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

INTRODUCTION

The existence of a coronary artery aneurysm (CAA) can pose significant risk for death. It can cause thrombosis, dissection, rupture or myocardial infarction. An exceedingly rare involvement of the left main coronary artery (LMCA), particularly giant-sized is even more catastrophic, a finding seen in only 0.1% of patients. Furthermore, co-existence with significant stenotic coronary artery disease (CAD) portends grim survival. Owing to the rarity of this combination, no data is available locally and only limited case reports are documented internationally. Hence, no consensus guidelines have been published yet. This paper aims to contribute to the sparse medical knowledge on the treatment approach and management of LMCA aneurysm with concomitant CAD.

CASE PRESENTATION

A 62-year-old male, Filipino, hypertensive and hyperlipidemic sought consult due to one-year exertional chest pain. Coronary angiogram revealed the LMCA to be a diffusely aneurysmal, large-sized vessel measuring 9.7 mm x 7.9 mm with a significant two-vessel CAD affecting the proximal left anterior descending (LAD) and right coronary artery (RCA). As per multidisciplinary decision, the patient underwent surgical revascularization via cardiopulmonary bypass graft (CABG) addressing the CAD and LMCA aneurysm managed conservatively through guideline-directed medical therapy. The patient’s course of treatment was uneventful. He returned for follow-ups for three months post-surgery and remained symptom-free.

DISCUSSION

Giant coronary artery aneurysms (GCAA) are vessel dilatations that exceed 4x the diameter of a normal adjacent artery. The patient had a unique case of GCAA involving the LMCA combined with two-vessel CAD. Few studies have documented a medical or surgical approach and long-term outcomes are unknown. Without sufficient evidence-based guidelines, the multidisciplinary decision was to perform CABG and manage the LMCA aneurysm conservatively.

CONCLUSION

Due to extremely limited information available on the giant LMCA aneurysm natural history, definitive management remains controversial. A multidisciplinary team approach is highly recommended for patient-specific needs to achieve favorable outcome and ensure survival.

Human ; Male ; Middle Aged: 45-64 Yrs Old ; Thrombosis ; Therapeutics ; Research Report ; Myocardial Infarction ; Coronary Artery Disease

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized cancer patients. The Khorana and Padua risk scores are widely used tools for predicting VTE, but their comparative performance in hospitalized cancer patients has not been fully assessed. This study aims to evaluate the predictive performance of these two risk assessment models in predicting VTE in hospitalized patients with malignancy.

METHODS

This cross-sectional study was conducted at a tertiary hospital between January 2022 and December 2023. A total of 200 hospitalized patients with malignancy were enrolled. Their baseline demographics, medical history and diagnostic data were collected. Patients were stratified into risk categories using the Khorana and Padua models, and their predictive abilities were assessed through sensitivity, specificity and area under the curve (AUC) analyses. The diagnosis of deep vein thrombosis (DVT) was confirmed with evidence of an intraluminal deep venous filling defect on CT or catheter venography, or a deep vein thrombus identified by color Doppler. Pulmonary embolism (PE) was diagnosed by pulmonary angiography showing an intraluminal filling defect of the pulmonary artery visualized through computed tomography pulmonary angiography or magnetic resonance imaging.

RESULTS

The Khorana score demonstrated a sensitivity of 83.3%, specificity of 77.5% and an AUC of 0.81. The Padua score showed a sensitivity of 76.7%, specificity of 85.5% and an AUC of 0.79. Both models showed good predictive accuracy. However, the Khorana score having a high sensitivity makes it suitable for identifying high-risk patients, while the Padua score having a high specificity makes it better at ruling out low-risk patients.

CONCLUSION

Both the Khorana and Padua scores are valuable tools for predicting VTE in hospitalized cancer patients, but the Khorana score may be more effective for cancer-specific risk stratification. Further prospective studies are needed to confirm these findings.

Human ; Male ; Female ; Morbidity ; Neoplasms ; Thromboembolism ; Venous Thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized cancer patients. The Khorana and Padua risk scores are widely used tools for predicting VTE, but their comparative performance in hospitalized cancer patients has not been fully assessed. This study aims to evaluate the predictive performance of these two risk assessment models in predicting VTE in hospitalized patients with malignancy.

METHODS

This cross-sectional study was conducted at a tertiary hospital between January 2022 and December 2023. A total of 200 hospitalized patients with malignancy were enrolled. Their baseline demographics, medical history and diagnostic data were collected. Patients were stratified into risk categories using the Khorana and Padua models, and their predictive abilities were assessed through sensitivity, specificity and area under the curve (AUC) analyses. The diagnosis of deep vein thrombosis (DVT) was confirmed with evidence of an intraluminal deep venous filling defect on CT or catheter venography, or a deep vein thrombus identified by color Doppler. Pulmonary embolism (PE) was diagnosed by pulmonary angiography showing an intraluminal filling defect of the pulmonary artery visualized through computed tomography pulmonary angiography or magnetic resonance imaging.

RESULTS

The Khorana score demonstrated a sensitivity of 83.3%, specificity of 77.5% and an AUC of 0.81. The Padua score showed a sensitivity of 76.7%, specificity of 85.5% and an AUC of 0.79. Both models showed good predictive accuracy. However, the Khorana score having a high sensitivity makes it suitable for identifying high-risk patients, while the Padua score having a high specificity makes it better at ruling out low-risk patients.

CONCLUSION

Both the Khorana and Padua scores are valuable tools for predicting VTE in hospitalized cancer patients, but the Khorana score may be more effective for cancer-specific risk stratification. Further prospective studies are needed to confirm these findings.

Human ; Male ; Female ; Morbidity ; Neoplasms ; Thromboembolism ; Venous Thromboembolism

Introduction: The growing popularity of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for weight management has inadvertently perpetuated demand for unregulated experimental peptides procured through gray markets. Retatrutide, a novel triple GLP-1/glucose-dependent insulinotropic polypeptide (GIP)/glucagon receptor agonist undergoing Phase III trials; AOD -9604, an abandoned synthetic human growth hormone fragment; and tesamorelin, a synthetic GHRH analogue, are increasingly self-administered without medical supervision. Their combined metabolic and thromboembolic risks remain unknown and unreported. Case: A 50-year-old Malaysian female with morbid obesity and poorly controlled type 2 diabetes mellitus (hemoglobin A1c 13%) presented with acute dyspnea, chest tightness, syncope, and cardiogenic shock. Three weeks prior, she had self-initiated subcutaneous retatrutide, AOD-9604, and tesamorelin procured through unregulated online platforms, achieving rapid weight loss of 10 kg. Despite markedly reduced oral intake from GLP-1-mediated gastrointestinal side effects, she continued her prescribed high-dose insulin regimen and sodium-glucose cotransporter-2 (SGLT2) inhibitor without dose adjustment. She developed concurrent diabetic ketoacidosis, confirmed biochemically, alongside massive saddle pulmonary embolism with right ventricular strain on echocardiography and computed tomography pulmonary angiography. She was successfully treated with systemic thrombolysis using alteplase, guideline-directed diabetic ketoacidosis management including fixed-rate insulin infusion and fluid resuscitation, and anticoagulation. The SGLT2 inhibitor was withheld throughout admission. She was discharged on rivaroxaban with counseling to cease all unregulated compounds. All three agents were submitted to the National Pharmaceutical Regulatory Authority/Malaysian Adverse Drug Reactions Advisory Committee for adverse drug reaction reporting. Conclusion To our knowledge, this is the first reported case of concurrent massive pulmonary embolism and diabetic ketoacidosis precipitated by unsupervised gray-market retatrutide, AOD-9604, and tesamorelin. Clinicians should enquire about unregistered supplement use, counsel insulin-dependent patients on sick-day rules when appetitesuppressing agents are initiated, and report adverse events to pharmacovigilance authorities.
AOD 9604 ; tesamorelin ; Diabetic Ketoacidosis ; Pulmonary Embolism ; Peptides

OBJECTIVES: Global epidemiological data indicate that 20% to 30% of intensive care unit (ICU) sepsis patients progress to deep vein thrombosis (DVT) due to coagulopathy, with an associated mortality rate of 25% to 40%. Existing prognostic tools have limitations. This study aims to develop and validate nomogram and machine learning models to predict in-hospital mortality in sepsis patients with DVT and assess their clinical applicability. METHODS: This multicenter retrospective study drew on data from the Medical Information Mart for Intensive Care IV (MIMIC-IV; n=2 235), the eICU Collaborative Research Database (eICU-CRD; n=1 274), and the Patient Admission Dataset from the ICU of Third Xiangya Hospital, Central South University (CSU-XYS-ICU; n=107). MIMIC-IV was split into a training set (n=1 584) and internal validation set (n=651), with the remaining datasets used for external validation. Predictors were selected via least absolute shrinkage and selection operator (LASSO) regression and Bayesian Information Criterion (BIC), and a nomogram model was constructed. An extreme gradient boosting (XGBoost) algorithm was used to build the machine learning model. Model performance was assessed by the concordance index (C-index), calibration curves, Brier score, decision curve analysis (DCA), and net reclassification improvement index (NRI). RESULTS: Five key predictors, age [odds ratio (OR)=1.02, 95% CI 1.01 to 1.03, P<0.001], minimum activated partial thromboplastin (APTT; OR=1.09, 95% CI 1.08 to 1.11, P<0.001), maximum APTT (OR=1.01, 95% CI 1.00 to 1.01, P<0.001), maximum lactate (OR=1.56, 95% CI 1.39 to 1.75, P<0.001), and maximum serum creatinine (OR=2.03, 95% CI 1.79 to 2.30, P<0.001), were included in the nomogram. The model showed robust performance in internal validation (C-index=0.845, 95% CI 0.811 to 0.879) and external validation (eICU-CRD: C-index=0.827, 95% CI 0.800 to 0.854; CSU-XYS-ICU: C-index=0.779, 95% CI 0.687 to 0.871). Calibration curves indicated good agreement between predicted and observed outcomes (Brier score<0.25), and DCA confirmed clinical benefit. The XGBoost model achieved an area under the receiver operating characteristic curve (AUC) of 0.982 (95% CI 0.969 to 0.985) in the training set, but performance declined in external validation (eICU-CRD, AUC=0.825, 95% CI 0.817 to 0.861; CSU-XYS-ICU, AUC=0.766, 95% CI 0.700 to 0.873), though it remained above clinical thresholds. Net reclassification improvement was slightly lower for XGBoost compared with the nomogram (NRI=0.58). CONCLUSIONS Both the nomogram and XGBoost models effectively predict in-hospital mortality in sepsis patients with DVT. However, the nomogram offers superior generalizability and clinical usability. Its visual scoring system provides a quantitative tool for identifying high-risk patients and implementing individualized interventions.
Humans ; Sepsis/complications* ; Machine Learning ; Nomograms ; Venous Thrombosis/complications* ; Retrospective Studies ; Hospital Mortality ; Male ; Female ; Middle Aged ; Aged ; Intensive Care Units ; Prognosis ; Bayes Theorem

BACKGROUND

Balancing the benefits of preventing venous thromboembolism (VTE) against the risks of bleeding is important for patients who need prophylactic anticoagulants. This study compared which of the bleeding scores (IMPROVE and HAS-BLED BRS scores) is better at predicting anticoagulant-related bleeding events in critically ill and non-critically ill patients at a tertiary hospital who received prophylactic enoxaparin.

METHODOLOGY

Sixty-nine (69) patients in the ICU and ward who received prophylactic enoxaparin were included in the study and followed until discharge. Demographic data, comorbidities and IMPROVE and HAS-BLED BRS scores were recorded, and bleeding events monitored.

RESULTS

During the study, 16% (11/69) of the study population experienced bleeding events, both major and minor. Patients with IMPROVE BRS ≥ 7 (high risk) were more likely to bleed than those with scores of < 7 (low risk) (p < 0.001). The average HAS-BLED BRS was 2.20 (±1.09). Patients with higher HASBLED BRS scores had a slightly higher rate of bleeding (bleeding event, 2.73 [±1.19] versus no bleeding event, 2.09 [±1.04]), but this difference was not statistically significant (p = 0.079). The IMPROVE BRS had a higher area under the curve (AUC) (0.96) than the HAS-BLED BRS (0.67) in predicting anticoagulant-related bleeding events.

CONCLUSION

In patients receiving prophylactic anticoagulants for VTE, the IMPROVE BRS was better at predicting major anticoagulant-related bleeding events than the HAS-BLED BRS, with higher sensitivity, specificity and accuracy. Both risk scoring systems are useful for assessing bleeding risk before starting pharmacologic VTE prophylaxis, but the IMPROVE BRS is more accurate.

Human ; Venous Thromboembolism

BACKGROUND

The significance of isolated calf deep vein thrombosis (ICDVT) remains unclear with current guidelines not being based on strong level of evidence. Given the uncertainties, the therapeutic approaches vary among institutions; hence, it is prudent to look at existing experience of an institution where examination of calf veins is routinely done during venous duplex ultrasound of the lower extremities.

METHODS

Using an analytical retrospective cohort design, this study investigated the clinical profile and outcomes of patients noted to have ICDVT on venous duplex scan at a single tertiary center from October 1, 2018 to June 30, 2023.

RESULTS

A total of 151 subjects were included in the study. Most of the cases had either stabilization (36.42%, 95% CI: 28.75%-44.64%) or complete resolution (35.76%, 95% CI: 28.14%-43.96%) of ICDVT. Recurrence occurred in 15.89% (95% CI: 10.46%-22.72%) while proximal DVT extension only occurred in 10.60% (95% CI: 6.18-16.64%) of the subjects. None of the factors studied, including therapeutic management, were significantly associated with proximal DVT extension, recurrence, pulmonary embolism and stabilization of ICDVT. When it comes to resolution of ICDVT, only therapeutic management was found to have significant association.

CONCLUSION

Previously cited medical risk factors do not play a role in the development of ICDVT complications. While anticoagulation contributes to resolution of ICDVT, it can safely be managed conservatively in cases of high bleeding risk.

Human ; Thrombosis

Systemic Lupus erythematosus (SLE) is a multiorgan autoimmune disease that affects 20-150 per 100,000 women. It is a mutagenic disease which causes formation of autoantibodies immune complexes that leads to inflammation in different organs leading to organ damage. We present a case of a young female who was newly diagnosed to have SLE. She presented with an elevated ANA, low C3 and elevated Anti-DS DNA. She first manifested with epistaxis and subsequently experienced the various complications of SLE such as infection, thrombosis, bleeding, ascites, etc. The initial presentation of normochromic, normocytic anemia and thrombocytopenia together with further work-ups supported another concomitant autoimmune disease, namely Evan’s syndrome. Evan’s syndrome is a rare manifestation of SLE, and is observed in only 2.73% of the population. In addition, the patient manifested with sudden onset of right-sided body weakness with Cranial CT scan findings of areas of focal infarction in the frontal lobe with concomitant acute intracranial hemorrhages. The evidence of both thrombosis and hemorrhage provided conflicting management strategies for this patient. The use of hydroxychloroquine, which is the cornerstone of lupus therapy, provided beneficial antithrombotic effects. A multidisciplinary approach to management and prudent choice of medications were vital in the success of treatment on such a complicated case.

Human ; Female ; Adult: 25-44 Yrs Old ; Lupus Erythematosus, Systemic ; Thrombosis ; Hemorrhage

Cardiac myxomas are primary cardiac tumors that presents with symptoms of hemodynamic derangement from obstruction of flow within the cardiac chambers or deformation of a cardiac valve and symptoms associated with embolization.

In this case report, we are presented with a 45-year-old female, diabetic with paroxysmal atrial fibrillation, fair functional capacity, ambulatory, with chief complaint of dyspnea. Admitted as a case of Left atrial myxoma with Pulmonary embolism (proximal right lower lobe, distal left main pulmonary artery division, and superior segmental division of the left lower lobe).

Left atrial myxoma was the first diagnostic consideration, followed by other primary cardiac tumors, and thrombus. Patient was then prepared for surgery and underwent excision of LA myxoma with CardioCel Bioscaffold patch on the inter-atrial septum, mitral ring annuloplasty with plication of the A2-A3 segment, thrombectomy of right inferior pulmonary vein, utilizing cardiopulmonary bypass. Upon pathological examination, the mass was found to be sarcoma with noted myxoid features. The objective of this report is to describe a case of this rare disease entity, and to discuss its presentation, pathological findings and management.

Human ; Female ; Middle Aged: 45-64 Yrs Old ; Pulmonary Embolism ; Pulmonary Artery ; Pulmonary Veins ; Atrial Fibrillation ; Atrial Septum ; Cardiopulmonary Bypass ; Hemodynamics ; Thrombectomy