the heart, decrease in global LV contractility (LV=39%) against the background of diffuse hypokinesia of the LV walls, grade II-III mitral insufficiency, grade II tricuspid insufficiency, pulmonary hypertension (42 mmHg. art.), compaction of pericardial leaves.

Taking into account complaints, anamnesis of the disease, objective and laboratory-instrumental data, the patient was diagnosed:

CHD. Fibrillation-atrial flutter, permanent form, tachysystolic variant. The risk of thromboembolic complications according to CHA2DS2-VASc is 2 points. The risk of hemorrhagic complications according to HAS-BLED is 1 point. Class of clinical manifestations EHRA IIa. Cardiomyopathy of complex genesis, including arrhythmogenic. Atherosclerosis of the aorta, aortic valve flaps. Expansion of the ascending aorta. Aortic insufficiency of the I degree.

Background: Hypertension stage III. Controlled arterial hypertension. CKD C2 (GFR 77 ml/min/1.73 m2). Creatinine clearance according to the Cockcroft-Gault formula = 74 ml/min. Risk 4 (very high). Target BP 130-139/70-79 mmHg.

Complication: CF IIA rEF (39%) FC II (NYHA). Mitral insufficiency of II-III degree. Tricuspid insufficiency of the II degree. Pulmonary hypertension of the II clinical group (42 mmHg).

Therapy was prescribed: metoprolol succinate 50 mg lunch, 25 mg in the evening; atorvastatin 40 mg in the evening; eplerenone 50 mg in the morning; torasemide 10 mg in the morning; rivaroxaban 20; ramipril 1.25 mg in the evening; dapagliflozin 10 mg 1 time per day.During the follow-up period October 2021 – December 2022, no deterioration was observed against the background of therapy, including dapagliflozin.

In November 2022, at the next control examination, he complained of weakness, fatigue, sweating, dizziness, shortness of breath with the usual load, climbing the stairs to the 3rd floor, there is no shortness of breath at rest, palpitations, intermittent interruptions in the heart, a feeling of lack of air, discomfort in the heart area, swelling of the legs in the evening.

Objectively: the condition is satisfactory, the consciousness is clear. The position is active. Oriented in space, time. The skin is clean, there is no physiological coloration, there is no swelling. Height 182 cm . Weight 80 kg. BMI 24.2 kg/m2. Breathing through the nose, free, the number of respiratory movements is 17. There is auscultative – vesicular respiration in the lungs. The heart tones are muted, arrhythmic, the rhythm of atrial fibrillation, the boundaries of the heart are expanded in both directions. BP 110/70 mm Hg. The tongue is overlaid with plaque; the pharynx is symmetrical; swallowing is preserved; the abdomen is soft, not swollen; the liver is not enlarged. Pasternatsky's symptom is negative; urination is normal. Neurological status without pathology.

During the examination:

An electrocardiogram (ECG) from 11/28/2022 revealed an irregular form of atrial flutter, with a ventricular rate of 67-104 beats per minute, an average atrial rate of 300 beats/min, EOS deviated to the left, signs of left ventricular hypertrophy, diffuse changes in the myocardium.

Holter ECG monitoring data showed that the basic rhythm was recorded on the ECG – atrial fibrillation with a pulse rate of 52-179 beats/min in the afternoon (the average pulse rate in the afternoon was 91 beats/min – tachysystolic form) and with a heart rate of 48-142 beats/min at night (the average heart rate at night was 77 beats/min – the normosystolic form). The average CHS was 85 beats/min- tachysystolic form. The recording contained ventricular polymorphic extrasystoles (103 in total), of which 6 episodes of paired extrasystoles, 2 episodes of group extrasystoles, 1 episode of volley extrasystoles. The circadian type of extrasystole is "mixed". Pauses over 1500 msec were recorded during the entire survey period (a total of 302 pauses), of which 4 pauses over 2000 msec. The maximum pause was 2082 msec (registered at 06.47). There were no diagnostically significant changes in the terminal part of the ventricular complex in the form of depression/elevation of the ST segment. The T-wave is within the normal range.

According to EchoCG from 11/28/2022: Left ventricle: CDR 61 mm. CSR 45 mm. KDO 183 ml CSR 98 ml UO 85 ml. FV 45% (according to Simpson). Atherosclerosis of the aorta, AK, the structure of the valves of the MK, TK. Severe insufficiency of the MK. Moderate insufficiency of TC. Global LV systolic function is reduced. Eccentric LV hypertrophy with signs of moderate dilatation. Pronounced dilatation of the left atrium, pronounced dilatation of the right atrium. Hypo-, akinesia of these segments. Aortic regurgitation (under the flaps). Mitral regurgitation III st. tricuspid regurgitation II st. pulmonary regurgitation I st.

The 6-minute walk test showed results of 362 m – II FC

Discussion. The therapy performed in the period from October 2021 to November 2022 showed positive results. During this follow-up period, the patient had no worsening of the clinical symptoms of heart failure, the condition remained satisfactory. When performing EchoCG in dynamics, it was noted that LV contractility improved, which is expressed in a decrease in LV volume and an increase in the ejection fraction from 39% when prescribing therapy to 45%.

Conclusion. CHF is the "finale" of cardiovascular diseases. If earlier patients with CHF had an unfavorable outcome, now with proper therapy it is possible to improve the life and condition of patients.This clinical example shows that the addition of dapagliflozin to the standard therapy for the treatment of CHF rEF FC II showed a positive effect associated with an improvement in clinical symptoms and quality of life.

About the authors

Loyman Mehman-ogly Allakhverdiev

Author for correspondence.
Email: loy25od@yandex.ru
ORCID iD: 0000-0002-8689-1128
Russian Federation, 460000, Russia, Orenburg, Sovetskaya st., 6

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