Introduction: Systemic lupus erythematosus (SLE) is increasingly being diagnosed in our country. This study aims to describe the clinical features, management strategies and outcome of patients with SLE during a ten-year period. Methods: This is a retrospective cohort study of patients first diagnosed with SLE at the National Kidney and Transplant Institute in 2004 who were then followed up in the next ten years. Results: Eighty-five patients were first diagnosed with SLE in 2004. The mean age was 28.1±12.03 years old. Hypertension (34.12%) was the most common co-morbid illness. Renal involvement (74.12%) was seen in a majority but only those with cardiopulmonary manifestations (mean=0.71 years, p=0.030) significantly affected survival. Eleven patients (12.94%) expired during the study period. Active disease and infection were the most common causes of death. Biopsyproven lupus nephritis had a significantly higher survival rate (mean=10.57 years, p=0.006). Those on hemodialysis had a significantly lower survival time (mean=8.82 years, p=0.040). Discussion: The estimated 10-year cumulative survival rate of patients with SLE in our cohort was 75%. This is comparable to the rates reported in some countries. Regular follow-up at six to eight weeks intervals with more frequent follow-up for patients with an SLE flare and/or on intensive immunosuppression was the most likely reason for studies reporting higher survival rates. The disparity in the survival rates may also be attributed to the frequency of exacerbations with better survival among those who never had exacerbations. The most common cause of death was due to septic shock secondary to pneumonia. The authors believe that one factor that was contributory to death was the degree of immunosuppression as observed in studies describing high doses of corticosteroids on those who have died. Conclusion The cumulative survival rate decreased from 90% at the time of diagnosis to 75% on the tenth year which was comparable to several countries. Patients with cardiopulmonary manifestations were found to significantly affect survival in this study. Although renal involvement was the most common initial manifestation, it did not significantly affect survival similar to other studies. However, biopsyproven lupus nephritis cases had better survival since this allowed treatment to be streamlined based on the class of lupus nephritis. Active disease and infection were the most common causes of death.
Lupus Erythematosus, Systemic ; Lupus Nephritis ; Survival

BACKGROUND. Acute myocardial infarction (AMI) among young people is relatively uncommon. The protection offered by a young age has been slowly taken away by the increased prevalence of risk factors for CHD in adolescents such as smoking, obesity, and lack of physical activity. CASE. This is a case of a 23-year-old male smoker with no known comorbid and heredofamilial diseases who was admitted due to sudden onset of severe, stabbing, substernal chest pain. ECG was done which showed sinus rhythm with some premature ventricular depolarizations occurring in bigeminy, and ST elevation on V4-V6, I and AVL with reciprocal ST depression on III, AVF (Fig 2) consistent with extensive anterior wall myocardial infarction. Troponin I was elevated (7.57 ng/ml). Coronary angiography was done revealing a luminal filling defect at the distal segment of the left main artery consistent with thrombus formation. The patient underwent percutaneous coronary intervention of the left main artery and left anterior descending artery with TIMI III flow after the procedure. He was then discharged improved and was advised to take his home medications with good compliance CONCLUSION. MI in younger patients does carry a better prognosis if appropriately treated to be taken into consideration when treating these young adults presenting with MI. Emphasis on the importance of secondary preventive measures should be noted.
Coronary Angiography ; Percutaneous Coronary Intervention ; Myocardial Infarction ; Risk Factors

Introduction: The American College of Cardiology/American Heart Association (ACC/AHA) revised the thresholds for the definition and treatment of hypertension that was recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) while the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure retained their previous classification but revised the recommendations for diagnosis and treatment. The impact of these changes in our setting is uncertain. This study aims to compare the prevalence of hypertension using the three proposed criteria in a primary preventive setting. Methods: This is a cross-sectional analytical study using data at the Primary Preventive Cardiology Clinic of the Philippine Heart Center from January 1, 2002 to December 31, 2017. Results: There were 2,082 patients in this study. The mean age is 57.1±10.9 years with a female predominance (72.5%). Most of the patients were married (67.3%, 1,401) and unemployed (67.1%, 1,398). Comorbid illnesses include dyslipidemia (48.2%) and type 2 diabetes mellitus (20.3%). The prevalence of hypertension using the JNC 7 and the 2018 ESC/ESH blood pressure (BP) classification was 56% (n=1,167). When the 2017 ACC/AHA BP classification was applied, there was a significant increase in the prevalence of hypertension to 80.3% (n=1671) (p<0.001) demonstrating an absolute increase of +24.2%. Conclusion The study shows a high prevalence of hypertension which further increased when the 2017 ACC/AHA BP classification was applied This can impose a significant public health burden that needs to be addressed to prevent or decrease hypertension-related complications. Use of the new guidelines may affect diagnosis and treatment of hypertension with potential cost implications.
Hypertension ; Prevalence ; Primary Prevention

Introduction: Acute coronary syndrome (ACS) presenting as non-ST-elevation myocardial infarction (NSTEMI) in a very young Filipina female with a maternal history of premature coronary artery disease and no comorbidities is a rare occurrence and seldom suspected. An integral approach using clinical presentation, information derived from ECG, cardiac troponin and risk assessment criteria should be used in order to arrive at the proper diagnosis and management. The other challenges encountered were angioedema secondary to clopidogrel hypersensitivity and financial constraints. These factors should be taken into consideration when deciding the short and long-term treatment especially after percutaneous coronary intervention and stenting. Case presentation: A 27-year-old active, female, Filipino, single, with a normal body mass index, non-smoker nonalcoholic drinker, no use of recreational drugs, no history of previous hospitalization, and comorbidities presented with sudden onset severe angina accompanied by diaphoresis and dyspnea. She was immediately brought to a local hospital, 12LECG showed T wave inversion on the inferior leads, troponin I was positive at 0.51ng/ml (0-.08) She was given aspirin, followed by clopidogrel in which she developed periorbital edema, dyspnea and was treated immediately with intravenous hydrocortisone and maintained on cetirizine and prednisone for five days. The clopidogrel was shifted to cilostazol. A coronary angiogram was done which showed a severe coronary artery disease at proximal right coronary artery. She underwent percutaneous coronary with stenting and was discharged stable and improved. Conclusion A delay in diagnosis and management may happen in a very young Filipino female presenting with acute chest pain and no comorbidities. A family history of premature coronary artery disease is a clinical marker of risk for acute coronary syndrome. A genetic testing may further establish this relationship. The clinical presentation of typical angina, T-wave inversions on inferior leads, highly abnormal cardiac troponin and very-high-risk criteria of recurrent or ongoing chest pain refractory to medical treatment warrants an immediate invasive strategy of coronary angiogram with revascularization. An angioedema secondary to clopidogrel hypersensitivity is a rare complication and can cause reluctance in a patient. The financial capacity to maintain long term treatment of dual antiplatelet should be considered for better compliance. A shared decision making between the physician and patient is a valuable tool in facing these challenges.
Myocardial Infarction ; Young Adult ; Cilostazol

Introduction: Superior mesenteric artery (SMA) syndrome is a rare and unusual acquired cause of functional duodenal obstruction whose diagnosis can be easily missed without knowledge of this condition. Case Presentation: We report a case of a 27-year-old female, presenting with post-prandial vomiting, early satiety, bloatedness and weight loss for about 10 months. Vital signs were stable. She was grossly underweight with a BMI of 11.72 kg/m2 (height=1.6m, weight=30kg). Physical examination was unremarkable. Gastrointestinal series revealed a narrowing in the third portion of the duodenum likely secondary to extrinsic compression. Contrast-enhanced CT scan of the whole abdomen was performed with 3D reconstruction. There were no definite signs of gastrointestinal obstruction. However, a narrow/acute aorto-mesenteric angle of 13 degrees compressing the third part of the duodenum was noted. Superior mesenteric syndrome was considered, prompting further work-up. Primary hyperthyroidism was the root cause of the patient’s weight loss that lead to this condition. Patient was given nutritional support, parenterally and enterally. She was discharged improved after oral feeding was tolerated and patient started to gain weight. Discussion: Superior mesenteric artery (SMA) syndrome is an uncommon medical condition brought about by a decrease in the aortomesenteric angle from the usual 45o to less than 15o resulting in vascular compression of the third part of the duodenum leading to gastrointestinal obstruction. A high index of suspicion is needed to prevent the diagnosis from being missed which may in turn lead to unnecessary testing and treatment. If recognized early, the condition may be managed conservatively. Surgical management is only required when conservative methods fail. Conclusion Early recognition and a thorough evaluation is therefore imperative so conservative measures can be maximized at the outset.
Superior Mesenteric Artery Syndrome

Introduction: Acute myocardial infarction (AMI) is rare in “very young” patients and studies among Filipinos are scarce. The objective of this study is to determine the prevalence, clinical, echocardiographic and angiographic features, and outcome of this population. Methods: A retrospective study of patients aged 19 to 30 years old who were diagnosed with AMI at the Philippine Heart Center from 2012 to 2016 was done. Results: The prevalence of AMI in very young Filipino adults at our institution was 0.93% (11/1182). The mean age was 26.5±3.4 years with a male predominance (82%). Chest pain was the most common symptom (91%). More than half of the patients did not have heredofamilial diseases. Eight patients were smokers (72%). There was one case of illegal drug use (methamphetamine) (9%). There were only two cases of non-ST elevation myocardial infarction (NSTEMI) (18%). ST elevation myocardial infarction (STEMI) of the anterior wall was seen in four cases (36%), inferior wall in three cases (27%) and anterolateral wall in two cases (18%). Six patients (45%) had left anterior descending artery (LAD) involvement. Two patients (18%) had right coronary artery (RCA) involvement. Two patients (18%) had both LAD and RCA involvement. The youngest patient, a 19-year-old female with Takayasu arteritis, had three-vessel involvement. Five patients (45%) underwent percutaneous coronary involvement (PCI) of the LAD while two had PCI of the RCA (18%). All patients were discharged improved. Discussion: Acute myocardial infarction (AMI) in the young has not been extensively studied among Asians. Chest pain is the most common clinical presentation with STEMI being more frequent than NSTEMI in this age group. Male gender and smoking were the most common risk factors. Conclusion Early recognition and prompt management of AMI, particularly revascularization (if indicated), are of paramount importance to optimize outcomes.
Smokers

BACKGROUND

Brugada syndrome is an inheritable syndrome that carries an increased risk of sudden cardiac death. This study aims to delineate the natural history, clinical and electrophysiologic profile, treatment strategies, and outcomes of patients with Brugada pattern electrocardiogram (ECG) and Brugada syndrome in a tertiary care hospital in the Philippines.

This is a retrospective observational study of patients diagnosed with Brugada pattern ECG and Brugada syndrome admitted in a single center from 2004 to 2019.

Twenty-three patients were included in the study. All patients were male. In both groups, the majority were nonsmokers (n = 13) and nonalcoholic beverage drinker (n = 14). In patients with Brugada pattern ECG, all presented as an incidental finding (n = 10; P < 0.001), whereas in Brugada syndrome, six patients presented with out-of-hospital resuscitated cardiac arrest (46.15%, P = 0.019). There were only three patients with a family history of sudden cardiac death. All patients had normal ejection fraction and sinus rhythm. Twenty-one patients had ST elevation (91.30%). Fourteen patients had spontaneous type 1 Brugada pattern ECG, whereas the rest were inducible to type 1 after flecainide test. Seven patients underwent implantable cardioverter defibrillator implantation before discharge; one patient died at the time of diagnosis, and one had recurrent admission for arrhythmia. No single patient received medical management.

Clinical profile, ECG findings, and outcomes were not significantly different between the two groups of patients except for the clinical presentation upon diagnosis. Treatment strategies were guideline-directed.

INTRODUCTION: Obesity has been linked to the development of type 2 diabetes mellitus (T2DM) and cardiovascular diseases. This study primarily aims to determine the prevalence of obesity among the Filipino patients in our institution since there have been no previous studies on this subset of patients. METHODS: A cross-sectional analytical study of 2,078 patients at the Primary Preventive Cardiology Out-Patient Clinic of the Philippine Heart Center (PHC) was done from January 1, 2002 to December 31, 2017. The prevalence of obesity was determined using the World Health Organization (WHO) and Asian classification. Factors associated with obesity were determined using binary logistic regression analysis. RESULTS: A majority of the patients were females (1499, 71.14%) with a higher mean age compared to the male patients (57.67±10.5 vs 55.66±11.8, p<0.001). Hypertension (68.5%), coronary artery disease (37.1%) and T2DM (20.3%) were the most common co-morbid illnesses in both genders. The mean body mass index (BMI) was 25.8±4.3 kg/m2 for the female patients while it was 25.2±4.1 kg/m2 for the male patients (p<0.001). The prevalence of obesity using the WHO and Asian classifications was 15% (n=312). Compared to the Asian criteria, there were significantly more patients classified as having normal weight (44.09% vs 24.95%, p<0.001) and overweight (37.98% vs 19.13%, p<0.001) using the WHO classification. Pre-obesity, an additional criterion of the Asian classification which was not adopted by WHO was seen in 37.98% of the patients. On multivariate analysis, female gender (OR 1.31, 95% CI [1.08-1.59)] p=0.006) and T2DM (OR 1.25, 95% CI [1.01-1.56], p=0.42) were significant factors associated with obesity while age (OR 0.98, 95% CI [0.98-0.99], p<0.001) was protective of obesity. CONCLUSION: The prevalence of obesity in our cohort was consistent with the worldwide prevalence reported by the WHO which underscores the need for effective weight management programs and primary preventive strategies 7to lower the prevalence and obviate the development of complications related to obesity. Female gender and T2DM were significant factors associated with obesity, while age was a significant protective factor of obesity.
Overweight ; Obesity ; Primary Prevention

Introduction: Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy that may occur in isolation or with an associated cardiac anomaly. It presents with a wide array of manifestations, prompting early recognition to be imperative to prevent progression of symptoms. Case presentation: We report a case of a 46-year-old male complaining of palpitations for 10 years who survived sudden cardiac arrest on the same year as symptom onset. Consult was advised but was not done until he had heart failure symptoms. Carvedilol, furosemide and digoxin were given. Initially, some improvement was noted but he later developed dyspnea on exertion prompting consult at our institution. Pertinent physical examination findings include a dynamic precordium, apex beat at sixth left intercostal space-anterior axillary line (LICS AAL), right ventricular heave, distinct heart sounds, normal rate, irregularly irregular rhythm, a grade 4/6 continuous murmur heard best at the left upper sternal border, suggestive of patent ductus arteriosus (PDA), and a grade 3/6 holosystolic murmur at the apex radiating to the axilla, suggestive of mitral regurgitation. Transthoracic echocardiography confirmed presence of a PDA (0.8cm) with left to right shunt and Qp/Qs of 2.7:1. Incidental finding of LVNC was noted characterized by prominent ventricular trabeculations and deep intertrabecular recesses. Optimal medical treatment for heart failure was given with symptomatic relief. Surgical closure of the PDA was contemplated after hemodynamic studies can confirm the absence of irreversible pulmonary hypertension. Discussion: Patients with LVNC may be asymptomatic or may present with heart failure, sudden cardiac death or arrhythmias. The diagnosis of LVNC poses a diagnostic challenge. Echocardiography is a cost-effective diagnostic tool that will allow early diagnosis. Cardiac magnetic resonance (CMR) imaging is an alternative diagnostic modality. Once the diagnosis has been confirmed, prompt initiation of guideline-directed medical treatment for heart failure may prevent progression of disease. Conclusion Left ventricular non-compaction may occur in isolation or in association with other congenital heart diseases such as patent ductus arteriosus. Closure of a PDA is indicated in the presence of a significant shunt and with confirmation of acute reversibility in the presence of pulmonary hypertension to prevent the possibility of decompensation in a patient with heart failure.
Ductus Arteriosus, Patent ; Cardiomyopathies ; Death, Sudden, Cardiac

Introduction: In contrast to embolic events to the brain, lungs and spleen which have been comprehensively discussed in literature, acute limb ischemia (ALI) due to septic embolism (SE) from infective endocarditis (IE) are uncommonly reported. There have been no reported cases of ALI as a complication of IE among Filipinos to date making this case report the first in our country Case Presentation: We report two cases of communityacquired native valve endocarditis caused by streptococcus spp. and enterococcus faecalis. Both patients had large and mobile vegetations in the mitral valve and aortic valve respectively on transthoracic echocardiography. The first one developed ALI (IIa) on the R leg after the initiation of antibiotics. The second case presented with ALI (IIa) on the R leg on admission. They were given the appropriate antibiotics and received systemic anticoagulation with heparin. The first case underwent successful emergency embolectomy on the R leg but developed new-onset ALI on the L leg and refused further intervention. Embolectomy was also recommended on the second patient who also re-fused any intervention. Despite maximal medical management, both patients subsequently expired Conclusion Infective endocarditis (IE) patients are at risk to develop SE before or during the initiation of appropriate antibiotics. ALI is a life threatening extra cardiac complication of IE. Early recognition and prompt aggressive management are therefore imperative.
Endocarditis