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

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

Key Findings • Very low-quality evidence from a single retrospective study suggests that continuous renal replacement therapy (CRRT) may reduce mortality among COVID-19 patients on invasive mechanical ventilation. Guidelines recommend CRRT for critically ill patients to minimize the risk of possible transmission, if this option is available. • Although uncommon, acute kidney injury (AKI) can occur in association with coronavirus disease 2019 (COVID-19) and is associated with increased in-hospital mortality. • There are currently no published or ongoing clinical trials directly comparing dialysis modalities for acute kidney injury in COVID-19 patients. • In reducing the risk of transmission during dialysis: currently, there are no studies comparing one dialysis modality to another. The method of dialysis is still primarily determined by the clinical picture of the patient, the expertise of the center, and the resources available. The American Society of Nephrology (ASN) recommends CRRT over intermittent hemodialysis (IHD) for critically ill patients with COVID-19 to minimize patient contact when it is available, and resources allow. Otherwise, intermittent hemodialysis may be done provided that, infection control measures are strictly followed. • Several international and local guidelines recommend strict adherence to infection prevention and control measures (e.g. hand hygiene, physical distancing, proper use of personal protective equipment (PPE), and cohorting of patients) who are undergoing dialysis.
Covid-19

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