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

Abstract Hyperkalemia (serum potassium >5.0 mEq/l) is a significant complication in patients with heart failure, chronic kidney disease, and diabetes mellitus, particularly when treated with renin-angiotensin-aldosterone system inhibitors (RAASi). Both hyperkalemia and RAASi interruption are associated with increased cardiovascular events, hospitalizations, and mortality. This expert opinion document, developed between January and December 2024 through a systematic process, aims to establish guidance for hyperkalemia treatment in Indonesian patients with cardiorenal diseases receiving RAASi therapy, addressing the unique challenges within the Indonesian healthcare context. A comprehensive literature review of international guidelines and regional studies was conducted by a panel of 11 expert specialists (3 cardiologists, 6 internist-nephrologists, and 2 internist-cardiologists), who evaluated 29 statements covering diagnosis, monitoring, prevention, and treatment of hyperkalemia. Of the 29 statements, 26 reached consensus: 17 statements achieved very high agreement (≥90%) and 9 attained high agreement (≥67% – <90%). The agreed statements covered key areas, including potassium monitoring frequency, RAASi dose optimization strategies, dietary modifications, and treatment thresholds. Three statements regarding alternative therapeutic approaches did not receive agreement (<67%) due to limited local availability and cost considerations. Key recommendations include structured monitoring protocols for high-risk patients, strategies for RAASi dose optimization while managing hyperkalemia risk, and specific interventions adapted to local resources. This document provides a practical approach for managing hyperkalemia in Indonesian patients with cardiorenal diseases while maintaining optimal RAASi therapy, considering local Indonesian healthcare resources and constraints.
Hyperkalemia ; Cardio-Renal Syndrome ; Renin-Angiotensin System ; Indonesia

Introduction: Cushing’s syndrome is a multisystem disorder with significant cardiovascular morbidity, yet presentation as acute heart failure is uncommon. When driven by adrenocortical carcinoma (ACC), the clinical course is often aggressive and rapidly fatal, with particularly poor out-comes in resourcelimited settings where access to therapy is constrained. Case: A 39-year-old previously well female presented with acute decompensated heart failure, newly diagnosed hypertension, type 2 diabetes mellitus, and obesity, preceded by a 3-year history of secondary amenorrhea and progressive weight gain. On admission, she exhibited florid Cushingoid features. Biochemical evaluation confirmed severe adrenocorticotropic hormone (ACTH)-independent hypercortisolism: morning serum cortisol 1,950 nmol/L, failure of suppression on overnight dexamethasone suppression test (post-ODST cortisol 2022.9 nmol/L), and elevated 24-hour urinary free cortisol (2,069 nmol/24 hours, 2.56 × upper limit of normal). Androgen excess was evident, with elevated dehydroepiandrosterone sulfate (DHEAS more than 27 µmol/L) and testosterone (9.91 nmol/L). ACTH was suppressed, supporting an adrenal source, while aldosterone was normal. Contrast-enhanced computed tomography demonstrated a large left adrenal mass (12 cm) with tumor thrombus extending into the inferior vena cava and renal veins, with extensive hepatic and pulmonary metastases, consistent with advanced ACC. Management was limited by disease severity and resource constraints. Ketoconazole was contraindicated due to transaminitis, and alternative steroidogenesis inhibitors were unavailable, leaving metyrapone as the only feasible option. Oncological therapy was deferred due to sepsis and clinical instability. Her course was fulminant, complicated by recurrent heart failure, sepsis, and metabolic derangements, culminating in refractory cardiopulmonary failure. She died within 1 month of diagnosis, prior to definitive oncological intervention. Conclusion Fulminant cortisol-secreting ACC may present catastrophically as acute heart failure and progress rapidly. Early recognition and timely access to multimodal cortisollowering therapy are critical, particularly in resourcelimited settings. In fulminant hypercortisolism, the challenge is not diagnosis—but timing.
Adrenocortical Carcinoma ; Hydrocortisone ; Heart Failure

Introduction: Thyroid stimulating hormone (TSH) suppression following differentiated thyroid carcinoma is widely recommended to reduce recurrence risk. However, this strategy assumes cardiovascular tolerance to supraphysiologic thyroid hormone exposure. In patients with advanced structural heart disease, this assumption may fail, exposing a critical limitation of guideline-directed TSH suppression. Case: We report a 71-year-old male with end-stage renal failure on hemodialysis and severe ischemic cardiomyopathy (ejection fraction 23%) who presented with acute decompensation characterized by dyspnea, rapid atrial fibrillation, and non–ST-elevation myocardial infarction. He had a history of papillary thyroid carcinoma treated with total thyroidectomy and radioactive iodine over 20 years prior and was maintained on levothyroxine 200 mcg daily for TSH suppression. Despite biochemically euthyroid indices (TSH 1.8 mIU/L, free thyroxine 4 17 pmol/L), he developed recurrent arrhythmia with heart failure decompensation. This case highlights a dissociation between biochemical euthyroidism and tissue-level thyrotoxicity in a structurally compromised myocardium. Papillary thyroid carcinoma after definitive therapy typically follows an indolent course with low short-term mortality. In contrast, in severe left ventricular dysfunction, excess thyroid hormone increases adrenergic sensitivity and myocardial oxygen demand, precipitating arrhythmia and ischemia. This risk is amplified in end-stage renal disease, where altered hormone handling renders biochemical indices less reliable. Conclusion Biochemical euthyroidism does not equate to physiological safety. In patients with advanced cardiovascular disease, thyroid hormone therapy should be titrated to cardiovascular tolerance rather than oncologic targets alone, and routine TSH suppression may be inappropriate.
Thyroxine ; Heart Failure ; Thyrotropin

Introduction: The coexistence of autoimmune thyroid disease and type 1 diabetes mellitus is well established; however, their sequential or concurrent presentation in very young children remains uncommon. We demonstrate two paediatric cases with concurrent Graves' disease and type 1 diabetes mellitus, each illustrating distinct complications and clinical courses. Cases: A 3-year-old female presented with anterior neck swelling, weight loss, and persistent tachycardia. Biochemical evaluation confirmed severe thyrotoxicosis (T4 152.3 pmol/L, TSH <0.008 mIU/L) with markedly elevated antithyroglobulin and anti–thyroid peroxidase antibodies. Thyroid ultrasonography demonstrated a diffusely enlarged, hypervascular gland with nodular changes, consistent with Graves’ disease. During longitudinal follow-up, she developed polyuria, polydipsia, and hyperglycemia, with positive pancreatic autoantibodies confirming type 1 diabetes mellitus. Notably, serial early morning cortisol measurements were persistently low, raising concern for evolving adrenal insufficiency and suspicion of autoimmune polyglandular syndrome type 2. Comprehensive endocrine evaluation is ongoing. A 4-year-old male presented with a 1-year history of recurrent self-limiting fever followed by significant fatigability for 1 month. Salient examination on admission revealed tachycardia, anterior neck swelling, and an incidental pansystolic murmur. Thyroid function tests confirmed thyrotoxicosis (T4 38.6 pmol/L, TSH <0.008 mIU/L). Serial serum glucose was markedly elevated on admission, prompting further testing that confirmed type 1 diabetes mellitus with positive pancreatic autoantibodies. Echocardiography demonstrated moderate-to-severe mitral regurgitation with heart failure secondary to prolonged uncontrolled hyperthyroidism state. Cardiac function improved with restoration of a euthyroid state, highlighting the reversible nature of thyrotoxic heart failure. Conclusion These cases highlight the progressive nature of childhood autoimmunity, where Graves’ disease may precede the development of type 1 diabetes mellitus and evolving features of autoimmune polyglandular syndrome type 2. They further emphasize that thyrotoxic heart failure is potentially reversible with restoration of a euthyroid state, underscoring the importance of early recognition and vigilant long-term surveillance.
Diabetes Mellitus, Type 1 ; Graves Disease ; Heart Failure ; Diabetes Mellitus, Type 2

Extracorporeal membrane oxygenation (ECMO) is primarily used in clinical practice to provide continuous extracorporeal respiratory and circulatory support for patients with severe heart and lung failure, thereby sustaining life. It is a key technology for managing severe heart failure and respiratory failure that are difficult to control. With the accumulation of clinical experience in ECMO for circulatory and/or respiratory support, as well as advancements in biomedical engineering technology, more portable and stable ECMO devices have been introduced into clinical use, benefiting an increasing number of critically ill patients. Although ECMO technology has become relatively mature, the timing of ECMO initiation, management of sudden complications, and monitoring and early warning of physiological indicators are critical factors that greatly affect the therapeutic outcomes of ECMO. This article reviews traditional methods and artificial intelligence techniques used in risk assessment related to ECMO, including the latest achievements and research hotspots. Additionally, it discusses future trends in ECMO risk management, focusing on six key areas: multi-center and prospective studies, external validation and standardization of model performance, long-term prognosis considerations, integration of innovative technologies, enhancing model interpretability, and economic cost-effectiveness analysis. This provides a reference for future researchers to build models and explore new research directions.
Extracorporeal Membrane Oxygenation ; Humans ; Artificial Intelligence ; Risk Assessment ; Respiratory Insufficiency/therapy* ; Heart Failure/therapy*

OBJECTIVE: To explore the correlation between albumin (Alb) combined with diuretic treatment and the mortality risk of septic patients with pre-existing congestive heart failure based on the United States Critical Care Medical Information Database-IV (MIMIC-IV), and to conduct the external validation. METHODS: A retrospective cohort study was conducted. The clinical data of septic patients with pre-existing congestive heart failure admitted to the intensive care unit (ICU) from 2008 to 2019 in the MIMIC-IV 2.0 were extracted, including demographic characteristics, comorbidities, laboratory indicators on the first day of ICU admission, severity of illness, treatment measures, etc. For external validation, clinical data were collected from septic patients with pre-existing congestive heart failure admitted to the ICU of the Second People's Hospital of Shenzhen from October 2022 to December 2023. The patients were divided into Alb alone group and Alb combined with diuretic group. The ICU mortality was defined as the primary outcome event, and the 30-day and 60-day mortality were defined as the secondary outcomes. Multivariate Cox proportional hazard regression analysis was conducted to investigate the relationship between Alb combined with diuretic treatment and the mortality risk of ICU and 30 days in septic patients with pre-existing congestive heart failure, and subgroup analysis was performed. Kaplan-Meier survival curve was plotted to compared the 60-day cumulative survival rate between the Alb alone group and Alb combined with diuretic group. RESULTS: (1) Analysis results of data from MIMIC-IV: a total 1 754 patients were enrolled, of which 378 in the Alb alone group, and 1 376 in the Alb combined with diuretic group. Compared with the Alb alone group, the patients in the Alb combined with diuretic group had significantly lower ICU, 30-day, and 60-day mortality [ICU mortality: 19.11% (263/1 376) vs. 30.42% (115/378), 30-day mortality: 18.90% (260/1 376) vs. 32.54% (123/378), 60-day mortality: 24.49% (337/1 376) vs. 39.15% (148/378), all P < 0.05]. Based on the multivariate Cox proportional hazard regression adjusted models considering demographic characteristics, comorbidities, laboratory indicators, severity of illness, and treatment measures, it was shown that the use of Alb combined with diuretic was significantly associated with a reduced risk death of ICU and 30 days [ICU mortality risk: hazard ratio (HR) = 0.597, 95% confidence interval (95%CI) was 0.460-0.774, P < 0.001; 30-day mortality risk: HR = 0.557, 95%CI was 0.433-0.716, P < 0.001]. Subgroup analysis revealed that after adjusting for variables, regardless of gender, age, and whether or not patients had comorbidities such as hypertension, diabetes, severe liver disease, acute renal insufficiency, and sequential organ failure assessment (SOFA) score, the ICU mortality risk was significantly reduced in patients treated with Alb combined with diuretic (all HR < 1, P < 0.05), with no interaction observed (all P > 0.05). Kaplan-Meier survival curve showed the 60-day cumulative survival rate of patients in the Alb combined with diuretic group was significantly higher than that in the Alb alone group (Log-rank test: χ ² = 49.62, P < 0.05). (2) External validation: a total of 385 patients were enrolled, of which 144 in the Alb alone group, and 241 in the Alb combined with diuretic group. Compared with the Alb alone group, the patients of the Alb combined with diuretic group had significantly lower ICU, 30-day, and 60-day mortality [ICU mortality: 19.92% (48/241) vs. 31.25% (45/144), 30-day mortality: 19.09% (46/241) vs. 28.47% (41/144), 60-day mortality: 24.07% (58/241) vs. 34.03% (49/144), all P < 0.05]. The results of multivariate Cox proportional hazard regression analysis, subgroup analysis, and Kaplan-Meier survival curve analysis were consistent with the data analysis of the MIMIC-IV database. CONCLUSIONS Combination therapy of Alb and diuretic was associated with reduced mortality risk in septic patients with pre-existing congestive heart failure.
Humans ; Heart Failure/mortality* ; Retrospective Studies ; Sepsis/drug therapy* ; Intensive Care Units ; Diuretics/therapeutic use* ; Male ; Female ; Aged ; Middle Aged ; Proportional Hazards Models ; Hospital Mortality

Lingguizhugan Decoction (LGZG) demonstrates significant efficacy in treating various cardiovascular diseases clinically, yet its precise mechanism of action remains elusive. This study aimed to elucidate the potential mechanisms and effects of LGZG on isoproterenol (ISO) continuous stimulation-induced chronic heart failure (CHF) in mice, providing direct experimental evidence for further clinical applications. In vivo, continuous ISO infusion was administered to mice, and ventricular myocytes were utilized to explore LGZG?s potential mechanism of action on the ?1-adrenergic receptor (?1-AR)/Gs/G protein-coupled receptor kinases (GRKs)/?-arrestin signaling deflection system in the heart. The findings reveal that LGZG significantly reduced the messenger ribonucleic acid (mRNA) expression of hypertrophy-related biomarkers [atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP)] and improved cardiac remodeling and left ventricular diastolic function in mice with ISO-induced CHF. Furthermore, LGZG inhibited the overactivation of Gs/cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) signaling and downregulated the downstream transcriptional activity of cAMP-response element binding protein (CREB) and the expression of the coactivator CBP/P300. Notably, LGZG downregulated the expression of ?-arrestin1 and GRK 2/3/5 while upregulating the expression of ?1-AR and ?-arrestin2. These results suggest that LGZG inhibits Gs/cAMP/PKA signaling and ?-arrestin/GRK-mediated desensitization and internalization of ?1-AR, potentially exerting cardioprotective effects through the synergistic regulation of the ?1-AR/Gs/GRKs/?-arrestin signaling deflection system via multiple pathways.
Animals ; Heart Failure/genetics* ; Signal Transduction/drug effects* ; Drugs, Chinese Herbal/pharmacology* ; Mice ; Male ; G-Protein-Coupled Receptor Kinases/genetics* ; Mice, Inbred C57BL ; Humans ; Isoproterenol ; Arrestins/genetics* ; Chronic Disease

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common chronic conditions worldwide. The coexistence of HF and COPD creates a detrimental synergy that accelerates disease progression and substantially worsens patient prognosis. To guide the evidence-based management of patients with HF and COPD, experts from the Cardiac Electrophysiology and Cardiac Function Branch of the Chinese Society of Geriatrics and the COPD Group of the Chinese Thoracic Society systematically reviewed the research progress, guidelines, and expert experience, formulating this consensus. The consensus covers epidemiological data, diagnosis, drug treatment, non-pharmacological interventions, and long-term management, while highlighting the critical role of multidisciplinary collaborations. Furthermore, it introduces an integrated diagnostic framework that addresses the complex interplay between HF and COPD. The document advocates for personalized therapeutic approaches and structured follow-up protocols to improve patient outcomes and quality of life.
Humans ; Pulmonary Disease, Chronic Obstructive/complications* ; Heart Failure/complications* ; Consensus ; Quality of Life

Ambient air pollution is increasingly being recognized as a risk factor for heart failure; however, its effects on cardiac biomarkers remain unclear. This scoping review assessed the existing evidence on the association between air pollution and cardiac biomarkers in heart failure, described the key concepts, synthesized data, and identified research gaps. Following the PRISMA-ScR guidelines, PubMed, Embase, Web of Science, and CNKI databases were searched for studies on air pollution, heart failure, and biomarkers. A total of 765 records were screened, and 81 full texts were assessed for eligibility, resulting in 15 studies. The results showed that the exposure to particulate matter was associated with elevated N-terminal pro-B-type natriuretic peptide and troponin levels. Several studies have linked particulate matter exposure to a higher cardiovascular risk and heart failure biomarkers. Inflammatory and oxidative stress markers were consistently elevated across studies, supporting the biological relevance of these associations. However, few studies have focused specifically on populations with heart failure or clinically relevant biomarkers, and the evidence for gaseous pollutants remains inconclusive. These findings highlight the need to integrate environmental risk assessment into heart failure care and inform policy efforts to reduce the pollution-related cardiovascular burden. Further research should address these gaps through improved exposure assessments and the integration of mechanistic evidence.
Heart Failure/epidemiology* ; Biomarkers/metabolism* ; Humans ; Air Pollution/adverse effects* ; Air Pollutants/adverse effects* ; Particulate Matter/adverse effects* ; Environmental Exposure ; Natriuretic Peptide, Brain/blood* ; Oxidative Stress ; Troponin/blood*