Case Report
A 58-years old man, a Municipal employee with athletic experience
presented with two tendon ruptures in the rotator cuff tendon in
different shoulders after two minor traumas.
He had a history of ischemic heart disease and went under percutaneous
coronary intervention (PCI) procedure (4 years ago), 10 year-ASCVD risks
score 22.7%, benign prostate hypertrophy, hypertension and diabetes
mellitus. He has been prescribed 40mg Atorvastatin once a day, 0.4mg
Tamsulosin once daily, 5mg Amlodipine once daily, Dutasteride 0.5mg once
a day, Metoprolol 12.5mg every 12 hours, Metformin 500 mg every 8 hours,
Pioglitazone 15mg every day, and ASA 80mg once a day. The patient has no
history of alcohol or smoking. He has a familial history of hypertension
and heart disease.
Before these accidents, the patient remembers having aches in both his
shoulders after playing sports, like soccer which he did not experience
before. The first trauma occurred in 2020 when the patient was climbing
a gentle slope mountain. He slipped on his left hand and suffered pain
at that moment but it was light enough for him to be neglected, and he
didn’t seek medical advice. He also mentions that similar accidents had
happened before, too but he got better in a little time. After some time
(he can’t recall specifically), the patient had the same falling
accident while participating in an indoor soccer match. It caused too
much pain in his shoulder that made the patient visit a doctor. The pain
was intense and he had difficulty raising his hand.
MRI (figure 1) ordered for him. Full-thickness tearing seen at the
critical zone of the supraspinatus tendon. It was related to this minor
trauma. That was why the doctor performs surgery on him and did not
change his drugs. also partial tearing in right rotator cuff tendon was
present at that time but it was not diagnosed and no action was taken
against it. After two years he slipped on his right hand which caused
the same pain that he experienced two years before.it was intense,
non-radiating pain that worsened at night and especially when he
abducted his hand. He visited a doctor again and was ordered to do an
MRI (figure 2). The evidence of complete tearing in the rotator cuff
tendon was seen besides joint effusion. So he went under Arthroscopic
tendon repair procedure for the second time.
After these two minor traumas, suspicion was raised about atorvastatin
side effects to be the real cause.
The Naranjo adverse drug reaction (ADR) probability scale was
calculated, and the patient achieved a score of 7, which means tendon
rupture probably happened due to atorvastatin.
Additional investigation was done which was normal.
Finally, due to the recurrent tendon rupture and Naranjo scale score,
Atorvastatin was considered as the causative agent and it was
discontinued.
As for the high score of 10 year-ASCVD risks, it was necessary to
prescribe an alternative drug with mortality-reducing effects in
cardiovascular patients, as same as statins. After enough studies,
Evolocumab 140mg once in two weeks, was selected as an alternative from
the family of PCSK9 inhibitors.