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

The study was conducted to investigate the mechanism of Xinyang Tablets( XYP) in modulating the fat mass and obesity-associated protein(FTO)/N6-methyladenosine(m6A) signaling pathway to ameliorate ventricular remodeling in heart failure(HF). A mouse model of HF was established by transverse aortic constriction(TAC). Mice were randomized into sham, model, XYP(low, medium, and high doses), and positive control( perindopril) groups(n= 10). From day 3 post-surgery, mice were administrated with corresponding drugs by gavage for 6 consecutive weeks. Following the treatment, echocardiography was employed to evaluate the cardiac function, and RT-qPCR was employed to determine the relative m RNA levels of key markers, including atrial natriuretic peptide( ANP), B-type natriuretic peptide( BNP), β-myosin heavy chain(β-MHC), collagen type I alpha chain(Col1α), collagen type Ⅲ alpha chain(Col3α), alpha smooth muscle actin(α-SMA), and FTO. The cardiac tissue was stained with Masson's trichrome and wheat germ agglutinin(WGA) to reveal the pathological changes. Immunohistochemistry was employed to detect the expression levels of Col1α, Col3α, α-SMA, and FTO in the myocardial tissue. The m6A modification level in the myocardial tissue was measured by the m6A assay kit. An H9c2 cell model of cardiomyocyte injury was induced by angiotensin Ⅱ(AngⅡ), and small interfering RNA(siRNA) was employed to knock down FTO expression. RT-qPCR was conducted to assess the relative m RNA levels of FTO and other genes associated with cardiac remodeling. The m6A modification level was measured by the m6A assay kit, and Western blot was employed to determine the phosphorylated phosphatidylinositol 3-kinase(p-PI3K)/phosphatidylinositol 3-kinase(PI3K) and phosphorylated serine/threonine kinase(p-Akt)/serine/threonine kinase(Akt) ratios in cardiomyocytes. The results of animal experiments showed that the XYP treatment significantly improved the cardiac function, reduced fibrosis, up-regulated the m RNA and protein levels of FTO, and lowered the m6A modification level compared with the model group. The results of cell experiments showed that the XYP-containing serum markedly up-regulated the m RNA level of FTO while decreasing the m6A modification level and the p-PI3K/PI3K and p-Akt/Akt ratios in cardiomyocytes. Furthermore, FTO knockdown reversed the protective effects of XYP-containing serum on Ang Ⅱ-induced cardiomyocyte hypertrophy. In conclusion, XYP may ameliorate ventricular remodeling by regulating the FTO/m6A axis, thereby inhibiting the activation of the PI3K/Akt signaling pathway.
Animals ; Ventricular Remodeling/drug effects* ; Heart Failure/physiopathology* ; Signal Transduction/drug effects* ; Mice ; Male ; Alpha-Ketoglutarate-Dependent Dioxygenase FTO/genetics* ; Drugs, Chinese Herbal/administration & dosage* ; Mice, Inbred C57BL ; Humans ; Adenosine/analogs & derivatives* ; Myocytes, Cardiac/metabolism* ; Disease Models, Animal

Renshen Decoction is derived from the Synopsis of the Golden Chamber and is also known as Lizhong Pills or Lizhong Decoction, with the effects of warming the middle, dispelling cold, tonifying Qi, and strengthening the spleen, primarily treating spleen-stomach deficiency-cold syndrome. In modern clinical practice, Lizhong Pills and Lizhong Decoction are more frequently used, while Renshen Decoction is less common. Currently, this decoction is often applied in the treatment of gastric ulcers, infantile rotavirus diarrhea, chronic nephritis, autoimmune diabetes, allergic rhinitis, and other conditions, but reports on its use for coronary heart disease and angina pectoris are limited. Research has shown that in the original text, chest impediment(chest pain and stuffiness) includes not only coronary heart disease but also conditions such as coronary microcirculation disorders, X syndrome, coronary artery bridge, cardiomyopathy, heart valve disease, heart failure, chronic obstructive pulmonary disease, pulmonary heart disease, pulmonary arterial hypertension, hypotension, arrhythmia, and other diseases characterized by chest tightness. The name Renshen Decoction focuses on Panax ginseng without mentioning "Lizhong", indicating that its primary target is not the middle energizer but rather the deficiency of vital Qi and the collapse of the heart vessel. "Qi counterflow from the hypochondrium and rushing up to chest" encompasses acute inferior myocardial infarction combined with gastrointestinal irritation, and diseases with chest tightness as the main clinical manifestation combined with slow arrhythmias associated with vagus nerve excitement, nausea, and vomiting. Renshen Decoction is formulated for the deficiency-induced chest impediment, corresponding to the complication stage of coronary heart disease in modern clinical practice, which includes acute myocardial infarction with hypotension, cardiogenic shock, heart failure, and bradyarrhythmia. This differs from the excess-induced chest impediment addressed by Zhishi Xiebai Guizhi Decoction in the same article. The chest impediment treated by Renshen Decoction includes both the acute critical stage of cardiovascular diseases and the recovery phase of major illnesses. Pathophysiologically, the syndrome associated with Renshen Decoction may be closely related to ischemia, heart failure, hypotension, shock, and bradycardia. In terms of formula differentiation, Renshen Decoction must be distinguished from Zhishi Xiebai Guizhi Decoction and Chaihu Jia Longgu Muli Decoction. Renshen Decoction represents the ancient "Cardiac Triple Therapy".
Humans ; Drugs, Chinese Herbal/administration & dosage* ; Coronary Disease/physiopathology* ; Heart Failure/physiopathology* ; Hypertension, Pulmonary/physiopathology* ; Hypotension/physiopathology*

This study aims to explore the protective effect of Chaihu Jia Longgu Muli Decoction on rats with heart failure after myocardial infarction, and to clarify its possible mechanisms, providing a new basis for basic research on the mechanism of classic Chinese medicinal formula-mediated inflammatory response in preventing and treating heart failure induced by apoptosis after myocardial infarction. A heart failure model after myocardial infarction was established in rats by coronary artery ligation. The rats were divided into sham group, model group, and low, medium, and high-dose groups of Chaihu Jia Longgu Muli Decoction, with 10 rats in each group. The low-dose, medium-dose, and high-dose groups of Chaihu Jia Longgu Muli Decoction were given 6.3, 12.6, and 25.2 g·kg~(-1) doses by gavage, respectively. The sham group and model group were given an equal volume of distilled water by gavage once daily for four consecutive weeks. Cardiac function was assessed using color Doppler echocardiography. Myocardial pathology was detected by hematoxylin-eosin(HE) staining, apoptosis was measured by TUNEL assay, and mitophagy was observed by transmission electron microscopy. The levels of tumor necrosis factor-α(TNF-α), interleukin(IL)-1β, and N-terminal pro-B-type natriuretic peptide(NT-proBNP) in serum were detected by enzyme-linked immunosorbent assay(ELISA). The expression of apoptosis-related proteins B-cell lymphoma 2(Bcl-2), Bcl-2-associated X protein(Bax), and cleaved caspase-3 was detected by Western blot. Additionally, the expression of phosphorylated nuclear transcription factor-κB(NF-κB) p65(p-NF-κB p65)(upstream) and nuclear factor kappa B inhibitor alpha(IκBα)(downstream) in the NF-κB signaling pathway was assessed by Western blot. The results showed that compared with the sham group, left ventricular ejection fraction(LVEF) and left ventricular short axis shortening(LVFS) in the model group were significantly reduced, while left ventricular end diastolic diameter(LVEDD) and left ventricular end systolic diameter(LVESD) increased significantly. Myocardial tissue damage was severe, with widened intercellular spaces and disorganized cell arrangement. The apoptosis rate was increased, and mitochondria were enlarged with increased vacuoles. Levels of TNF-α, IL-1β, and NT-proBNP were elevated, indicating an obvious inflammatory response. The expression of pro-apoptotic factors Bax and cleaved caspase-3 increased, while the anti-apoptotic factor Bcl-2 decreased. The expression of p-NF-κB p65 was upregulated, and the expression of IκBα was downregulated. In contrast, the Chaihu Jia Longgu Muli Decoction groups showed significantly improved of LVEF, LVFS and decreased LVEDD, LVESD compared to the model group. Myocardial tissue damage was alleviated, and intercellular spaces were reduced. The apoptosis rate decreased, mitochondrial volume decreased, and the levels of TNF-α, IL-1β, and NT-proBNP were lower. The expression of pro-apoptotic factors Bax and cleaved caspase-3 decreased, while the expression of the anti-apoptotic factor Bcl-2 increased. Additionally, the expression of p-NF-κB p65 decreased, while IκBα expression increased. In summary, this experimental study shows that Chaihu Jia Longgu Muli Decoction can reduce the inflammatory response and apoptosis rate in rats with heart failure after myocardial infarction, which may be related to the regulation of the IκBα/NF-κB signaling pathway.
Animals ; Apoptosis/drug effects* ; Drugs, Chinese Herbal/administration & dosage* ; Rats ; Myocardial Infarction/physiopathology* ; Male ; NF-kappa B/genetics* ; Heart Failure/etiology* ; Rats, Sprague-Dawley ; Signal Transduction/drug effects* ; NF-KappaB Inhibitor alpha/genetics* ; Humans ; Tumor Necrosis Factor-alpha/genetics*

Heart failure(HF) is the terminal stage of various cardiovascular diseases, characterized by high morbidity and mortality, and it represents one of the major disease burdens for families and society. In recent years, as research on the molecular mechanisms of HF has deepened, a competing endogenous RNA(ceRNA) network mediated by long non-coding RNAs(lncRNAs) and circular RNAs(circRNAs) has been gradually constructed. Extensive research results have confirmed that the ceRNA network is widely involved in pathological processes such as inflammation, oxidative stress, myocardial hypertrophy, apoptosis, remodeling of extracellular matrix components and structure, and ferroptosis in HF. It reveals the complex pathological mechanisms of HF at the epigenetic level. Traditional Chinese medicine(TCM) plays a unique role in improving symptoms and prognosis of HF and intervenes in the ceRNA network in HF through multi-level and multi-target mechanisms. It improves key pathological processes such as myocardial fibrosis and inflammation, making progress in treating HF at the molecular level. This article summarized recent Chinese and international research on the regulatory mechanisms of ceRNA networks in HF, elaborated on the mechanisms of action of ceRNA networks in different pathological stages of HF, and summarized how effective components and compounds of TCM intervene in the ceRNA network to improve HF, so as to refine the molecular mechanisms of HF and provide directions for more precise molecular targeted therapeutic strategies.
Humans ; Heart Failure/metabolism* ; Medicine, Chinese Traditional ; Animals ; Drugs, Chinese Herbal/therapeutic use* ; RNA, Circular/genetics* ; RNA, Long Noncoding/metabolism* ; Gene Regulatory Networks/drug effects* ; RNA/metabolism* ; RNA, Competitive Endogenous

This paper aimed to investigate the therapeutic effect and mechanism of action of the Yiqi Fumai Formula(YQFM), a kind of traditional Chinese medicine(TCM), on mice with experimental heart failure based on the "heart-gut axis" theory. Based on the network pharmacology integrated with the group collaboration algorithm, the active ingredients were screened, a "component-target-disease" network was constructed, and the potential pathways regulated by the formula were predicted and analyzed. Next, the model of experimental heart failure was established by intraperitoneal injection of adriamycin at a single high dose(15 mg·kg~(-1)) in BALB/c mice. After intraperitoneal injection of YQFM(lyophilized) at 7.90, 15.80, and 31.55 mg·d~(-1) for 7 d, the protective effects of the formula on cardiac function were evaluated using indicators such as ultrasonic electrocardiography and myocardial injury markers. Combined with inflammatory factors in the cardiac and colorectal tissue, as well as targeted assays, the relevant indicators of potential pathways were verified. Meanwhile, 16S rDNA sequencing was performed on mouse fecal samples using the Illumina platform to detect changes in gut flora and analyze differential metabolic pathways. The results show that the administration of injectable YQFM(lyophilized) for 7 d significantly increased the left ventricular end-systolic internal diameter, fractional shortening, and ejection fraction of cardiac tissue of mice with experimental heart failure(P<0.05). Moreover, markers of myocardial injury were significantly decreased(P<0.05), indicating improved cardiac function, along with significantly suppressed inflammatory responses in cardiac and intestinal tissue(P<0.05). Additionally, the species of causative organisms was decreased, and the homeostasis of gut flora was improved, involving a modulatory effect on PI3K-Akt signaling pathway-related inflammation in cardiac and colorectal tissue. In conclusion, YQFM can affect the "heart-gut axis" immunity through the homeostasis of the gut flora, thereby exerting a therapeutic effect on heart failure. This finding provides a reference for the combination of TCM and western medicine to prevent and treat heart failure based on the "heart-gut axis" theory.
Animals ; Drugs, Chinese Herbal/administration & dosage* ; Heart Failure/microbiology* ; Mice ; Mice, Inbred BALB C ; Male ; Disease Models, Animal ; Gastrointestinal Microbiome/drug effects* ; Heart/physiopathology* ; Humans ; Signal Transduction/drug effects*

This study explored the efficacy and mechanisms of Shenqi Buqi Granules in treating chronic heart failure(CHF) of Qi deficiency using proteomics and bioinformatics methods. A total of 18 healthy participants(health group) and 19 patients with Qi deficiency-type CHF(experimental group) were enrolled and treated with Shenqi Buqi Granules for 12 weeks. Clinical indicators, including Qi deficiency scores, complete blood count, biochemical parameters, lipid profiles, and cardiac function, were collected from pre-and post-experimental groups. Serum proteomics analysis was performed. Differential proteins were screened through differential analysis and K-means clustering. Further analyses, including subcellular localization, Kyoto Encyclopedia of Genes and Genomes(KEGG) pathway enrichment, and protein-protein interaction(PPI) network construction, were conducted to identify pathways and proteins associated with Shenqi Buqi Granules treatment. Spearman correlation analysis focused on proteins most correlated with the core phenotype of CHF of Qi deficiency. The results show that Shenqi Buqi Granules treatment reduced Qi deficiency scores and brain natriuretic peptide levels of pre-experimental group. A total of 1 594 proteins were quantified in the proteomics analysis, with 98 proteins showing differential expression between healthy group and experimental group before and after treatment. Subcellular localization analysis revealed 6 protein sources, while KEGG pathway enrichment highlighted biological processes including angiogenesis, immune inflammation, calcium homeostasis, cytoskeletal regulation, protein synthesis, and energy metabolism. Core genes identified included CD34, CSF1, CALM1, CALML3, PPP1CA, PFN1, and 3 ribosomal large subunit proteins. Correlation analysis between core proteins and Qi deficiency scores revealed that CD34(r=-0.67, P<0.05) and PPP1CA(r=0.62, P<0.01) were most strongly associated with Qi deficiency scores. This study suggests that Shenqi Buqi Granules improves Qi deficiency scores and CHF symptoms by regulating angiogenesis, immune inflammation, calcium homeostasis, cytoskeletal regulation, protein synthesis, and energy metabolism. CD34 and PPP1CA are identified as core proteins involved in the therapeutic effects of Shenqi Buqi Granules on Qi deficiency.
Humans ; Drugs, Chinese Herbal/therapeutic use* ; Heart Failure/metabolism* ; Male ; Female ; Proteomics ; Middle Aged ; Qi ; Aged ; Protein Interaction Maps/drug effects* ; Adult ; Chronic Disease

Heart failure (HF) is the end-stage of all cardiac diseases, characterized by high prevalence, high mortality, and heavy social and economic burden. Early warning of HF exacerbation is of great value for outpatient management and reducing readmission rates. Currently, remote dynamic monitoring technology, which captures changes in hemodynamic and physiological parameters of HF patients, has become the primary method for early warning and is a hot research topic in clinical studies. This paper systematically reviews the progress in this field, which was categorized into invasive monitoring based on implanted devices, non-invasive monitoring based on wearable devices, and other monitoring technologies based on audio and video. Invasive monitoring primarily involves direct hemodynamic parameters such as left atrial pressure and pulmonary artery pressure, while non-invasive monitoring covers parameters such as thoracic impedance, electrocardiogram, respiration, and activity levels. These parameters exhibit characteristic changes in the early stages of HF exacerbation. Given the clinical heterogeneity of HF patients, multi-source information fusion analysis can significantly improve the prediction accuracy of early warning models. The results of this study suggest that, compared with invasive monitoring, non-invasive monitoring technology, with its advantages of good patient compliance, ease of operation, and cost-effectiveness, combined with AI-driven multimodal data analysis methods, shows significant clinical application potential in establishing an outpatient management system for HF.
Humans ; Heart Failure/physiopathology* ; Monitoring, Physiologic/methods* ; Wearable Electronic Devices ; Remote Sensing Technology ; Early Diagnosis ; Electrocardiography ; Hemodynamics

Peripheral nerve block (PNB) has been successfully used as the sole anesthetic for Peritoneal dialysis (PD) catheter insertion, and has been shown to provide satisfactory anesthesia and analgesia perioperatively, especially among critically – ill patients.

This report describes the anesthetic management of an 18 – year old underweight patient with End-stage renal disease (ESRD) and decompensated heart failure who was scheduled for PD catheter insertion. He was given a left lateral Transversus abdominis plane (TAP) block and a right Rectus sheath (RS) block as the main anesthetic. Fifteen mL of Isobaric Bupivacaine 0.375% with Epinephrine 1:400,000 dilution was injected for the TAP block, and 10mL for the RS block, for a total volume of 25mL (93.7mg). Sedation was given via a Remifentanil infusion at 0.1mcg/kg/min. Intraoperatively, the patient was awake, conversant, and comfortable, no pressors were used, and no conversion to general anesthesia was done. Post-operatively, he had good pain control, with a pain score of 1/10, and successfully underwent dialysis via the PD catheter on the 2ndhospital day.

This pediatric patient who is critically ill is not a good candidate for general or neuraxial anesthesia due to the risk of hemodynamic instability and perioperative decompensation. PNB was done to provide anesthesia, and ensure good pain control post-operatively, and a right TAP and left RS were done instead of a bilateral TAP to lower the LA volume and decrease the risk of LA toxicity.

Unilateral TAP with contralateral RS is a safe anesthetic technique among critically-ill pediatric patients who will undergo PD catheter insertion without the risk of hemodynamic instability with general or neuraxial anesthesia.

Human ; Male ; Adolescent: 13-18 Yrs Old ; End-stage Renal Disease (esrd) ; Kidney Failure, Chronic ; Heart Failure

INTRODUCTION

Eosinophilic Granulomatosis Polyangiitis (EGPA) is the rarest among the ANCA-associated vasculitis with an incidence of seven per million individuals. Cardiac involvement occurs in 15-60% of patients and is the most severe manifestation associated with poor prognosis and mortality. EGPA typically affects the left side of the heart. There is only one published study to date that describes a case of right sided heart failure from pulmonary arterial hypertension.

CASE

A 40-year-old, Filipino, female, complained of rash, wheezing and right sided heart failure symptoms. After a thorough work-up, she was managed as a case of EGPA based on palpable, erythematous, nonpruritic rash on the lower extremities, peripheral eosinophilia (54%), adult-onset asthma, mononeuritis multiplex, cardiac symptoms, (+) p-ANCA and leukocytoclastic vasculitis with eosinophils and early granuloma formation on skin punch biopsy. The 2D-echocardiography showed an elevated estimated pulmonary pressure with signs of right sided volume overload. Chest computed tomography with contrast revealed right atrial and biventricular enlargement, hepatomegaly and unremarkable pulmonary findings. Methylprednisolone along with intravenous cyclophosphamide pulse therapy were initiated which resulted in the resolution of symptoms with normalization of blood eosinophils. Repeat 2D-echocardiogram had unremarkable findings as well. With the improvement noted, she was then maintained on glucocorticoids and mycophenolate mofetil.

DISCUSSION

Although EGPA commonly presents with symptoms of asthma, rhinosinusitis and/or peripheral eosinophilia, one uncommon presentation would be cardiac manifestations, specifically progressive pulmonary arterial hypertension with subsequent right sided heart failure. High dose glucocorticoids along with other immunosuppressants such as cyclophosphamide, are the treatment options in managing life-threatening conditions. Early detection is crucial in the prevention of grave outcomes.

Human ; Female ; Adult: 25-44 Yrs Old ; Heart Failure ; Hypertension, Pulmonary ; Vasculitis