What is the best approach to manage a patient with a complex medical history including cardiac issues, chronic conditions, and multiple deficiencies?

Managing Complex Multimorbidity: A Structured Four-Domain Framework

For this patient with extensive cardiovascular disease, multimorbidity, and polypharmacy, implement the American College of Cardiology's four-domain framework prioritizing therapies with the greatest net benefit across conditions while conducting comprehensive medication reconciliation to address polypharmacy risks. 1

Immediate Priority: Comprehensive Medication Reconciliation

Conduct an urgent medication reconciliation session to create an accurate list of all current medications including the missing medications listed (aspirin, vitamin D3, diphenoxylate-atropine, donepezil, duloxetine, ferric gluconate, ferrous sulfate, furosemide, lubiprostone, metoprolol succinate, mirtazapine, pantoprazole, rivaroxaban, valsartan, zolpidem), as medication discrepancies represent a critical safety issue in this complex patient. 2, 3

• Schedule a dedicated appointment with a pharmacist or nurse to physically review all medication bottles (prescription, over-the-counter, supplements) against the electronic record to identify discontinued, missing, or incorrectly taken medications. 1, 2
• Evaluate for high-risk drug interactions particularly given rivaroxaban use with CKD stage 3b (GFR 30-44), recent NSTEMI, and multiple medications affecting bleeding risk. 2, 4
• Assess for drug-disease interactions including NSAIDs (if any) worsening heart failure and renal function, anticholinergics affecting cognitive impairment, and medications exacerbating orthostatic hypotension contributing to falls. 2

Four-Domain Assessment Framework

The American College of Cardiology recommends organizing care around four interconnected domains rather than single-disease guidelines for patients with atherosclerotic cardiovascular disease and multimorbidity. 1

Domain 1: Medical Care and Treatments

Prioritize therapies offering broad benefits across multiple conditions rather than "stacking" single-disease guideline recommendations that lead to harmful polypharmacy. 1

Cardiovascular optimization sequence:

• For acute on chronic HFpEF with recent NSTEMI: Ensure guideline-directed medical therapy is optimized, recognizing that therapies must be sequenced rather than simultaneously initiated. 1
• Address anticoagulation complexity: With paroxysmal atrial fibrillation, recent NSTEMI, post-TAVR status, and CKD stage 3b, rivaroxaban dosing requires verification against renal function (should be 15 mg daily with CrCl 30-49 mL/min per FDA labeling). 4
• Evaluate aspirin continuation: Combined aspirin and rivaroxaban significantly increases bleeding risk, particularly with CKD, recent gout, thrombocytopenia, and peptic ulcer history—consider discontinuing aspirin unless specific post-PCI indication remains. 1

Anemia management:

• Investigate microcytic anemia etiology given ferrous sulfate and ferric gluconate use, peptic ulcer history, and anticoagulation—iron deficiency anemia in heart failure independently worsens outcomes. 1
• Monitor for bleeding sources particularly gastrointestinal given GERD, peptic ulcer history, and anticoagulation. 2

Deprescribing considerations:

• Use validated tools (Beers Criteria, STOPP/START) to identify potentially inappropriate medications in this elderly patient with cognitive impairment, falls, and polypharmacy. 2
• Target medications where harm outweighs benefit, particularly sedating medications (mirtazapine, zolpidem) contributing to falls, cognitive impairment, and daytime fatigue. 2

Domain 2: Physical Functioning

Address functional decline systematically as difficulty walking, falls, generalized muscle weakness, and multiple pain syndromes significantly impact quality of life and mortality risk. 1

• Implement structured physical therapy focusing on fall prevention, strengthening exercises, and mobility aids given osteoarthritis, chronic back pain, venous insufficiency, and history of compression fractures. 1
• Evaluate for cardiac rehabilitation appropriateness post-NSTEMI and TAVR, as exercise programs improve functional capacity and reduce hospitalizations in heart failure patients. 1
• Assess nutritional status given multiple deficiencies (vitamin B12, vitamin D, iron) and ensure supplementation is optimized—malnutrition accelerates functional decline. 2
• Address pain management for chronic knee, shoulder, and back pain without NSAIDs (contraindicated with heart failure, CKD, and anticoagulation)—consider physical therapy, topical agents, and judicious use of acetaminophen. 1

Domain 3: Mind and Emotion

Screen and treat depression, anxiety, and cognitive impairment as these conditions worsen cardiovascular outcomes, medication adherence, and functional status. 1

• Assess current antidepressant efficacy: Duloxetine and mirtazapine use suggests treated major depressive disorder, but recurrent depression, anxiety, and insomnia indicate inadequate control. 1
• Evaluate cognitive impairment progression: With mild cognitive impairment, memory loss, and donepezil use, assess whether cognitive decline affects medication management, self-care, and decision-making capacity. 1
• Screen for treatment burden and overwhelm: Patients with multimorbidity frequently feel overwhelmed by complex regimens—use Patient Health Questionnaire-2 for depression screening and assess medication burden perception. 1
• Discuss advance care planning: Given severe cardiac disease, multiple hospitalizations, and cognitive impairment, establish healthcare proxy and clarify goals of care before crisis situations. 1

Domain 4: Social and Physical Environment

Identify barriers to adherence and self-management including medication costs, transportation, caregiver support, and health literacy. 1

• Assess medication affordability: With extensive polypharmacy including rivaroxaban (expensive), evaluate formulary options and patient assistance programs to prevent cost-related nonadherence. 1, 3
• Evaluate caregiver support: Given cognitive impairment, functional limitations, and complex medication regimen, determine if patient requires assistance with medication management, appointments, and activities of daily living. 1
• Address fall hazards at home: With recurrent falls, dizziness, syncope, and mobility impairment, conduct home safety assessment and consider occupational therapy evaluation. 3
• Ensure care coordination: Establish a primary clinician or patient-centered medical home to coordinate multiple specialists (cardiology, nephrology, geriatrics) and prevent fragmented care. 1

Establish Multidisciplinary Heart Valve Team

Given severe aortic stenosis status post-TAVR, nonrheumatic mitral regurgitation, and complex cardiac disease, ongoing management requires a Heart Valve Team composed of cardiologists, structural interventionalists, cardiovascular surgeons, and imaging specialists. 1

• Monitor for TAVR complications including paravalvular leak, conduction abnormalities (patient has pacemaker), and prosthetic valve endocarditis risk. 1
• Assess mitral regurgitation progression as moderate-to-severe mitral regurgitation may require intervention, particularly if contributing to heart failure exacerbations. 1

Monitoring and Follow-Up Strategy

Increase monitoring frequency during care transitions (recent CHF exacerbation, NSTEMI) as these represent high-risk periods for adverse events and medication errors. 2, 3

• Schedule follow-up within 7-14 days post-hospitalization for medication reconciliation, symptom assessment, and early identification of decompensation. 2
• Monitor renal function closely given CKD stage 3b, heart failure, and multiple nephrotoxic medications—adjust drug dosing as creatinine clearance changes. 1, 4
• Track key laboratory values: Potassium (on valsartan, furosemide, with CKD), INR/bleeding parameters (on rivaroxaban with thrombocytopenia), hemoglobin (microcytic anemia with anticoagulation), and troponin trends (recent NSTEMI with elevated baseline troponin). 2
• Assess functional status at each visit using standardized tools to detect decline requiring intervention escalation or goals of care discussion. 1

Critical Pitfalls to Avoid

• Do not apply single-disease guidelines rigidly—guideline "stacking" creates harmful polypharmacy without considering net benefit across conditions or patient priorities. 1
• Do not overlook medication reconciliation—the extensive missing medication list represents a critical safety gap requiring immediate resolution. 2, 3
• Do not ignore bleeding risk—combination anticoagulation with rivaroxaban, thrombocytopenia, CKD, peptic ulcer history, and recent gout creates substantial hemorrhage risk requiring careful monitoring. 1, 4
• Do not dismiss functional and cognitive decline—these domains directly impact mortality, quality of life, and ability to manage complex medical regimens. 1
• Do not delay advance care planning—with progressive multimorbidity, cognitive impairment, and multiple life-limiting conditions, establish goals of care proactively. 1