INTRODUCTION: The pandemic caused by coronavirus disease 2019 (COVID-19) posed a serious challenge to all health care systems in the world. It has been found to be harmful in people with underlying cardiovascular diseases, particularly in patients with systemic hypertension, which may be due to upregulation of angiotensin-converting enzyme 2 (ACE2) expression, which may lead to increased severe acute respiratory syndrome coronavirus 2 virulence. Renin-angiotensin system inhibitor (RASI) acts by blocking the angiotensin-converting enzyme and angiotensin II type 1 receptors, which in turn affects the production of the ACE2 protein. Hence, there have been arguments on whether to continue or discontinue this medication. Given the widespread use of RASIs globally and the fact that they are generally cardioprotective, research into the safety of continuing these maintenance medications in patients hospitalized with mild to moderate COVID-19 is immensely needed. METHODS: This meta-analysis involved review of observational studies among hypertensive patients on maintenance ACE inhibitor or angiotensin-receptor blocker with confirmed mild to moderate COVID-19 infection. Analyses were performed to determine the adjusted hazard ratio of each event using the raw data obtained from each study. Random-effects model and Cochran-Mantel-Haenszel method were utilized at 95% confidence interval. To check for heterogeneity, χ2 test and I2 statistic were calculated. Cochrane ReviewManager (RevMan version 5.3) was used for data analysis, and forest plots were generated. RESULTS: At 95% confidence interval, the adjusted hazard ratios for all-cause mortality and intensive care unit (ICU) admission at 95% confidence interval were 1.64 (1.22, 2.21) and 1.93 (1.34, 2.79), respectively. The tests of overall estimate effect for both outcomes were P < 0.0001 for all-cause mortality and P = 0.0003 for ICU admission. CONCLUSION Discontinuation of maintenance RASI during hospitalization is associated with increased all-cause mortality and ICU admission among hypertensive patients with mild to moderate COVID-19 infection.
Angiotensin-Converting Enzyme Inhibitors ; Coronavirus:COVID-19

BACKGROUND Hypertension is the most common risk factor for cardiovascular disease in the Philippines. Despite the availability of antihypertensive medications that are effective, safe, and tolerated by Filipino patients, the numbers of uncontrolled hypertensives are still increasing. Several factors play in the poor control of blood pressure, particularly resistant hypertension and hyperactive sympathetic nervous system. Renal denervation therapy is a novel device that has been shown to lower blood pressure in patients with resistant and difficult-to-treat hypertension and is deemed safe in clinical trials. A Philippine Working Group composed of specialists in cardiology, hypertension, vascular surgery, and clinical epidemiology has come up with consensus statements in identifying patients who will benefit from the procedure. Locally, there is a need to have hypertension centers treating uncontrolled and resistant hypertension and offer renal denervation therapy to appropriate Filipino patients.
Blood Pressure

BACKGROUND: Studies have shown that inflammation plays a role in the pathogenesis of acute coronary syndrome (ACS). The use of platelet-to-lymphocyte ratio (PLR) as a marker for inflammatory conditions such as malignancy, systemic lupus erythematosus, and rheumatoid arthritis has been demonstrated in several studies. The aim of this study is to determine whether an elevated PLR taken on admission is associated with in-hospital mortality and major adverse cardiac events among ACS patients. METHODS: This is a single-center, retrospective correlational study. It included all ACS STsegment elevation myocardial infarction and non–ST-segment elevation myocardial infarction adult patients admitted from January 2011 to December 2020. Complete blood count on admission was used to derive the PLR. Patient’s course in the ward was reviewed for development of adverse clinical outcomes such as in-hospital mortality, arrhythmias, heart failure, cardiogenic shock, and reinfarction. Primary outcome for this study was in-hospital mortality, and the secondary outcomes were the development of other complications previously mentioned. Optimal cutoff value associated with in-hospital mortality was determined using receiver operating characteristic curve. RESULTS: A total of 342 patients were included in the study. Forty-three (12.57%) of the sample had in-hospital mortality and was noted to have higher PLR compared with patients who did not develop complications. Univariate logistic regression analysis showed a significant relationship between a high PLR and occurrence of in-hospital mortality (P = 0.0039). The optimal cutoff value of PLR that can predict in-hospital mortality is 165, with 52.17% sensitivity, 56.76% specificity, and an area under the curve of 59.69%. On the other hand, a high PLR did not show association with the development of complications during the hospital stay. CONCLUSION A PLR of >165 is a cheap, readily available marker that can be used to predict in-hospital mortality among Filipino patients with ACS.
Acute Coronary Syndrome

INTRODUCTION COVID-19 (coronavirus disease 2019), which is caused by the human severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), has reached a pandemic level. As a novel disease, local epidemiologic data are important to determine high-risk age groups, as well as risk factors that contribute to mortality. This study is a retrospective cohort study of 182 COVID-19–positive patients confirmed by real-time polymerase chain reaction. Baseline demographics and data on the preexisting cardiovascular comorbidities of 182 COVID-19 patients were collected by chart review and underwent statistical analysis using STATA 14 software (StataCorp, College Station, Texas). In the study, the majority of COVID-19 patients were 61 years or older (44.5%), with a higher prevalence of individuals 61 years or older among those who died (68.4%) compared with survivors (38.2%) (P = 0.005). In terms of gender, half of the patients were male (57.7%). In terms of cardiovascular disease, the most prevalent was hypertension (48.3%), followed by diabetes (28.0%). The prevalence of coronary artery disease (CAD) was significantly higher among patients who died (15.8%) compared with survivors (2.8%) (P = 0.022). In the univariate logistic regression analysis, older age was significantly associated with increased odds for mortality (odds ratio, 1.06; 95% confidence interval, 1.03–1.09). In terms of comorbidities, having CAD was significantly associated with increased odds for mortality (odds ratio, 6.6; 95% confidence interval, 1.7–24.6). Other variables were not significantly associated with mortality. In our study, advanced age and the presence of underlying CAD have been associated with an increased risk of in-hospital mortality among COVID-19 patients.
Cardiovascular Diseases ; COVID-19 ; mortality ; Sex

BACKGROUND: Sacubitril/valsartan is currently a standard medication in the treatment of reduced ejection fraction heart failure (HFrEF), and studies have also shown its efficacy for controlling hypertension. However, its efficacy varies between populations, and current recommendations are predominantly based on non Asian data. Hence, this study synthesizes the available evidence to determine its overall efficacy and safety among Asians. METHODS: A systematic search through PubMed, ScienceDirect, Cochrane, HERDIN PLUS, and ClinicalTrials.gov was done to include randomized controlled trials with Asian data comparing sacubitril/valsartan against an active control. The Cochrane Risk of Bias 2.0 was used to assess each article for bias. Forest plots in fixed-effects model for major adverse cardiovascular events (MACEs), hypertension control, and safety were created using RevMan 5.4. RESULTS AND DISCUSSION: Ten articles with an overall low risk of bias were included involving 6120 Asians. Sacubitril/valsartan showed better hypertension control against conventional angiotensin blocker (odds ratio [OR], 1.63; confidence interval [CI], 1.38–1.92; I2 = 7%). However, MACE reduction was not significant in HFrEF (hazard ratio, 0.89; CI, 0.73–1.08; I2 = 0%) or acute myocardial infarction (hazard ratio, 0.90; CI, 0.65–1.24; I2 = 0%). Safety was comparable to conventional angiotensin-converting enzyme inhibitors angiotensin receptor blocker (ARB) with a severe adverse event OR of 0.81 (CI, 0.44–1.50; I2 = 38%) and nonsevere adverse event OR of 1.09 (CI, 0.88–1.35; I2 = 44%). These results implicate the nee for efficacy studies focused on Asians, reassessment of the strength of recommendations in the treatment of heart failure, and consideration of sacubitril/valsartan as a treatment option for hypertension. CONCLUSION Among Asians, better hypertension control is seen with LCZ696 than conventional ARB. However, MACE reduction in HFrEF or acute myocardial infarction is insignificant, although there is a trend toward benefit. Finally, safety is comparable to conventional angiotensin-converting enzyme inhibitors/ARBs.\.
Asian ; Heart Failure ; Hypertension ; LCZ696 ; sacubitril and valsartan sodium hydrate drug combination

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS.
Acute Coronary Syndrome ; Critical Pathways ; Quality of Health Care