Background: The diagnosis of ST-elevation myocardial infarction on standard 12-lead electrocardiography is crucial to the timely institution of appropriate medical therapies and interventions. However, the electrocardiographic diagnosis may be prone to observer variability. Objectives: We wanted to determine the 1) inter-observer variability among clinicians from a training hospital in the diagnosis of ST-elevation myocardial infarction (STEMI) from emergency room electrocardiograms (ECG) of patients presenting with chest pain, and 2) the accuracy of clinician readings compared to the final cardiac diagnosis in the official patient records Methods: Forty electrocardiograms were independently interpreted by 40 clinicians which included 10 cardiologists (CC), 5 cardiology fellows (CF). 15 internal medicine (IM), and 10 internal medicine residents (MR), using uniform copies of the standard 12-lead electrocardiogram print-outs. All readers were blinded to the patient's clinical profile. The accuracy of clinician readings (% of tracings correctly identified as STEMI) were compared against a reference standard, which was the final cardiac diagnosis made based on historical, electrocardiographic, biochemical, and angiographic data. Results: The overall level of agreement among all readers (intergroup variability) was only fair with a kappa of 0.24. The level of agreement within the groups (intra-group variability) was likewise "fair" for the IM (0.35), MR (0.32), and CC (0.30 groups. Agreement was much less (0.18) among the cardiology fellows (0.18) among the cardiology fellows (CF). Accuracy of ECG diagnosis varied among the groups: IM (68%), MR (60%), CF (52%) and CC (50%). Conclusions There is substantial inter-group variability in the electrocardiographic diagnosis of STEM by clinicians. The accurate diagnosis of STEMI, based on pure electrocardiographic informa-tion, varied among readers with different training backgrounds. These findings suggest that the electrocardiographic diagnosis of STEM may be influenced by training background and experience. as well as presence or absence of supplemental medical information necessary to make a comprehensive and accurate cardiac diagnosis. More importantly, this underscores the need to harmonize electrocardiographic interpretations and recognize the value of reading ECGs in light of pertinent clinical data
ST Elevation Myocardial Infarction ; Emergency Service, Hospital ; Electrocardiography

BACKGROUND

The COVID-19 pandemic greatly affected training programs because of changes in patient load and service assignments. This posed certain challenges in the implementation of the pre-COVID-19 training curriculum recommendations by the Philippine Heart Association Specialty Board on Adult Cardiology.

OBJECTIVE

This article describes the challenges, training adjustments and innovations, and the impact on the training program of these changes instituted by the University of the Philippines-Philippine General Hospital (UP-PGH) Division of Cardiovascular Medicine (DCVM) during the COVID-19 pandemic.

METHODS

This is a descriptive article based on review of changes and improvements of the UP-PGH DCVM training manual and guidelines adopted during the COVID-19 pandemic.

FINDINGS

The COVID-19 pandemic challenges provided opportunities for innovation of the training program. The program emphasized focus on maximizing team-based learning from every clinical encounter toward achievement of learning outcomes and competency. The training committee closely monitored the learning environment and trainee's learning progress to achieve outcomes beyond the traditional metrics such as census and procedural numbers. It adopted online clinical encounters, conference, and case discussion. To enhance learning, virtual engagement supplemented physical encounters between consultants and training fellows assigned to various clinical rotations. Real-world research results on the impact of COVID-19 on cardiovascular health were utilized to enhance knowledge. Risk mitigation and transmission reduction strategies were adopted to ensure safety of all staff. The division also incorporated a strong wellness program to provide holistic approach to trainees' and trainers' health. New competencies were developed such as telemedicine, infection prevention and control, and creation of virtual patient education programs.

CONCLUSION

The training institution met the challenges posed by the COVID-19 pandemic with resiliency and unity. The adjustments and innovations in training instituted by PGH DCVM proved useful in addressing the challenges posed by the pandemic. The situation was viewed as an opportunity to innovate and pursue a better program adaptive of the ever-changing environment, toward forming competent future cardiologists by enhancing focus not only on numbers but rather on the process of achievement of learning outcomes, embracing virtual and online strategies, institutionalization of wellness program, and development of new guidelines in the approaching patient management cognizant of both health care provider and patient safety and new competencies such as patient virtual education and telemedicine in cardiology.

INTRODUCTION: Maldistribution of echocardiographic expertise is a relevant issue in an archipelago such as the Philippines. We specifically looked at (1) the nationwide census of physician echocardiographers, cardiac sonographers, and cardiac laboratory managers; (2) their geographic distribution; and (3) background training and laboratory classification. METHODS: Data from paper and online surveys conducted in 2015 and 2021 were consolidated alongside the existing society database. Surveys (Google Forms; Google, Mountain View, California) were disseminated through a variety of online, social media, and communication avenues and focused on three categories of respondents: (1) physician echocardiographers, (2) cardiac sonographers, and (3) laboratory managers. The main variables of interest included estimated census per category and geographical distribution. Secondary variables included training background and laboratory classification. RESULTS: In 2021, there were 651 physician echocardiographers, 2487 cardiac sonographers, and 443 cardiac laboratory managers on record, with86 readers, 405 sonographers, and 101 managers responding to the survey. The majority of the surveyed readers (41.2%), sonographers (48.3%), and laboratory managers (28.2%) were situated in the National Capital Region. Close to half of the readers were level III echocardiographers. The majority of the sonographers (46.7%) were nurses, followed by medical technologists (21.8%) and radiologic technologists (18.9%).Most laboratory managers were in nontraining hospitals (38.2%) or stand-alone facilities (20.9%). The minority were in hospitals with cardiology (18.2%) or internal medicine (22.7%) training programs. CONCLUSION Geographical maldistribution of echocardiographic resources is still evident, with the majority of human resources being concentrated in the metropolis. The majority of the sonographers have nursing as their training background, and many laboratory managers are situated in facilities with no established training programs.
echocardiography ; laboratories ; resources ; health resources ; surveys and questionnaires

INTRODUCTION: Cardiac hemangiomas are rare benign primary tumors.We present the successful management of a patient with a hemangioma causing significant right ventricular outflow tract (RVOT) obstruction.
CLINICAL PRESENTATION: A 54-year-old  female  with  no  co-morbidities  presented  with  progressive  right-sided  heart failure  symptoms.Examination  revealed  a  prominent right  ventricular  heave,  irregular  cardiac  rhythm,murmurs  consistent  with  pulmonic  stenosis  and  tricuspid regurgitation,  ascites,  and  bipedal  edema.  Given the echo features of the mass and the patient's clinical course,we  favored  a  benign  cardiac  tumor  over  malignancy.Differentials included  myxoma,  fibroma,  and  papillary fibroelastoma. Medical management included enoxaparin and carvedilol as anticoagulation and rate control for the atrial flutter, respectively. Surgical treatment consisted of tumor excision and tricuspid valve annuloplasty.
RESULTS: Intra-operatively, the stalk was indeed attached to the RV free wall. Histopathology was consistent with primary cardiac hemangioma. The patient's post-operative course was complicated by pneumonia, acute kidney injury, and tracheostomy, but she was eventually discharged improved after a month in the ICU.
SIGNIFICANCE: This report highlights a rare primary cardiac tumor in an unusual location. While there have been several reports in the world literature on cardiac hemangiomas, less than ten cases have been shown to have significant RVOT obstruction as in our patient.
CONCLUSION: Cardiac hemangiomas should be part of the differential diagnosis for an intracardiac mass in the right ventricle.  Meticulous  echocardiography  can  be  a  non-invasive and inexpensive aid to diagnosis and pre-operative planning.

Human ; Female ; Middle Aged ; Tricuspid Valve ; Carvedilol ; Enoxaparin ; Tricuspid Valve Insufficiency ; Heart Ventricles ; Tracheostomy ; Myxoma ; Heart Neoplasms ; Propanolamines ; Hemangioma ; Pulmonary Valve Stenosis

Background. Despite the recent advances in advanced cardiac life support (ACLS), there has been no significant improvement in survival among patients who undergo cardiac arrest. To date, there are no local guidelines on the requirements or standards of in-hospital cardiac arrest teams in the Philippines. In addition, there are still no studies on the outcomes of cardiac arrests among adult patients in a tertiary hospital in the Philippines. Objectives. The objective of this study is to investigate patient-, event-, and hospital-related factors associated with survival among adult patients who underwent in-hospital cardiac arrest in the service wards and intensive care units of a tertiary hospital. Methods. This is a prospective cross-sectional study conducted over three months in 2018. Patient-, event- and hospital-related data were collected from each patient with a cardiac arrest event who was referred to the cardiac arrest teams based on the modified Utstein form of reporting cardiac arrests. Survival to discharge from cardiac arrest was the main outcome. Results. The study included 119 patients, 47.9% male, with a mean age of 50.1 years (SD 16.7). Survival rate was 6.7%. The mean response time did not differ between survival group (1.46 minutes) and mortality group (1.82 minutes) (p value = 0.26). The presence of a shockable initial rhythm (3.6% vs 3/8; p value = 0.01), shorter lag time to initiation of electrical therapy (6.0 vs 9.3 ± 5.6 min; p value = 0.02), shorter time to establishment of an airway (2.75 ± 1.6 vs. 6.98 ± 5.2 min; p value = 0.01), and shorter duration of resuscitation (7 ± 4.6 vs. 13.0 ± 7.9 min; p value = 0.01) were significantly associated with survival. The presence of underlying illnesses is associated with higher mortality. The most common hospital-related problems identified were the need to cover long distances, delay in the call, and the lack of elevators. Conclusion. The survival rate of patients who underwent cardiac arrest and resuscitation by a cardiac arrest team is low. The initial presenting rhythm, lag time to initiation of electrical therapy, time to establishment of airway, duration of resuscitation, as well as the underlying disease can significantly affect survival. Streamlining the resources of the hospital to address these matters can have an impact on survival.
Advanced Cardiac Life Support ; Heart Arrest

Introduction: Myocarditis is a rare but serious complication of systemic lupus erythematosus (SLE). Existing literature on adult Filipino SLE patients with myocarditis is limited. This study aims to determine clinical characteristics and outcomes of myocarditis in Filipino patients with lupus. Methods: Review of medical records (between 2015 and 2017) of eight adult patients with lupus myocarditis in a tertiary government hospital was done. Clinical features, electrographic and echocardiographic findings, management, and outcomes were described. Results: All patients were females with a mean lupus duration of 10 months at the time myocarditis was diagnosed. Half of them had severe lupus activity, mostly with concomitant hematologic activity (100%) and nephritis (75%). Echocardiography showed wall motion abnormalities in all patients, with 63% having global hypokinesia and 75% having moderate to severe hypokinesia of the left ventricular wall. Treatment included methylprednisolone pulse therapy (88%) and high-dose steroids (13%). One patient died from cardiogenic and septic shock prior to receiving MPPT. Most patients (75%) were clinically improved at the time of discharge. Conclusion Filipino patients with lupus typically present with myocarditis early in the course of the disease, with high disease activity and concomitant hematologic activity and nephritis. Outcomes are generally favorable with early immunosuppressive therapy.
Lupus Erythematosus, Systemic ; Myocarditis

The assessment of mitral valve anatomy can be difficult or even misleading on standard cardiac imaging procedures. Such is the scenario in a 40-year-old woman with an incidental finding of atrial septal defect (ASD) and consideration of a trileaflet versus double-orifice mitral valve (DOMV) on transthoracic two-dimensional echocardiography. Further interrogation using transesophageal two dimensional and transthoracic three-dimensional (3D) echocardiography (to allow more accurate assessment and simultaneous viewing of multiple imaging planes) revealed the typical “seagull wing” configuration of the mitral valve on long-axis view and two distinct but nearly equal-sized orifices on short-axis view, one oriented anteriorly and the other posteriorly. The patient’s DOMV was classified as an incomplete bridge type as confirmed on 3D imaging, with each orifice having its own set of papillary muscles and chordal attachments. The mitral regurgitation was graded as severe, resulting from leaflet prolapse of the anterior orifice. No left ventricular outflow tract obstruction was demonstrated in this case, and the overall left ventricular systolic function was preserved. The ASD was of the primum type, with the configuration and exact location verified through 3D imaging. The accurate detection of congenital anomalies via noninvasive techniques and complementary advanced modalities is vital for preoperative planning, as well as anticipation of potential complications related to the structural anomalies. To our knowledge, this is the first local report of DOMV with primum ASD in an adult.

Objective. Several studies showed that genetic factors affect responsiveness to statins among different populations. This study investigated the associations of candidate genetic variants with poor response to statins among Filipinos.

Methods. In this unmatched case-control study, dyslipidemic participants were grouped into statin responders and poor responders based on the degree of reduction in LDL-c from baseline. DNA from blood samples were genotyped and analyzed. The association of candidate variants with statin response was determined using chi-square and logistic regression analysis.

Results. We included 162 adults on statins (30 poor responders as cases, 132 good responders as controls). The following variants are nominally associated with poor response to statin among Filipinos at a per-comparison error rate of 0.05: rs173539 near CETP (OR=3.05, p=0.015), rs1800591 in MTTP (OR=3.07, p=0.021), and rs1558861 near the BUD13-ZPR1-APOA5 region (OR=5.08, p=0.004).

Conclusion. Genetic variants near CETP, MTTP and the BUD13-ZPR1-APOA5 region are associated with poor response to statins among Filipinos. Further study is recommended to test the external validity of the study in the general Filipino population.

Lipids ; Hydroxymethylglutaryl-CoA Reductase Inhibitors

Background. Low levels of high-density lipoprotein cholesterol (HDL-c) is a well-recognized risk factor in the development of cardiovascular diseases. Associated gene variants for low HDL-c have already been demonstrated in various populations. Such associations have yet to be established among Filipinos who reportedly have a much higher prevalence of low HDL-c levels compared to other races.

Objective. To determine the association of selected genetic variants and clinical factors with low HDL-c phenotype in Filipinos.

Methods. An age- and sex-matched case-control study was conducted among adult Filipino participants with serum HDL-c concentration less than 35 mg/dL (n=61) and those with HDL-c levels of more than 40 mg/dL (n=116). Genotyping was done using DNA obtained from blood samples. Candidate variants were correlated with the low HDL-c phenotype using chi-squared test and conditional logistic regression analysis.

Results. Twelve single nucleotide polymorphisms (SNPs) were associated with low HDL-c phenotype among Filipinos with univariate regression analysis. The variant rs1260326 of glucokinase regulator (GCKR) (CT genotype: adjusted OR=5.17; p-value=0.007; TT genotype: adjusted OR=6.28; p-value=0.027) remained associated with low HDL-c phenotype, together with hypertension and elevated body mass index, after multiple regression analysis.

Conclusion. The variant rs1260326 near GCKR is associated with low HDL-c phenotype among Filipinos. Its role in the expression of low HDL-c phenotype should be further investigated prior to the development of possible clinical applications.

Cardiovascular Diseases ; Dyslipidemias ; Genetics ; Polymorphism, Single Nucleotide