BACKGROUND: Atrial fibrillation (AF) is the most common cause of embolic stroke. Although there is impressive risk reduction in stroke associated with warfarin therapy in clinical trials and guidelines on anticoagulation in AF, there are limited data on how well these goals are being met. This study aims to determine the adherence to guidelines on anticoagulant management among adult patients with AF at the Department of Internal Medicine Ward of the University of the Philippines - Philippine General Hospital (UP-PGH).
METHODS: This is a prospective study, which included patients aged 18 years and older with diagnosis of AF, which can be paroxysmal, persistent, long-standing or permanent. Upon admission, patients were interviewed and information like age, gender, duration of AF, co-morbid illnesses, and medical history were collected using a checklist. Risk factors for bleeding, use of antiplatelet/anticoagulant agents and International Normalized Ratio (INR) values were also determined.
RESULTS: There were 40 subjects included in the study, majority of which were female (77.5%) and in the 40-50 years age range (35%). There were 21 (52.5%) patients who had valvular AF and 19 (47.5%) who had non-valvular AF. Of those patients with valvular AF, 80.9% received warfarin. Of those patients with non-valvular AF, 94.7% were at moderate or high risk for thromboembolism, but only 47.4% of those patients received warfarin. We found that only a small percentage of patients (16%) had INR in the therapeutic range of 2.0-3.0. The majority of the patients had their INR in the sub-therapeutic ranges at 40% and 24% at INR values of 1.5-1.99 and 0-1.49 respectively. The majority of the patients on warfarin had INR monitoring ? 30 days, and these were patients already on chronic or long-term warfarin use. Those patients who had more frequent INR monitoring were those newly initiated on the treatment whose INR values where in the sub-therapeutic range.
CONCLUSION: The adherence of anticoagulant management among AF patients admitted at the Internal Medicine Wards of UP-PGH, to evidence-based clinical practice guidelines, was high at 80.9% for patients with valvular AF and was quite low at 47.4% for non-valvular AF patients. Patients were found to have low bleeding risks based on a HAS-BLED score and patients with moderate to high thromboembolic risk factors were more often prescribed with warfarin, although only a few patients achieved a therapeutic INR. A more frequent INR monitoring including a close follow-up with the patients should be performed to achieve target INR in most patients with AF. Moreover, we should not discount starting anticoagulation in patients with non-valvular AF who have moderate to high thromboembolic risk factors.

Human ; Male ; Female ; Middle Aged ; Adult ; Warfarin ; Anticoagulants ; Atrial Fibrillation ; Platelet Aggregation Inhibitors ; Thromboembolism ; Stroke ; Hemorrhage ; Blood Coagulation ; Risk Reduction Behavior

INTRODUCTION: Ventricular tachycardias (VT) are commonly associated with structural heart disease. However, 10% of VTs have no identifiable cause. Right ventricular outflow tract ventricular tachycardia (RVOT VT), a small subgroup of idiopathic VTs localized in the right ventricular outflow tract is highly sensitive to adenosine (ADO). Only 11% of RVOT VT is ADO-insensitive, posing a diagnostic challenge. We present a peculiar case of an ADO-insensitive RVOT-VT storm and the challenges of recognizing and managing it in a resource-limited setting.

CASE SUMMARY: A 15-year-old female, asthmatic, complained of palpitations, lightheadedness, chest pain and dyspnea a few hours prior to admission. She had a similar episode a month ago, which necessitated ER admission, electrical cardioversion and amiodarone.

On admission, she was tachycardic but normotensive. She had diffuse wheezes. Cardiac exam was normal. ECG revealed a wide complex tachycardia (WCT). Work-up revealed a normal chest x-ray, thyroid function tests and electrolytes. Echocardiogram showed a structurally normal heart. She was managed as a case of viral myocarditis and SVT with aberrancy. Vagal maneuvers and adenosine was given which slowed down the tachycardia. She was then started on IV anti-arrhythmics however, sustained symptomatic VT recurred on the same day. ECG analysis showed a WCT, LBBB, AV dissociation with positive QRS complexes in inferior leads suggestive of VT originating from the RVOT. RVOT VT storm was considered and adenosine (maximum dose) was given. The patient did not revert to sinus, hence, ADO-insensitive RVOT VT was considered. Cardioversion terminated the VT storm.

On electrophysiology study, the VT was induced/ localized at the RVOT via 3D mapping. Ablation of the RVOT focus was performed, immediately terminating the VT. Post ablation, the patient was asymptomatic and was discharged improved with excellent prognosis.

DISCUSSION: This case report highlights two things. The ECG remains a reliable tool in recognizing and localizing VTs clinically. Secondly, it highlights the importance of prompt recognition of ADO-insensitive RVOT VT because its management and prognosis is very different from the common causes of VT.

Human ; Female ; Adolescent ; Anti-arrhythmia Agents ; Amiodarone ; Electric Countershock ; Adenosine ; Dizziness ; Myocarditis ; Beta-apocarotenoid-14' ; ,13' ; -dioxygenase ; X-rays ; Tachycardia, Ventricular ; Echocardiography ; Heart Ventricles ; Dyspnea ; Chest Pain ; Electrocardiography ; Prognosis ; Electrolytes ; Thyroid Function Tests ; Electrophysiology

BACKGROUND: Implantable cardioverter-defibrillator (ICD) is the therapy of choice in the prevention of SCD. The ICD has been proven to improve survival among survivors of cardiac arrest, patients who are at risk of having one because of myocardial scarring and low left ventricular ejection fraction, and those with primary inherited arrhythmia syndromes. The insertion of an ICD is indicated for survivors of cardiac arrest due to ventricular fibrillation or hemodynamically unstable sustained ventricular tachycardia after the exclusion of any reversible cause. At present, there are no nationwide data regarding the prevalence of ventricular tachyarrhythmias requiring an ICD. OBJECTIVES: The aim of this study was to determine the (1) total hospitalization claims per year (2017 and 2018) for arrhythmias requiring an ICD, (2) total number of cardioverter-defibrillator insertions done for patients mentioned in (1), (3) prevalence of hospitalization for cardiac arrhythmias requiring insertion of ICD among patients admitted for medical conditions for 2017 and 2018, (4) the demographic profile of patients who were hospitalized for cardiac arrhythmias requiring insertion of ICD, (5) type of facilities (primary, secondary, or tertiary; government or private) where the patients were confined, and (6) duration of hospitalization and mortality rate of patients admitted for the above conditions. METHODS: This is a descriptive study using the database of Philippine Health Insurance Corporation (PhilHealth) on hospital claims of admitted patients 19 years or older in PhilHealth-accredited hospitals from January 1, 2017, to December 31, 2018. Anonymized records were reviewed using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) of the World Health Organization. The codes relevant to the study question were chosen and used. The PhilHealth Relative Value Scale (RVS) codes were used to determine the procedures that the patients underwent for their cardiac arrhythmias. Patients’ demographic profile, diagnosis, region, hospitalization stay and status on discharge, and type of facility of admission were collected. Descriptive statistics using median value and interquartile range for quantitative data and frequency and percentage for categorical data were reported. RESULTS: In 2017 and 2018, among patients 19 years or older, there were 1282 and 1480 claims of cases of cardiac arrhythmias requiring an ICD (based on ICD-10 codes), whereas those who underwent placement of an ICD (based on RVS codes) numbered 50 and 45, respectively. The prevalence of hospitalization for cardiac arrhythmias related to ICD among patients who were admitted for medical conditions was 0.05% and 0.06%, for the same years. The overall in-hospital mortality rates were 10.84% and 9.46% in each year for those who were admitted for cardiac arrhythmias that required an ICD; however, there were no recorded mortalities for those who underwent implantation of a cardioverter-defibrillator. For patients with arrhythmias requiring an ICD (based on ICD-10 and RVS codes), the median (first quartile [Q1], third quartile [Q3]) age was 59 (43, 72) years. In 2018, the median (Q1, Q3) age was 57 (38, 71) years. There were similar proportions of males (53%) and females (47%) in both years. The majority of cases based on ICD-10 codes of cardiac arrhythmias requiring an ICD were confined in government hospitals, whereas most of the claims for procedures based on RVS codes were in private hospitals. Most of the procedures were done in the National Capital Region. The duration of hospitalization was 3 to 4 days. CONCLUSION Based on PhilHealth claims, the admission due to cardiac arrhythmias requiring ICD is common in both private and government hospitals. Cardioverter-defibrillator implantation is being done mostly in the National Capital Region and private hospitals. There is a wide gap between the prevalence of cardiac arrhythmias requiring an ICD and the frequency of implantation of the lifesaving device.
implantable cardioverter-defibrillator ; Defibrillators, Implantable ; Death, Sudden, Cardiac ; Brugada Syndrome

INTRODUCTION: Radiofrequency catheter ablation (RFA) is an interventional cardiac electrophysiologic procedure that uses heat energy for definitive management of supraventricular tachycardias. It is a class I recommendation for chronic management of most supraventricular arrhythmias. No local data exist in the incidence hospitalization for SVT and utilization of RFA for this condition. The study aimed to obtain the prevalence of hospitalization of patients with supraventricular tachycardias where RFA is utilized, including the patients’ demographic profile, length of hospitalization, and mortality rate. METHODOLOGY: Philippine Health Insurance Corporation claims for hospitalization from January 1, 2017, to December 31, 2018, were reviewed. Data analysis was done using median and interquartile range for continuous data, and frequency and percentage distribution for categorical data. RESULTS: There were 1121 and 1149 claims for hospitalization for SVTs (atrial paroxysmal tachycardia, atrioventricular paroxysmal tachycardia, nodal paroxysmal tachycardia, and junctional tachycardia) in 2017 and 2018, respectively. This represents four hospitalization claims for SVT per 10,000 of the total PHIC claims. The majority of patients were female with median age of 52 years. Only 25 and 19 patients underwent radiofrequency ablation in 2017 and 2018, respectively. The majority of these patients were male and younger with a median age of 31 years. No mortality was recorded among patients admitted for catheter ablation. CONCLUSION In 2017 and 2018, hospitalization claims for SVT requiring catheter ablation were 0.04% (four hospitalization claims for SVT per 10,000 of the total claims) in both years. The majority of patients were admitted with pharmacologic therapy on discharge with very low utilization of radiofrequency ablation for long-term management.
Arrhythmias, Cardiac ; Tachycardia, Supraventricular ; Radiofrequency Ablation ; prevalence ; Hospitalization

BACKGROUND: Symptomatic bradycardia, commonly attributed to sinus node dysfunction/ sick sinus syndrome, or atrioventricular (AV) blocks or conduction disorders from chronic fascicular blocks, is treated by implantation of a permanent pacemaker. Despite it being a class 1 recommendation, there is a perception based on informal surveys that permanent pacemaker implantation (PPI) is underutilized. The Philippines showed slow growth in the volume of implantation from 1049 in 2015 to 1225 in 2016. The Philippine pacemaker data after 2016 are incomplete and unreliable because of the lack of a national registry. It is the aim of this study to ascertain the prevalence of cardiac arrhythmias requiring PPI and the volume of its utilization in the Philippines. OBJECTIVES: The aims of this study were to (1) to determine the prevalence of hospitalization claims in 2017 and 2018 for cardiac arrhythmias requiring PPI, (2) to determine the regional distribution of arrhythmias requiring PPI, (3) to determine the regional distribution of hospitalization claims for PPI, (4) to determine the number of hospitalization claims for specific cases requiring PPI and the corresponding mortality rate, (5) to determine the number of hospitalization claims for PPI and the corresponding mortality rate, and (6) to describe the demographic profile of patients with indications and with claims for PPI, as well as the duration of hospitalization and type of facilities where the hospital claims were filed. METHODS: This is a descriptive study of Filipino patients 19 years or older, admitted for cardiac arrhythmias requiring PPI in the Philippine Health Insurance Corporation (PhilHealth)–accredited hospitals in 2017 and 2018. The data for disease prevalence were gathered from the database of PhilHealth using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) of the World Health Organization. The procedures that the patients underwent were determined using the latest PhilHealth Relative Value Scale (RVS) codes. Other variables gathered were the demographic data, diagnosis, region, duration of hospital stay, type of facility on admission, and the status on discharge. Qualitative data were tabulated and presented as frequency and percent distribution. Quantitative data were reported as median with corresponding quartiles (Q1 and Q3). RESULTS: Based on the 2017 and 2018 database of PhilHealth, out of the nationwide total medical admissions, there were 958 total claims for arrhythmias requiring pacemaker implantation in 2017 and 1144 total claims in 2018. The prevalence in both years was similar (0.04%). There were 549 and 683 total claims for PPI, in 2017 and 2018, respectively, and preponderantly done in the National Capital Region. Sick sinus syndrome/tachycardia–bradycardia syndrome had the greatest number of total claims for both years. More than half of the patients who had PPI were females. The median age was similar (67 and 68 years old for both years and 73 and 75 years old in 2017 and 2018, based on ICD-10 and RVS codes, respectively). The duration of hospitalization was a median of 4 days (ICD-10 codes) and 5 to 6 days (RVS codes). Most of the hospital claims for cardiac arrhythmias (76%–79%) requiring PPI were filed in private facilities. Mortality among those diagnosed was 3.6% for complete atrioventricular block and 0.3% for sick sinus syndrome but was low among those who underwent PPI (0.8%–2.2%). CONCLUSION The prevalence of hospitalization claims for arrhythmias requiring PPI was 0.04%, both in 2017 and 2018. There is a big gap between the number of cases requiring a permanent pacemaker and the number that underwent the procedure. Hospitalization claims, based on ICD-10 codes and RVS codes, were centralized in the National Capital Region and private hospitals. The mortality rate among those who had the procedure was low.
Arrhythmias, Cardiac ; prevalence ; Hospitalization

BACKGROUND: Radiofrequency ablation (RFA) is the recommended treatment of choice for supraventricular tachycardia (SVT), whereas implantable cardioverter-defibrillator (ICD) is recommended for patients at high risk for sudden death due to ventricular tachycardia/fibrillation. Radiofrequency ablation has been proven to improve the quality of life of patients with SVT, whereas an ICD has been shown to reduce mortality among patients at risk for sudden cardiac death. Both procedures are expensive and usually beyond the reach of the average Filipino patient. OBJECTIVES: The objectives are to (1) determine the cost of hospitalization for cardiac arrhythmias that require RFA and cardioverter-defibrillator implantation in the Philippines, (2) propose revised Philippine Health Insurance Corporation (PhilHealth) benefit packages for both procedures, and (3) determine the budget impact of the proposed revised packages. METHODS: Hospitalization costs were obtained for both RFA and cardioverter-defibrillator implantation from two government tertiary care hospitals. A range of hospitalization costs involving possible lower and higher cost scenarios was estimated. Based on these estimates and the yearly number of arrhythmias that require these procedures, revised benefit packages for both RFA and cardioverter-defibrillator implantation were proposed to PhilHealth. The budget impact analysis for the first 3 and 5 years of implementation of these revised packages was subsequently calculated. RESULTS: The estimated hospitalization costs for RFA ranged from Philippine pesos (PHP) 248,485 to 310,480, whereas for cardioverter-defibrillator implantation, the costs ranged from PHP 509,122 to 581,940. These amounts are greatly disparate from the present PhilHealth coverages, which are PHP 9700 and 18,000 for RFA and cardioverter-defibrillator implantation, respectively. Based on these hospitalization costs, the proposed RFA benefit package is PHP 275,000 to 310,000, whereas for an ICD benefit package, PHP 513,000 to 576,000 is proposed. The incremental cost of more than PHP 300 million for RFA and more than PHP 700 million for an ICD is distributed for the next 3 or 5 years of implementation for these benefit packages, respectively. CONCLUSION The present PhilHealth case rates for both RFA and cardioverter-defibrillator implantation are greatly underestimated, which probably is the reason for their underutilization. There is a need to revise these case rates with due consideration of their actual hospitalization costs to lessen inequity in accessing these procedures.
Radiofrequency Ablation ; Defibrillators, Implantable