Four-year clinical outcomes of Filipino patients with or at risk for atherothrombotic events from the REACH registry

INTRODUCTION: Patients with established atherothrombotic disease (EAD) or those with only atherothrombotic risk factors are at high risk for cardiovascular events and death. There are scant data on the clinical profile of stable Filipino patients with or at risk for atherothrombosis and their long-term outcomes. The authors'objective is to present the baseline clinical profile and four-year cardiovascular outcomes in Filipino outpatients with EAD and those with multiple atherothrombotic risk factors in comparison to the Asian and Global populations METHODS: The Reduction of Atherothrombosis for Continued Health (REACH) registry is an international, prospective cohort of 68,236 patients aged at least 45 years old with either EAD or at least three atherothrombotic risk factors enrolled from 44 countries in 2003-2004. The Philippine cohort consists of 1040 outpatients with EAD (N=913) or at least three atherothrombotic risk factors (N=127) consecutively enrolled and followed up for at least one to four years for the occurrence of cardiovascular death (CVD), myocardial infarction (MI) and stroke. RESULTS: Nine hundred fifty-five Filipino outpatients (96)% completed the four-year follow-up. Mean age is 65.5 years with similar sex distribution. Common risk factors included diabetes (46%), hypertension (87.4%), hypercholesterolemia (62.9%), and smoking history (29.7%). Ninety-two percent had EAD-- 43% with coronary artery disease, 45% with cerebrovascular disease (CVD) and four percent with peripheral artery disease (PAD). The combined primary endpoint of CVD/MI/stroke was 14.7%, but higher (19.8%) among those with polyvascular disease. Cerebrovascular disease (CVD) patients had the highest CVD/MI/stroke rates (17.6%); PAD patients had the highest CVD/MI/stroke and hospitalization rate (33.2%). Baseline medication usage is 81.1% for antiplatelet agents, 62.6% for statins and 69% for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker but four-year follow-up medication usage rates were lower. CONCLUSION: Filipino outpatients with or at risk for atherothrombosis experienced high long-term rates of CV events. This is the first report of long-term cardiovascular outcomes of stable Filipino outpatients with this high-risk profile.

Endovascular coil embolization of multiple pulmonary arteriovenous malformations in Osler-Weber-Rendu disease: A challenging pursuit

Pulmonary arterionevous malformation (PAVMs) are a rare disorder with an incidence of 2-3/1,000,000 population. Approximately 70% of cases are associated with Osler-Weber-Rendu Disease. This intrapulmonary malformation causes hypoxemia and dyspnea largely attributed to the right to left shunting. We present a case of 25-year-old male who was admitted for fever and headaches with chronic history of epistaxis, hemoptysis, cyanosis and clubbing. Central cyanocis and clubbing were evident with hypoxemia of 65%. Heart sounds and peripheral pulses were normal. There was no systolic bruit noted in the lung bases. Multiple telangiectasias were seen in the truncal area and abdomen. Chest x-ray revealed multi-chambered cardiomegaly with no opacifications. CBC showed erythrocytosis with hematocrits of 0.68-0.78. Transthoracic echocardiography showed intact interatrial and interventricular septum, with contrast study suggestive of intrapulmonary shunting. CT angiography revealed PAVMs in bilateral lung fields. Pulmonary angiography demonstrated diffuse PAVMS in the left lung with 3 large PAVMs with multiple feeders > 7mm and smaller PAVMs in the Right lower lobe. The diagnosis was Multiple Pulmonary Arteriovenous Malformation, Osler-Weber-Rendu Disease, Brain Abscess Left Temporoparietal area. Craniotomy with brain abscess evacuation was done. Left pneumonectomy or Right lobectomy was considered but was deemed unacceptable due to high morbidity and mortality. Endovascular coil embolization was done on the 3 large fistulas on the Left lobe. Post procedure, his arterial oxygenation improved to 96%. He has no recurrence of hemoptysis, no headaches and with less episodes of shortness of breath 2 months on follow-up. Diagnosing the complex diffuse intrapulmonary malformations requires a high index of suspicion among patients with chronic cyanosis, chronic history of bleeding, and brain abscess. Treatment of this condition and its associated complications remain a big challenge and should be highly individualized.

Acquired arteriovenous fistula of the right common iliac artery and left common iliac vein and bilateral lower extremity deep venous thrombosis in a woman presenting as high output heart failure

Acquired intraabdominal arteriovenous fistula (AVF) is a rare disorder where the communication most commonly occurs between the abdominal aorta and inferior vena cava. Ilioiliac AVF has been reported previously, but is exceedingly rare. We present a case of acquired arteriovenous fistula of the right common iliac artery and left common iliac vein with extensive collateralization (ilioiliac AVF) in a 36-year-old female who presented with symptoms of high output congestive heart failure 18 years after sustaining an abdominal gunshot wound.