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

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*

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

INTRODUCTION

Exercise intolerance in patients with heart failure (HF) leads to a lower quality of life. An increasing number of studies suggest that early initiation of guided-directed medical therapy (GDMT) leads to better outcomes. Sodium-glucose cotransporter-2 (SGLT-2) inhibitor is one of the cornerstones in HF treatment, but its effectiveness in improving quality of life remains uncertain.

METHODS

A comprehensive search of randomized controlled trials (RCT) was conducted. Outcome measures for cardiovascular death and HF symptoms using the Kansas City Cardiomyopathy Questionnaire - Total Symptom Score (KCCQ-TSS) in the early phase of treatment and at 8 months were analyzed using the Review Manager V5.4. The KCCQ-TSS ranges from 0 to 100, with higher scores indicating fewer symptoms and physical limitations associated with HF. The treatment effect was shown as a win ratio, in which a value greater than 1 indicates superiority.

RESULTS

Five RCTs were included in the meta-analysis. There was improvement in HF symptoms based on the KCCQ-TSS (HR 3.39 [95%CI: 2.95-3.89]I2 = 68%, p < 0.00001) with substantial heterogeneity. The major source of heterogeneity identified was the interval when the KCCQ-TSS was performed, hence a subgroup analysis that specifically monitored patients during the eighth month of treatment was done, which showed improvement in HF symptoms (HR 3.16 [95%CI: 2.98-3.36)I2 = 8%, p < 0.00001) in SGLT-2 inhibitors compared to placebo.

CONCLUSION

The meta-analysis showed that initiation of SGLT-2 inhibitors resulted in improvement of HF symptoms which may lead to improvement of patients’ quality of life. Therefore, SGLT-2 inhibitors in all types of HF are effective in promoting better quality of life.

Heart Failure ; Quality Of Life

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