BACKGROUND: Cardiac Amyloidosis is a disorder of protein misfolding and metabolism in which insoluble fibrils are deposited in the myocardial extracellular matrix causing organ dysfunction and eventually death. It can exhibit cardiac signs and symptoms, or it can be identified through screening in patients who exhibit extracardiac symptoms of amyloidosis. As there were no clear clinical signs of cardiac amyloidosis and a biopsy is required to show amyloid deposition, the condition has been historically challenging to diagnose. Thus, a high index of suspicion based on the clinical presentation and the outcomes of the preliminary testing arecrucial to determine the approach to diagnosis. CASE SUMMARY: We outline a case of 75-year-old Filipino male who was admitted due to progressive exertional dyspnea. Cardiac Amyloidosis was considered due to evaluation findings of heart failure with preserved ejection fraction with restrictive type of cardiomyopathy. This was subsequently confirmed through extracardiac fat pad biopsy, echocardiographic strain analysis and Technetium (99mTc) Pyrophosphate (PYP) single photon emission computed tomography scan (SPECT). CONCLUSION This case report discussed the red flags of clinical manifestations of cardiac amyloidosis and highlighted the use of non-invasive diagnostic modalities to diagnose the disease. Cardiac amyloidosis remains a rare entity and with emerging therapies that have the potential to improve patient outcomes, early diagnosis is really important. Having high index of suspicion based on signs and symptoms can lead to early detection and an increased number of patients being referred for treatment.
Human ; Male ; Aged: 65-79 yrs old ; Coronary Artery Disease

INTRODUCTION: Several electrocardiographic (ECG) criteria have previously been suggested to diagnose left ventricular hypertrophy (LVH). Studies on diagnostic performance of each criterion in Asian population were limited and this study was done to determine the diagnostic performance of the six different ECG criteria, including the newly developed Peguero–Lo Presti criterion, in diagnosing LVH in Filipino patients. METHODOLOGY: A single-center retrospective cohort study was conducted. The comparison of ECG to echocardiographic diagnosis of LVH was assessed by Spearman ρ correlation. The area under the curve analysis was used to evaluate discrimination ability of ECG-LVH criteria to identify echocardiography-LVH. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the six criteria were described with 95% confidence interval, with P < 0.05 considered statistically significant. RESULTS: A total of 325 patients were included in the final analysis; 56.61% had LVH, 23.07% of which were both ECG-based and echocardiography-based LVH. The Peguero–Lo Presti criterion had the highest sensitivity (53.1%), a lower specificity (75.5%), and a lower accuracy (68.6%), compared with the other criteria. Sokolow-Lyon index had highest specificity (97.2%) and positive predictive value (75.0%). Cornell voltage had relatively better discriminative performance (area under the curve, 0.73). CONCLUSION Having a higher sensitivity, the Peguero–Lo Presti criterion can be used as a screening tool for LVH more than the Sokolow-Lyon and Cornell voltage. Cornell voltage criterion has higher correlation with left ventricular mass index and better discriminative ability for the detection of LVH. Further studies with the possibility of combining different ECG criteria are suggested to increase the sensitivity of the ECG criteria.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has drastically changed lives, challenging all to adapt new norms and survive. Safety guidelines for physician have been set, yet fear for health and safety hounds the physician. OBJECTIVE: The aims of this study were to segment cardiologists’ viewpoints according to perceived stressors and coping mechanisms in their clinical practice during the COVID-19 pandemic and to draw implications to coping in the light of the model of salutogenesis. METHODS: Q methodology, a mixed-method type of research, was used after approval from the UST Hospital Research Ethics Committee. Using convenience sampling, 30 adult cardiologists were included in this study. Following an informed consent to participate, they ranked-order 33 statements that answer the questions: “What are the stressors has this COVID-19 pandemic brought in your clinical practice of cardiology? How did you cope?” This was done on a Q grid with two “most agree” statements and two “most disagree” statements (Q-sort). A short interview followed the sorting to understand their most agree and most disagree statements. Q-sorting and interview were done via teleconferencing and in person. The Q sorts were then entered into a web-based PQMethod software (http://schmolck.org qmethod/downpqdos.htm). Typologies were generated through inductive approach. RESULTS: Three typologies were generated: the profession-driven cardiologists, the protocoldriven cardiologists, and the faith-driven cardiologists. CONCLUSION This study painted different personas of cardiologists as they conduct their practice in this pandemic. These typologies enabled the formulation of individual and group salutogenic measures that can help health care providers cope in this COVID-19 pandemic.
Cardiology ; COVID-19

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.

INTRODUCTION: Functional capacity is a strong predictor of mortality and nonfatal cardiovascular outcomes in both men and women with and without coronary artery disease. This study aimed to compare the distance traveled of the 6-minute walk test (6MWT) to the metabolic equivalent (MET) of the treadmill exercise test (TET) as a measure of functional capacity among healthy ManilaMed (Medical Center Manila) employees and to determine and compare the distance traveled in 6MWT and the MET of TET according to general characteristics such as age, sex, height, weight, and body mass index (BMI) as determinants of maximal walking distance and the cause of the early termination of the TET. METHODS: This was a single-center prospective cross-sectional study done at a private tertiary hospital. All participants underwent TET and 6MWT. Metabolic equivalent of TET, distance traveled in 6MWT, and the computed MET of the distance traveled were recorded and analyzed. RESULTS: Fifty healthy employees performed both the 6MWT and the TET to measure their functional capacity. Twenty-two were males, and 28 were females. The mean age was 31.80 ± 7.17 years, and the mean ± SD for BMI was 25.05 ± 4.32 kg/m2. Using 400 m as predictor of good functional capacity, the farther the distance traveled (>400 m), the higher the MET they achieved in the TET, and the lower the distance traveled (<400 m), the lower the MET achieved in the TET (t test P = 0.0125). This study also showed that more than or equal to 400-m distance traveled in the 6MWT can be used as a measure of good functional capacity in this population. However, there was a significant difference (t test P = 0.006) in the computed MET in the 6MWT in relation to the MET achieved in TET. In this study age, sex, and BMI were the predictors of the distance traveled in the 6MWT (P = 0.0049) and in the TET. CONCLUSION The distance traveled in meters in the 6MWT can be used as an objective measure of functional capacity in healthy population, and >400-m distance can be used as a parameter of good functional capacity. The formula used to compute MET in the 6MWT is not comparable with the MET achieved in TET. Age, sex, and BMI significantly influenced the performance in the 6MWT and TET.

INTRODUCTION: Resistant hypertension is blood pressure (BP) that remains above target despite treatment with maximum doses of three antihypertensive drugs, which may include a diuretic. The prevalence of resistant hypertension is unknown, and there are no local studies in the Philippines concerning this condition. METHODS: A retrospective descriptive cohort study was conducted in the Hypertension Clinic of the Section of Hypertension of the Philippine General Hospital. A total of 51 patients were diagnosed with resistant hypertension, and charts were reviewed and analyzed. RESULTS: Majority of the patients were female (31 [60.8%]), with a mean age of 56.3 years. All of them presented with symptoms; the most common presenting symptoms were headache, exertional dyspnea, nape pain, dizziness, and easy fatigability. Of the 51 patients, 45% also had diabetes mellitus, 11.8% had dyslipidemia, and 7.8% had a previous history of preeclampsia. Approximately 35% of these patients were smokers. The average BP before referral to the section was 167/94 mm Hg. By this time, most patients will either be on a four-drug regimen (42.1%) or a three-drug regimen (36.8%). The median number of visits in the Hypertension Clinic before control of BP was three follow-ups, with the average BP being 119/71 mm Hg. The regimens of the patients with controlled BP are three-drug combination (36.4%), four-drug combination (36.4%), and five-drug combination (27.3%). CONCLUSION Early referral to a hypertension specialist may benefit a patient with resistant hypertension, decreasing the number of follow-up visits to control a patient’s BP. Patients with resistant hypertension may require four- to five-drug regimens, which may be needed to adequately control a patient’s BP.
Drug Combinations ; Hypertension

INTRODUCTION: Accurate determination of volume status for patients with end-stage renal disease is essential in determining ultrafiltration rate during hemodialysis (HD). To complement the current dry weight method, inferior vena cava (IVC) collapsibility, made accessible by pointof-care ultrasonography, is considered. This study determined the utility of IVC measurement in estimating the volume status of patients during HD in comparison to clinical parameters. METHODS: A single-center cross-sectional design including 53 HD patients was conducted, with IVC measurements done through the Butterfly iQ ultrasound (Butterfly Network, Burlington, Massachusetts). RESULTS: Most patients were hypervolemic before HD based on weight (94.3%) and IVC collapsibility index (IVC CI; 75.5%), but only 30% had clinical symptoms. Body weight, maximum IVC diameter, minimum IVC diameter, and indexed IVC size significantly decreased after HD, whereas IVC-CI, blood pressure, and heart rate were unchanged. For the subset of patients with symptoms, absolute values of IVC measures were higher, but did not significantly change after HD, unlike in those without symptoms. For volume classification, there are discrepancies in the classifications based on the different measures, with most improvement seen when weight was used, but which was not reflected in IVC-CI. Change in weight and IVC measures were not significantly correlated. DISCUSSION This pilot study showed that the current dry weight method provides ultrafiltration rate estimation without causing intradialytic events. However, IVC can be a supplemental parameter to set higher targets and increase volume removal enough to cause intravascular change, especially in symptomatic patients. The incongruencies in classifying volume status suggest that there is no single measure to determine hemodynamic status and that using multiple parameters may provide a more reliable estimate.

INTRODUCTION: Hemostasis of the radial artery after transradial coronary procedure can be achieved either manually by means of a gauze or through a device compression band, and radial artery occlusion (RAO) is one of its common complications. The study sought to compare the occurrence of RAO between the two hemostasis methods being used after a transradialcoronary procedure. METHODS: This was a prospective, randomized, open-label, blinded endpoint study. A total of 137 patients undergoing a transradial coronary procedure were randomized equally using block randomization sampling technique. Radial artery patency was evaluated by color duplex ultrasonography within 24 to 72 hours after the procedure. The primary endpoint was early RAO. Secondary endpoints included complications such as access-site bleeding, pain, and hematoma. RESULTS: Three (2.19%) early RAOs occurred: one (1.47%) in the band compression device group and two (2.9%) in the manual gauze compression group (P = 1.000). There were no significant differences between the two groups regarding access-site bleeding (type 1 bleeding, 3 [4.48%] vs 2 [2.90%]; P = 0.678), pain (median pain score of 0 [0–6] vs 0 [0–7]; P = 0.742), and hematoma (grade I: 3 [4.41%]vs 2 [2.9%]; grade II: 0 vs 2 [2.9%]; grade III: none, and grade IV: 0 vs 2 [2.9%]) (P = 0.363). DISCUSSION Compression band device and manually applied gauze compression have similar rates of early RAO, access-site bleeding, pain, and hematoma.
Hemostasis

Single coronary artery (SCA) is a rare congenital anomaly in which there is an isolated coronary artery that arises from a single coronary ostium and provides coronary blood supply to the entire myocardium. SCA is classified based on Lipton Classification which includes the origin, branching pattern and course. We aim to present a rare case of congenital anomaly that presented with atypical symptoms and to discuss the features and classification of a single coronary artery. This is a case of a 30-year-old Filipino, male, known type 1 diabetes mellitus came in with diarrhea and vomiting, which later had severe abdominal pain. A consideration of Mesenteric ischemia was entertained due to abdominal pain not compatible with physical exam findings. He then underwent CT angiogram of the abdomen which was unremarkable, so a consideration of atypical presentation of chest pain was considered since patient is diabetic hence he underwent CT coronary angiogram and was noted to have SCA as an incidental finding.

INTRODUCTION: A vast number of COVID-19 cases have been reported worldwide since the initial outbreak in China, and the disease has since become a global pandemic. Knowledge on this predominantly respiratory illness is evolving with studies suggesting myocardial injury reflected by elevated cardiac enzymes portending to more severe disease. CT scoring indices provide visual, semi-quantitative assessment of lung involvement and have aided in determining extent of COVID-19 pneumonia but, none have been validated for prognostication. Establishing a relationship between these non-invasive diagnostic parameters could provide timely identification and proper allocation of limited medical resources to patients in need of more aggressive therapy. METHODS AND RESULTS: A total of 50 COVID-19 patients were retrospectively enrolled and their clinical parameters collected from an electronic medical database. There was a total of 31 patients with troponin I-HS with chest CT scan done and another 42 patients for NT-proBNP and chest CT. The levels of both cardiac biomarkers in patients with clinically severe COVID pneumonia were higher than those with mild and moderate disease. Rank-order analysis showed that both troponin I-HS (moderate, p=0.0003174) and NT-proBNP (moderate, p=0.006255) correlated positively with CT severity scores. Furthermore, there is a significant relationship between mortality and septic shock with both Troponin I-HS (p<0.001; p=0.002) and NT-proBNP (p=0.004; p=0.031). CONCLUSION The cardiac markers troponin I-HS and NT-proBNP increased significantly at more severe CT scores and more notably, these biomarkers predicted the development of septic shock and mortality in COVID-19 pneumonia.
COVID-19 ; NT-proBNP ; pro-brain natriuretic peptide (1-76) ; Troponin I