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The association of withdrawing maintenance renin-angiotensin system inhibitor on all cause mortality and intensive care unit admission among hypertensive patients admitted for mild to moderate COVID-19 infection: A meta-analysis of observational studies

Arlene Melissa T. Dychiching ; Erwin D. Dizon

Philippine Journal of Cardiology.2024;52(1):45-50.

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

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2023 Philippine Working Group Consensus Statement on renal denervation therapy for the management of hypertension

Raymond Oliva ; Deborah Ignacia D. Ona ; Lourdes Ella G. Santos ; Felix Eduardo Punzalan ; John David Tan ; Gilbert Villela ; Benjamin Balmores ; Krizia Camille Yap-Uy ; Roberta Maria Cawed-Mende ; Jose Nicholas Cruz

Philippine Journal of Cardiology.2024;52(1):12-18.

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

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The correlation of platelet-to-lymphocyte ratio levels with clinical outcomes in acute coronary syndrome patients admitted in a tertiary hospital from January 2011 to December 2020

Jehaila B. Tenorio ; Brian Joseph M. Calinawagan ; Kara Kirsty V. Congjuico

Philippine Journal of Cardiology.2024;52(1):21-26.

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

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Impact of age, sex, and cardiovascular disease in mortality in COVID-19 at the Medical City

Raymond G. Olazo ; Lucky Cuenza

Philippine Journal of Cardiology.2024;52(1):27-32.

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

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Efficacy and safety of sacubitril/valsartan in adverse cardiovascular event reduction and hypertension control among Asians: A systematic review and meta-analysis of randomized controlled trials

Patrick Vera Cruz ; Wisdom Ang ; Jose Bernardo Calatrava

Philippine Journal of Cardiology.2024;52(1):33-44.

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

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Development of a clinical pathway for acute coronary syndrome at Philippine General Hospital

Cecileen Anne M. Tuazon ; Paul Anthony O. Alad ; Albert Roy M. Rollorazo ; Lauren Kay Evangelista ; Ruth Divine Agustin ; Valerie Ramiro ; John Christopher Pilapil ; Bianca Velando ; Mark Joseph M. Abaca ; Jerahmeel Aleson L. Mapili ; Diana R. Tamondong-Lachica ; Eric Oliver D. Sison ; John C. Añ ; onuevo ; Felix Eduardo R. Punzalan

Philippine Journal of Cardiology.2024;52(1):61-92.

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

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Diagnostic performance of electrocardiographic criteria compared with echocardiographic diagnosis of left ventricular hypertrophy in patients at the Outpatient Department

Mary Grace A. Marquez ; Romulo Rommel Rosita

Philippine Journal of Cardiology.2023;51(1):55-61.

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.

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Perspectives of adult cardiology consultants regarding practice of clinical cardiology in the COVID-19 pandemic: A Q methodology study

Julianne Marie E. Yamamoto ; Clarissa M. Mendoza

Philippine Journal of Cardiology.2023;51(1):62-68.

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

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Windows, wings and wonder: Advanced cardiac imaging via transesophageal two-dimensional and transthoracic three-dimensional echocardiography for the accurate diagnosis of double-orifice mitral valve in the background of primum atrial septal defect: A case report

Jose Donato A. Magno ; Myla Salazar Supe ; Lilibel L. Ramos-Salamanca ; Rei A. Salangsang

Philippine Journal of Cardiology.2023;51(1):69-78.

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.

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A comparison of the 6-minute walk test to treadmill exercise test as a tool to evaluate functional capacity in healthy ManilaMed employees: The CoST TET study

Nicy F. Narvas ; Mariel Barcelon-Cruz ; Felix Eduardo Puzalan

Philippine Journal of Cardiology.2023;51(1):79-84.

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.

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