Clinical Case Analysis: Type II Diabetes, Hypertension, and COPD

Patient Overview and Lab Results

M.K. is a 45-year-old female with a history of Type II diabetes mellitus and primary hypertension. In addition, she is overweight and maintains a poor diet. The patient has been smoking for the past 22 years and has recently been diagnosed with chronic bronchitis. Current symptoms include a chronic cough that tends to be more severe in the mornings and productive with sputum, light-headedness, distended neck veins, excessive peripheral edema, and increased urination at night. M.K. is currently on several medications, including Lotensin and Lasix for hypertension, along with Glucophage for Type II diabetes mellitus.

From an analysis of M.K.'s lab results, this report offers clinical findings and treatment recommendations, as well as suggestions for additional conditions M.K. may be at risk for given her health history, lifestyle, and the following lab results:

Vitals: BP 158/98 mm Hg

CBC: Hematocrit 57% | Glycosylated hemoglobin (HbA1c) 7.3%

Arterial Blood Gas Assessment: PaCO2 52 mm Hg | PaO2 48 mm Hg

Lipid Panel: Cholesterol 242 mg/dL | HDL 32 mg/dL | LDL 173 mg/dL | Triglycerides 1,000 mg/dL

Hypertension and Risk of Heart Failure

One in every three American adults has high blood pressure, and about half of them have the condition under control (CDC, 2016). According to the CDC (2016), 35% of women in M.K.'s age bracket have high blood pressure. High blood pressure increases the patient's risk for heart attack (70% of people having a heart attack have high blood pressure), stroke (80% of people who have a stroke have high blood pressure), chronic heart failure (70% of people with chronic heart failure had high blood pressure), and kidney disease (CDC, 2016). M.K.'s blood pressure was most recently recorded at 158/98 mm Hg, which qualifies her for a diagnosis of Stage 1 Hypertension. The patient is currently taking Lotensin and Lasix to manage her hypertension. Lotensin is a targeted medication for hypertension, and Lasix is a diuretic frequently prescribed in conjunction with Lotensin because the two drugs can have a positive, synergistic effect on blood pressure control. Unfortunately, M.K.'s hypertension remains uncontrolled despite these interventions.

Moreover, M.K.'s uncontrolled pulmonary hypertension places her at increased risk of developing serious health problems, including heart failure, which — given the cluster of problems she currently faces — may have already occurred (Wolf-Maier et al., 2004). There are several types of heart failure: left-sided, right-sided, and congestive. Left-sided heart failure can be systolic or diastolic. Diastolic left-sided heart failure, also known as diastolic dysfunction, refers to the inability of the left ventricle muscles to relax and refill with blood due to stiffening. With systolic left-sided heart failure, the ventricle cannot contract or pump with enough force to circulate blood adequately. Both types can be treated pharmacologically, though different drugs are indicated for each condition.

Right-sided heart failure, also known as right ventricular heart failure, usually follows left-sided heart failure (American Heart Association, 2015). Congestive heart failure can be even more severe, causing edema and interfering with kidney function (American Heart Association, 2015). M.K.'s distended neck veins and persistent coughing may indicate that she has already experienced at least one type of heart failure and should be evaluated further. An echocardiogram would clarify which type of heart failure M.K. may have. Right-sided heart failure is more closely associated with her comorbidities, including both uncontrolled hypertension and chronic bronchitis — classified under chronic obstructive pulmonary disease (COPD). It is therefore suspected that M.K. may have right-sided heart failure. Medications like Lasix can help, but she may also need additional pharmacological treatments such as beta blockers, angiotensin II receptor blockers, aldosterone antagonists, or inotropes if her condition worsens. Given that the patient has already been prescribed Lanoxin, it is likely that the medical team has already recognized symptoms of systolic heart failure.

M.K. is among the two-thirds of Americans at increased risk for cardiovascular events due to inadequate blood pressure control: "only 34% of the 50 million American adults with hypertension have their blood pressure controlled to a level of <140/90 mm Hg" (Ellis, 2003, p. 3). Monotherapy — relying on medication alone without accompanying lifestyle changes — is unlikely to make a meaningful difference in M.K.'s future. Patients like M.K. who resist lifestyle modification have difficulty "accepting the need for therapeutic lifestyle changes" that could save their lives or improve their quality of life (Ellis, 2003, p. 3). It is therefore recommended that healthcare teams work collaboratively with M.K. and her family to promote lifestyle change, possibly through counseling interventions aimed at identifying the root causes of the patient's resistance. As Ellis (2003) notes, "the achievement of blood pressure goals is possible, and, most importantly, lowering blood pressure significantly reduces cardiovascular morbidity and mortality" (p. 3).

The patient was tested for HbA1c, a glycated hemoglobin measure. A controlled study of over 1,000 individuals showed that HbA1c is a "reliable predictor of coronary artery disease and the magnitude of perfusion defects," and that left ventricular dysfunction and the incidence of non-fatal myocardial infarctions are higher at an HbA1c level greater than 7.3% (Fatima, 2013, p. 489). M.K.'s HbA1c level is exactly 7.3%, placing her cardiopulmonary risk at an extraordinary level. Furthermore, M.K.'s lipid panel shows total cholesterol at 242 mg/dL (high), HDL at 32 mg/dL (too low), and LDL at 173 mg/dL (high). Her triglycerides are severely elevated at 1,000 mg/dL, which qualifies her for a diagnosis of hypertriglyceridemia. Hypertriglyceridemia is "common in the United States" because so many Americans lead lifestyles similar to M.K.'s (Sweeney, 2016). Having diabetes mellitus, obesity, and a sedentary lifestyle further increases her risk for heart failure and other cardiovascular complications (Sweeney, 2016). M.K.'s lipid values reflect her poor diet and place her at elevated risk for atherosclerosis, which in turn increases her likelihood of heart failure. The patient could be placed on a cholesterol-lowering medication such as Lipitor to help address this risk.

COPD, Chronic Bronchitis, and Smoking

M.K.'s chronic bronchitis, a feature of COPD, also illustrates her ongoing unwillingness to change her smoking habits. According to Pauwels and Rabe (2004), COPD is the fifth leading cause of death worldwide and "a major cause of chronic morbidity and mortality" representing "a substantial economic and social burden throughout the world" (p. 613). Tobacco smoking is "by far the major risk factor for COPD" (Pauwels & Rabe, 2004, p. 613). Healthcare workers sometimes underestimate the "substantial morbidity associated with COPD," causing patients to also underestimate their likelihood of serious harm (Pauwels & Rabe, 2004, p. 613). At this stage, M.K. has already been diagnosed with chronic bronchitis, and her symptoms — sputum production and chronic cough — continue accordingly. Chronic bronchitis and other components of COPD are progressive and will worsen, especially if exposure to the causative agent, such as cigarette smoke, continues. The only way M.K. can potentially stop or even partially reverse her chronic bronchitis is to quit smoking.

Unfortunately, M.K. has been smoking for 22 years, and "the disease may still progress due to the decline in lung function that normally occurs with aging, and some persistence of the inflammatory response" (Pauwels & Rabe, 2004, p. 613). COPD is often comorbid with other conditions M.K. already has, including pulmonary hypertension. There are many other clinical consequences of chronic bronchitis beyond pulmonary issues: "Many patients with COPD may have decreased fat-free mass, impaired systemic muscle function, osteoporosis, anemia, depression, pulmonary hypertension, cor pulmonale, and even left-sided heart failure" (Mosenifar, 2016). M.K.'s heart failure may therefore already be left-sided and progressing toward right-sided or congestive heart failure. As Mosenifar (2016) also notes, COPD has been associated with chronic depression, which may account for the patient's lack of motivation to change her lifestyle and her health-avoidant behaviors.

In a population-based, cross-sectional study of 1,927 participants, researchers discovered a link between COPD and increased risk for mild cognitive impairment (MCI); a separate study showed similarly that the prevalence of MCI was significantly higher in patients with COPD than in those without (Mosenifar, 2016). Patients with COPD have nearly twice the odds of developing cognitive impairment, and the longer they have the disease, the more likely they are to develop MCI (Mosenifar, 2016). Progressive cardiac and respiratory failure often coincide, demonstrating a strong connection between M.K.'s heart failure and her COPD — both of which may be more attributable to smoking than to diet alone, as patients with chronic bronchitis are frequently overweight (Fayyaz, 2016).

The strongest and most important clinical recommendation is to get M.K. to stop smoking immediately. If the patient refuses to stop smoking, any additional interventions will be limited in their effectiveness. M.K. should be encouraged to explore smoking cessation aids, including nicotine patches and similar alternatives. Counseling may also help identify the root causes of her addiction. If the patient continues to smoke but the healthcare team is still willing to intervene, cough suppressants might provide short-term symptomatic relief. Short-acting beta-agonists, ipratropium bromide, and theophylline "can be used to control symptoms such as bronchospasm, dyspnea, and chronic cough" (Fayyaz, 2016). Some nonsteroidal anti-inflammatory drugs may also be useful. Antibacterials such as amoxicillin and doxycycline may be helpful in certain situations; however, antibiotics have not proven effective in treating chronic bronchitis generally and should be used with caution (Fayyaz, 2016). The long-term goal remains smoking cessation for meaningful symptom reduction.

Conclusion and Treatment Recommendations

The patient's problems — diabetes, hypertension, chronic bronchitis, and hypertriglyceridemia — are all preventable, making M.K.'s case a frustrating one for healthcare workers. When patients like M.K. exhibit an unwillingness to change, they place a significant burden on the healthcare system. It is possible that M.K.'s healthcare team has, in the past, inadvertently enabled the progression of her diseases through monotherapy: an almost exclusive reliance on medications to treat the symptoms of conditions that are rooted in lifestyle choices. Rather than treating symptoms alone, the healthcare team needs to take a more proactive and assertive stance, providing M.K. with whatever tools she needs to make meaningful lifestyle changes. Instead of being permissive and accommodating, the team should reinforce the emphasis on lifestyle modification — perhaps by presenting M.K. with the compelling and incontrovertible clinical evidence. If her cognitive function remains sufficiently intact, the combination of hard evidence and firm guidance from her providers may have an impact. If her cognitive difficulties are more severe than currently recognized, the patient may require psychiatric interventions, family counseling, or group therapy.

M.K. could be transitioned to a more effective diabetes medication given her elevated hemoglobin test results. She could also be offered Lipitor to slow the progression of atherosclerosis, as well as medication interventions to manage the symptoms of her chronic bronchitis. Ultimately, however, only a transformative lifestyle change will produce genuine and lasting improvement. M.K. is on a trajectory toward serious decline and premature death if she continues with her current lifestyle. A sustained commitment to smoking cessation and improved nutrition is the only path toward a meaningful improvement in her health outcomes and a more positive prognosis. Without these changes, the damage already done to her body will continue to progress.

References

American Heart Association (2015). Types of heart failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/Heartfailure/Aboutheartfailure/Types-of-Heart-Failure_UCM_306323_Article.jsp

CDC (2016). High blood pressure facts. Retrieved from http://www.cdc.gov/bloodpressure/facts.htm

Cheung, M. M. & Li, C. (2012). Diabetes and hypertension: Is there a common metabolic pathway? Current Atherosclerosis Reports, 14(2), 160–166.

Ellis, W. J. (2003). The economic impact of hypertension. Journal of Clinical Hypertension (Greenwich), 5(3 Suppl 2), 3–13.

Fatima, N., et al. (2013). Impact of glycosylated hemoglobin (HbA1c) on the extent of perfusion abnormalities and left ventricular dysfunction using gated myocardial perfusion imaging and clinical outcomes in diabetic patients. Nuclear Medicine Communications, 34(5), 489–494.

Fayyaz, J. (2016). Bronchitis clinical presentation. Medscape. Retrieved from http://emedicine.medscape.com/article/297108-clinical

Mosenifar, Z. (2016). Chronic obstructive pulmonary disease (COPD) clinical presentation. Medscape. Retrieved from http://emedicine.medscape.com/article/297664-clinical

Pauwels, R. A. & Rabe, K. F. (2004). Burden and clinical features of chronic obstructive pulmonary disease (COPD). The Lancet, 364(9434), 613–620.

Sweeney, M. E. T. (2016). Hypertriglyceridemia. Medscape. Retrieved from http://emedicine.medscape.com/article/126568-overview

Wolf-Maier, K., et al. (2004). Hypertension treatment and control in five European countries, Canada, and the United States. Hypertension, 43(1), 10–17.