OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

BACKGROUND AND OBJECTIVE.

Severe Acute Respiratory Syndrome - Coronavirus-2 (SARS-CoV-2) was initially known to affect the respiratory system and has been reported to also involve the cardiovascular system leading to myocardial damage. Remdesivir is one of the approved treatments for COVID-19, wherein viral replication is inhibited by terminating the RNA transcription prematurely. According to studies, the primary electrocardiographic effect of remdesivir in COVID-19 patients are sinus bradycardia and QT prolongation. The use of electrocardiogram (ECG) is an essential diagnostic tool in assessing the electrical conditions of the heart. The objective of this study is to describe the electrocardiographic profile of adult patients with COVID-19 who were given remdesivir and admitted in the University of the Philippines-Philippine General Hospital (UP-PGH). To this date, this is the only study done locally identifying the electrocardiographic profiles of adult patients with COVID-19 who were given remdesivir.

METHODS

This was a retrospective descriptive study involving adult patients with COVID-19 who were given remdesivir and admitted in UP-PGH from June 2021 to June 2022. Demographic profiles and 12-lead ECG done during the hospital admission were gathered. Descriptive statistics was used to summarize the clinical characteristics and the electrocardiographic findings of the patients.

RESULTS

There were 412 confirmed COVID-19 patients who were given remdesivir (mean age 56 years old; female 52%) included in this study. The most common comorbidities were hypertension, diabetes mellitus, and stroke. Majority of the patients had severe (58%) to critical (22%) COVID-19 infection. Most of the patients had sinus rhythm (94%), normal rate (72%), and normal axis (93%). The most common baseline ECG findings were non-specific ST-T wave changes (42%). Some patients had atrioventricular blocks (3.4%), bundle branch blocks (3.6%), prolonged QT interval (1.9%). Among those with repeat 12-L ECG (136 patients) during admission, ECG changes observed were sinus bradycardia (6%), prolonged QT interval (4%), and both (1.5%).

CONCLUSION

Based on this retrospective review, which to our knowledge is the only study done locally investigating the effects of remdesivir on ECG of adult Filipino patients with COVID-19 infection, majority of the patients had sinus rhythm, normal rate, and axis. The most common ECG finding was non-specific ST-T wave changes. This study demonstrated a low incidence of adverse ECG changes that would preclude the administration of remdesivir when indicated. These include sinus bradycardia and QT interval prolongation which did not require further interventions. ECG remains to be useful, low-cost noninvasive tool that can help monitor electrophysiologic adverse events of remdesivir.

Electrocardiography ; COVID-19 ;

BACKGROUND AND OBJECTIVE

COVID-19 has been associated with cardiac injury, often detectable through electrocardiographic (ECG) changes. This study seeks to characterize the cardiovascular and electrocardiographic profiles of adult patients diagnosed with COVID-19.

METHODS

This study included adult patients with confirmed COVID-19 from June 2021 to June 2022. Clinical profiles and 12-lead ECG tracings were obtained from electronic medical records and reviewed independently by three cardiologists. Descriptive analysis was performed to summarize the cardiovascular and electrocardiographic findings in this population.

RESULTS

The study included 998 COVID-19 patients (mean age: 50 years; 53.7% male). The most common comorbidities were hypertension, diabetes, and dyslipidemia. A majority (31.36%) presented with severe COVID-19 infection. The most frequent significant ECG abnormalities observed at admission were sinus tachycardia (22.8%), and atrial fibrillation (11.02%). Additional ischemic findings included ST segment depression (2.91%), T-wave inversion (1.70%), and ST segment elevation (2.71%).

CONCLUSION

The baseline ECG findings among COVID-19 patients were predominantly normal; however, significant abnormalities were also identified. The most frequent abnormalities included sinus tachycardia, atrial fibrillation, and ischemic changes, all of which may have clinical implications.

Human ; Coronavirus Disease 19 ; Covid-19 ; Electrocardiography ; Atrial Fibrillation

INTRODUCTION

Heart failure (HF) is a common cause of hospitalization, heart failure-related readmission, poor quality of life, and mortality. It also poses a substantial economic burden. The heart failure clinical practice guideline (HFCPG) was developed to provide evidence-based recommendations on the diagnosis and management of chronic HF with reduced ejection fraction (HFrEF) among adult Filipino patients in the outpatient setting for primary care physicians.

METHODS

The GRADE approach and an Evidence-to-Decision framework were used to evaluate the evidence and formulate recommendations. The strength and direction of each recommendation were determined through voting, with consensus reached if 75% of all CP members agreed.

RESULTS

The HFCPG provides 19 recommendations and one good practice statement in response to 14 identified clinical questions. Careful history-taking and physical examination, use of chest x-ray to detect cardiomegaly and/or pulmonary congestion, two-dimensional echocardiography for HF diagnosis, and baseline determination of serum sodium, potassium, and creatinine to guide management have been highly recommended; however, the 12-lead electrocardiogram should not be solely used for HF diagnosis. Judicious use of diuretics to relieve congestion, use of selected beta-blockers, renin-angiotensin-aldosterone blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors are strongly recommended for the treatment of HFrEF.

CONCLUSION

HFrEF is a complex condition that requires early recognition and careful management. Guideline-directed medical therapies, particularly the evidence-based pillars of treatment, are recommended, as well as early discussion of palliative care, timely determination of advanced heart failure and the need for referral to higher levels of care.

Human ; Heart Failure ; Outpatient Care ; Ambulatory Care ; Primary Health Care

BACKGROUND AND OBJECTIVES

Heart Failure (HF) remains a major health concern worldwide. In the Philippine General Hospital (PGH), HF is consistently a top cause of mortality and readmissions among adults. The American College of Cardiology (ACC) and European Society of Cardiology (ESC) published guidelines for interventions that improve quality of life and survival, but they are underused and untested for local acceptability. Hospitals overseas used order sets created from these guidelines, which resulted in a considerable decrease in in-hospital mortality and healthcare costs. We aimed to develop an order set for adult patients with acute heart failure (AHF) admitted to the PGH Emergency Department (ED) to improve care outcomes.

METHODS

This study utilized a mixed methods approach to create the AHF order set. ESC and ACC HF guidelines were appraised using the AGREE II tool. Class I interventions for AHF were included in the initial order set. Through focused group discussions (FGD), clinicians and other care team members involved in the management of AHF patients at PGH ED modified and validated the order set. Stakeholders were asked to use online Delphi and FGD to get a consensus on how to amend, approve, and carry out the order given.

RESULTS

Upon review of HF guidelines, 29 recommendations on patient monitoring, initial diagnostic, and therapeutic interventions were adopted in the order set. Orders on subspecialty referrals and ED disposition were introduced. The AHF patient was operationally defined in the setting of PGH ED. The clinical orders fit the PGH context, ensuring evidence-based, cost-effective, and accessible care responsiveness to patients’ needs and suitable for local practice. Workflow changes due to COVID-19 were considered. Potential barriers to implementation were identified and addressed. The final order set was adopted for implementation through stakeholder consensus.

CONCLUSION

The PGH developed and adopted its own AHF order set that is locally applicable and can potentially optimize outcomes of care.

Human ; Quality Of Life ; Critical Pathways ; Quality Improvement

OBJECTIVE

This study aims to determine the clinical profile and incidence of in-hospital outcomes of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP).

METHODS

A retrospective descriptive cohort study. A review of medical records was done from July 2017 to October 2023 to collect data and in-hospital outcomes of patients who underwent CABG surgery under Z benefit package.

RESULTS

One hundred twenty-six patients were included in the study. The mean age of patients was 60 years and majority of them were male and came from NCR. Hypertension was the leading cause of comorbidity. The top two most common in-hospital outcomes were hospital-acquired pneumonia and postoperative atrial fibrillation. Most commonly observed caused of increased length in hospitalization was pneumonia. The mean Society of Thoracic Surgeons (STS) (operative mortality) and Euro scores were 1.04 ± 0.82 and 0.88 ± 0.56, respectively. All patients had successful surgical outcome with no mortality and an average length of stay in the hospital of six days.

CONCLUSIONS

This study will serve as a future reference to enhance screening criteria and improved in-hospital outcomes for those who will undergo CABG under Z benefit package. The study also showed insights on clinical profile and in-hospital outcomes of patients who underwent CABG in our own institution and this may give way to a larger scale of study involving multiple centers who also offer the said program.

Human ; Coronary Artery Bypass ; Atrial Fibrillation ; Insurance, Health

BACKGROUND AND OBJECTIVE

COVID-19 has been associated with cardiac injury, often detectable through electrocardiographic (ECG) changes. This study seeks to characterize the cardiovascular and electrocardiographic profiles of adult patients diagnosed with COVID-19.

METHODS

This study included adult patients with confirmed COVID-19 from June 2021 to June 2022. Clinical profiles and 12-lead ECG tracings were obtained from electronic medical records and reviewed independently by three cardiologists. Descriptive analysis was performed to summarize the cardiovascular and electrocardiographic findings in this population.

RESULTS

The study included 998 COVID-19 patients (mean age: 50 years; 53.7% male). The most common comorbidities were hypertension, diabetes, and dyslipidemia. A majority (31.36%) presented with severe COVID-19 infection. The most frequent significant ECG abnormalities observed at admission were sinus tachycardia (22.8%), and atrial fibrillation (11.02%). Additional ischemic findings included ST segment depression (2.91%), T-wave inversion (1.70%), and ST segment elevation (2.71%).

CONCLUSION

The baseline ECG findings among COVID-19 patients were predominantly normal; however, significant abnormalities were also identified. The most frequent abnormalities included sinus tachycardia, atrial fibrillation, and ischemic changes, all of which may have clinical implications.

Human ; Coronavirus Disease 19 ; Covid-19 ; Electrocardiography ; Atrial Fibrillation

BACKGROUND AND OBJECTIVE

Physician adherence to the recommended management of patients with heart failure with reduced ejection fraction (HFrEF) at the outpatient setting is crucial to reduce the burden of subsequent rehospitalization, morbidity, and mortality. Recently updated guidelines recommend early and rapid titration to optimal doses of medications in the first 2 to 6 weeks of discharge. In the absence of local data, our study evaluates physician adherence to guideline-recommended treatment in this setting.

METHODS

This is a retrospective cross-sectional study among post-discharge HFrEF patients at the outpatient department from December 2022 to May 2023 with a follow-up within three months. Clinical profile and treatment were extracted from medical records. Adherence to the 2021 ESC Guidelines Class I recommendations, among eligible patients, is measured as quality indicators. Data are presented using descriptive statistics.

RESULTS

A total of 99 patients were included in the study. Overall, adherence to prescription of beta-blockers (94.8%), ACEI/ARNI/ARBs (88.5%), and diuretics (100%) were high. Prescription of mineralocorticoid receptor antagonists (MRA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) were 67% and 57.3%, respectively. Over three months of follow-up, improvement in the quality of care was demonstrated with ACEI/ARNI/ARBs (81.8% to 90.9%), MRA (68.7 to 81.2%), and SGLT2i (58% to 67.7%). Beta-blocker use is consistently high at 97%. In the 3rd month post-discharge, titration to optimal doses was achieved in only 26.4%, 15%, and 6.25% for those on beta-blockers, ACEI/ARNI/ARB, and MRA, respectively. For non-pharmacologic management, referral to HF specialty was made in 30% and cardiac rehabilitation in 22.2%.

CONCLUSION

Among patients with HFrEF seen at the outpatient, there is good physician adherence to betablockers, ACEI/ARNI/ARBs, and diuretics. MRA and SGLT2i prescription, referral to HF specialty and cardiac rehabilitation, and up-titration to optimal doses of oral medications for HF need improvement. Hospital pathway development and regular performance evaluation will improve initiation, maintenance, and up-titration of appropriate treatment.

Human ; Outpatients

OBJECTIVE

This study aimed to estimate the incidence of hypertension and determine the risk factors for hypertension among apparently healthy adult Filipinos.

METHODS

This observational prospective community-based study included apparently healthy adult individuals aged 20–50 years from the Life Course Study in Cardiovascular Disease Epidemiology (LIFECARE) Philippine cohort at baseline and followed-up after an average of four years. Sociodemographic data, psychosocial stress, and clinical and metabolic profiles were obtained and analyzed. Multivariable Cox regression analysis was performed to identify factors associated with the development of hypertension.

RESULTS

A total of 2,089 non-hypertensive participants were included, with 59% women and average age of 35 years (SD = 8.4). The incidence rate of hypertension was 38.1 per 1,000 person-years. The cumulative incidence of hypertension over a mean follow-up time of four years was 15.4% (95% CI = 13.9–17.0%). The risk of incident hypertension was higher among males (aHR=1.3, 95% CI: 1.0–1.8; p=0.044), ≥40 years old (aHR=3.9, 95% CI: 2.6–5.8; pCONCLUSION

The 4-year incidence rate of hypertension among apparently healthy adult Filipinos is high. Increased age, male sex, family history of hypertension, abdominal obesity, and high normal blood pressure were significantly associated with the development of hypertension.

Human ; Hypertension ; Incidence

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