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: Epidemiological evidence has shown that serum N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations, a diagnostic biomarker for heart failure, are positively associated with cardiovascular risk. Since NT-proBNP in serum is excreted in urine, it is hypothesized that urinary NT-proBNP concentrations are correlated with serum concentrations and linked with cardiovascular risk in the general population. METHODS: A total of 3060 community-dwelling residents aged ≥ 40 years without history of cardiovascular disease (CVD) were followed up for a median of 8.3 years (2007-2015). Serum and urinary concentrations of NT-proBNP at baseline were compared. The hazard ratios (HRs) and their 95% confidence intervals (CIs) for the association between NT-proBNP concentrations and the risk of developing CVD were computed using the Cox proportional hazards model. RESULTS: The median values (interquartile ranges) of serum and urinary NT-proBNP concentrations at baseline were 56 (32-104) pg/mL and 20 (18-25) pg/mL, respectively. There was a strong quadratic correlation between the serum and urinary concentrations of NT-proBNP (coefficient of determination [R CONCLUSIONS The present study demonstrated that urinary NT-proBNP concentrations were well-correlated with serum concentrations and were positively associated with cardiovascular risk. Given that urine sampling is noninvasive and does not require specially trained personnel, urinary NT-proBNP concentrations have the potential to be an easy and useful biomarker for detecting people at higher cardiovascular risk.
Adult ; Aged ; Aged, 80 and over ; Biomarkers/urine* ; Cardiovascular Diseases/urine* ; Female ; Heart Failure/diagnosis* ; Humans ; Incidence ; Japan/epidemiology* ; Male ; Middle Aged ; Natriuretic Peptide, Brain/urine* ; Peptide Fragments/urine* ; Prospective Studies ; Risk Assessment

AIMTo study the effects of rhBNP on the cardiac hemodynamics and renal function in dogs with heart failure.

METHODSCongestive heart failure in dogs was induced by either rapid ventricular pacing (RVP), 250 beats.min-1 for 7-14 days or by thoracic inferior vena cava constriction (TIVCC) to 1/2 its original diameter. When remarkable hemodynamic changes appeared rhBNP was infused intravenously at the dosage of 10, 30 and 100 ng.kg-1.min-1, each dose lasting 30 min.

RESULTSIn dogs (n = 7) with RVP heart failure, intravenous infusion of rhBNP at 10-100 ng.kg-1.min-1, caused decreases in mean arterial pressure (MAP), left ventricular systolic pressure (LVSP), LVdP/dtmax, pulmonary arterial pressure (PAP), left ventricular end diastolic pressure (LVEDP), total peripheral vascular resistance (TPR) and renal vascular resistance (RVR) dose-dependently, without significant changes in cardiac output (CO), LVdp/dt/P, left ventricular work (LVW), renal blood flow (RBF) and heart rate (HR). This suggested that rhBNP reduced the pre-load and after-load of the dogs with congestive heart failure but showed no distinct effect on the contractility of the heart. In dogs (n = 7) with TIVCC heart failure, there were remarkable decreases in MAP and LVEDP following the rhBNP infusion, without further reduction of CO, but no marked change in HR, LVSP, LVdP/dtmax, RAP and TPR. In both animal models of heart failure, there were significant increases in urine volume and sodium excretion which were more significant in TIVCC dogs than in RVP dogs.

CONCLUSIONrhBNP reduced the pre-load and after-load in dogs with heart failure and showed remarkable diuretic effect, but did not affect the contractility of the heart.

Animals ; Blood Pressure ; drug effects ; Diuretics ; pharmacology ; therapeutic use ; Dogs ; Female ; Heart Failure ; drug therapy ; physiopathology ; urine ; Hemodynamics ; drug effects ; Kidney ; blood supply ; drug effects ; Kidney Function Tests ; Male ; Natriuretic Peptide, Brain ; pharmacology ; therapeutic use ; Recombinant Proteins ; pharmacology ; therapeutic use ; Sodium ; urine ; Vascular Resistance ; drug effects ; Vasodilator Agents ; pharmacology

AIMTo study the effects of rhBNP and milrinone on the cardiac hemodynamics and renal function in anesthetized dogs.

METHODSThe actions of rhBNP given cumulatively i.v. 10, 30 and 100 ng.kg-1 for 30 min and milrinone of single dose (100 micrograms.kg-1, i.v.) on cardiac hemodynamics and renal function were studied in anesthetized open-chest dogs.

RESULTSIn anesthetized dogs (n = 7) intravenous infusion of rhBNP at 10-100 ng.kg-1, caused decreases in mean arterial pressure (MAP), left ventricular systolic pressure (LVSP), LVdp/dtmax, pulmonary arterial pressure (PAP), left ventricular end diastolic pressure (LVEDP), total peripheral resistance (TPR) and renal vascular resistance (RVR) dose-dependently, without significant changes in cardiac output (CO), LV(dp/dt)/P, renal blood flow (RBF) and heart rate (HR), increases in urinary volume and sodium excretion. In anesthetized dogs (n = 6), there were remarkable decreases in MAP, LVEDP, PAP, TPR, RBF, RVR and urinary volume following the MIL (100 micrograms.kg-1, i.v.), with significant increases of LVSP, +/- LVdp/dtmax, HR and CO, but no marked changes in urinary volume and sodium excretion.

CONCLUSIONrhBNP reduces the pre-load and after-load in the anaesthetized dogs but showed no distinct effect on the contractility of the heart. Positive inotropic and chronotropic actions have been demonstrated after intravenous injection of milrinone 100 micrograms.kg-1 in anesthetized dogs.

Anesthesia ; Animals ; Cardiotonic Agents ; pharmacology ; Dogs ; Drug Interactions ; Female ; Heart ; drug effects ; physiology ; Hemodynamics ; Kidney ; drug effects ; physiology ; Male ; Milrinone ; pharmacology ; Natriuretic Peptide, Brain ; pharmacology ; Recombinant Proteins ; pharmacology ; Sodium ; blood ; urine ; Urine