INTRODUCTION

Acute coronary syndrome (ACS) and end-stage renal disease (ESRD) are both prevalent globally. The diagnosis and management of ACS in ESRD is difficult because the interplay of cardiovascular and renal disease is complicated. The guidelines for ACS may not be applicable to the ESRD population because the trials from which these are drawn mostly excluded ESRD patients.

OBJECTIVE

To determine the clinical profile and outcomes of CKD patients on dialysis admitted for ACS in the Philippine General Hospital (PGH).

METHODS

We did a retrospective cohort study and employed a retrospective review of electronic medical records among ESRD patients presenting with ACS in PGH from May 2021 to November 2023. The collected data was analyzed using univariate and bivariate statistics using PRISM software.

RESULTS

A total of 48 patients with ESRD were admitted for ACS in this study – 8 with STEMI and 40 with NSTEMI. The mean age was 61 years old and 33 (68.8%) were male. Among those with STEMI, six (75%) presented with Kilip II or more. While among those with NSTEMI, 17 (42.5%) had a GRACE score >140 and 27 (67.5%) had an NSTEMI TIMI risk score >2. On average, the patients were on hemodialysis for 31 months prior to admission. The most common comorbidities were hypertension (91.7%) and heart failure (83.3%). On admission, 18 (37.5%) presented with SBP >160, 7 (14.6%) patients presented with shock, and 4 (8.3%) patients presented with cardiac arrest. 38 (79.2%) patients had anemia on admission. 21 (43.8%) patients had left ventricular hypertrophy on electrocardiogram while 34 (70.8%) patients had cardiomegaly on chest radiography. The average left ventricular ejection fraction on echocardiogram was 46% and 27 (90%) patients had segmental wall motion abnormalities. The most common angiographic finding was 3-vessel coronary artery disease seen in 50% of patients. Almost all patients received dualantiplatelet therapy, high dose statin, and beta-blocker. The mortality rate was high at 43.8% with cardiovascular causes being the most common cause of death.

CONCLUSION

This study demonstrates the high mortality rate among patients with ESRD presenting with ACS. Our study portrays that patients with ESRD present with higher risk features including abnormalities in vital signs, laboratories, imaging, high prognostications score, and high in-hospital morbidity.

Human ; Kidney Failure, Chronic ; End-stage Renal Disease ; Acute Coronary Syndrome ; Myocardial Infarction

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

Objectives: Adherence to clinical practice guidelines (CPG) has been shown to reduce inter-physician practice variation and improve quality of care. This study evaluated guideline adherence of physicians in two tertiary public hospitals to local CPG on COVID-19. Methods: This was a multicenter, retrospective chart review, rapid assessment method study. Guideline adherence and non-adherence (overuse and underuse) to 15 strong recommendations in the prevailing Philippine COVID-19 Living Recommendations were assessed among a sample of patients admitted in two centers from July to October 2021. Differences in adherence across COVID-19 disease severities and managing hospital units were analyzed. Results: A total of 723 patient charts from two centers were reviewed. Guideline adherence to dexamethasone use among patients with hypoxemia is 91.4% (95% CI 88.6 to 93.6) with 9.2% overuse. Tocilizumab was underused in 52.2% of patients with indications to receive the drug. There was overuse of empiric antibiotics in 43.6% of patients without suspicion of bacterial coinfection. Lowest adherence to antibiotic use was seen among patients with critical disease severity and those managed in the intensive care unit. None of the other non-recommended treatment modalities were given. Conclusion Management of COVID-19 in both centers was generally adherent to guideline recommendations. We detected high underuse of tocilizumab probably related to the global supply shortage during the study period and high overuse of antibiotics in patients without suspicion of bacterial coinfection. While the results of this study cannot be generalized in other healthcare settings, we recommend the application of similar rapid assessment studies in guideline adherence evaluation as a quality improvement tool and to identify issues with resource utilization especially during public health emergencies.
Guideline Adherence ; COVID-19 ; Quality Improvement

Objectives: Adherence to clinical practice guidelines (CPG) has been shown to reduce inter-physician practice variation and improve quality of care. This study evaluated guideline adherence of physicians in two tertiary public hospitals to local CPG on COVID-19. Methods: This was a multicenter, retrospective chart review, rapid assessment method study. Guideline adherence and non-adherence (overuse and underuse) to 15 strong recommendations in the prevailing Philippine COVID-19 Living Recommendations were assessed among a sample of patients admitted in two centers from July to October 2021. Differences in adherence across COVID-19 disease severities and managing hospital units were analyzed. Results: A total of 723 patient charts from two centers were reviewed. Guideline adherence to dexamethasone use among patients with hypoxemia is 91.4% (95% CI 88.6 to 93.6) with 9.2% overuse. Tocilizumab was underused in 52.2% of patients with indications to receive the drug. There was overuse of empiric antibiotics in 43.6% of patients without suspicion of bacterial coinfection. Lowest adherence to antibiotic use was seen among patients with critical disease severity and those managed in the intensive care unit. None of the other non-recommended treatment modalities were given. Conclusion Management of COVID-19 in both centers was generally adherent to guideline recommendations. We detected high underuse of tocilizumab probably related to the global supply shortage during the study period and high overuse of antibiotics in patients without suspicion of bacterial coinfection. While the results of this study cannot be generalized in other healthcare settings, we recommend the application of similar rapid assessment studies in guideline adherence evaluation as a quality improvement tool and to identify issues with resource utilization especially during public health emergencies
Guideline Adherence ; COVID-19 ; Quality Improvement