Quality of care of adult patients with ST-Elevation Myocardial Infarction (STEMI) at the emergency room of a tertiary hospital in the Philippines

@#<p style="text-align: justify;"><strong>Introduction.</strong> Coronary artery disease (CAD) remains a significant public health problem worldwide and in the Philippines. Adherence to guideline-directed therapy improves the quality of care (QOC).</p><p style="text-align: justify;"><strong>Objective.</strong> We aimed to evaluate the QOC initially received by ST-Elevation Myocardial Infarction (STEMI) patients at our Emergency Room (ER), based on compliance to 2014 PHA CAD guidelines recommendations.</p><p style="text-align: justify;"><strong>Methods.</strong> We reviewed the charts of adult patients with STEMI admitted at the ER who were not previously managed in a different hospital. The primary outcome was QOC assessed through quality indicators (QI) based on class I and IIa recommendations in the PHA CAD guidelines.</p><p style="text-align: justify;"><strong>Results.</strong> Of the 29 patients included, all had ECG done upon admission, but only four were done within 10 minutes (QI: 13.79%). All eligible patients received antiplatelets (QI: 100%). Six eligible patients (QI: 100%) received nitrates, and four eligible patients (QI: 100%) received morphine. Of 16 eligible patients, only six were reperfused within the recommended 12 hours of ischemia (QI: 37.5%), two by thrombolysis and four by the primary percutaneous coronary intervention (PCI).</p><p style="text-align: justify;"><strong>Conclusion.</strong> The timely performance of initial ECG and reperfusion need improvement. Suitable performance measures for the provision of nitrates and morphine to eligible patients were met. Investigating intrinsic and extrinsic factors that lead to the time delays observed are also recommended.</p>

Apolipoprotein levels in patients with Acute Coronary Syndrome (LIPAS): A pilot study

Introduction@#Lowering levels of low-density lipoprotein cholesterol (LDL-C) are proven to reduce cardiovascular risk. However, some individuals experience acute coronary events despite normal LDL-C levels. Recent studies have focused on modifiable lipoprotein targets, such as apolipoprotein B (apo-B) and apolipoprotein A-1 (apo A-1) and lipoprotein (a), as targets for therapy. Apo-B is the primary apolipoprotein of LDL-C representing total number of atherogenic particles. Apolipoprotein A-1 is the major component of HDL complex. This study will determine the prevalence of elevated apo-B and low apo A-1 among adult Filipinos with acute coronary syndrome (ACS).@*Methods@#This is a cross-sectional study involving 95 patients with ACS admitted in a tertiary hospital from November 2015 to May 2016. Levels of apo-B, apoA-1, lipoprotein (a), total cholesterol, triglyceride, LDL-C, and high-density lipoprotein cholesterol (HDL-C) were measured within 24 hours upon admission.@*Results@#Forty-eight (48%) percent of patients was diagnosed with Non ST-Elevation-ACS, 39% with ST-Elevation myocardial infarction (STEMI) and 13% with unstable angina.Thirtytwo (32%) percent were on low- to high-intensity statin treatment. The mean LDL-C, non-HDL-C, and HDL-C levels were 109 mg/dL, 135 mg/dL, and 36.89 mg/dL, respectively. The prevalence of elevated apo-B (mean=103.79 mg/ dL; target:<80 mg/dL) was 82%, while that of low apo A-1 (mean=119 mg/dL; target: >120 mg/dL for males, >140 mg/dL for females) was 63%. Lipoprotein (a) levels are high (mean = 48.51 nmol/L; normal:<35 nmol/L) in 42% of patients. Among those on statin therapy, the mean LDL-C was 85 mg/dl, but the mean apo B and lipoprotein (a) levels were elevated at 87.57 mg/dL and 41 nmol/L, respectively.@*Conclusion@#Elevated levels of apo B and lipoprotein (a) and low level of apo A-1 are highly prevalent in patients with ACS. Apo-B and lipoprotein (a) levels are likewise elevated among patients with normal LDL levels.

Prognostic impact of coronary collaterals in acute coronary syndrome (PICC-ACS): A meta-analysis of observational studies

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> The coronary collateral circulation (CCC) is an alternative source of blood supply in coronary artery disease (CAD). The prognostic value of the presence of CCC at the time of acute coronary syndrome (ACS) is undefined with regards to hard outcomes, particularly reduction in mortality. The study's aim is to determine if the presence of CCC demonstrated by coronary angiography during an ACS is associated with a reduction in mortality. </p><p style="text-align: justify;"><strong>METHODS:</strong> We conducted a systematic search of studies using MEDLINE, EMBASE, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials databases in all languages and examined reference lists of studies. The inclusion criteria were 1) observational; 2) population included adults >19 years old with an acute coronary syndrome; 3) reported data on mortality in association with the presence or absence of CCC on angiography; and 4) should have controlled for confounders by using logistic regression analysis. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale for observational studies. The outcome of interest was reduction in all-cause mortality, assessed using Mantel-Haenzel analysis of random effects to compute for risk ratios.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Pooled analysis from 11 identified trials with 8,370 subjects showed that among patients with ACS who underwent coronary angiography, the presence of CCC showed a trend towards benefit in terms of mortality, but was not statistically different from those without CCC [RR 0.65, (95% CI 0.38 to 1.12), p<0.0001, I2=74%]. In those ACS patients with CCC treated with PCI, a significant reduction in mortality was found [RR 0.43, (95% CI 0.29 to 0.64), p< 0.0001, I2=0%].</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> The presence of CCC during ACS showed a trend towards mortality reduction. Further, among patients treated with PCI, those with CCC had an incrementally significant reduction in mortality compared to those without CCC.</p>

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

@#<p style="text-align: justify;"><strong>INTRODUCTION: </strong>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</p><p style="text-align: justify;"><strong>METHODS:</strong> 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.</p><p style="text-align: justify;"><strong>RESULTS:</strong> 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.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> 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.</p>

Association of the platelet-lymphocyte ratio (PLR) with outcomes in patients admitted for acute coronary syndrome: The PLACS study

@#<p style="text-align: justify;"><strong>INTRODUCTION: </strong>Patients with acute coronary syndrome (ACS) exhibit a wide spectrum of early risk of death (one to 10 percent). High platelet counts may indicate a propensity for platelet-rich thrombi. Lymphocyte counts drop during ACS due to stress-induced cortisol release. Combining these two markers, recent studies have found that the platelet-tolymphocyte ratio (PLR) is associated with adverse cardiac events among patients with ACS, but local data is limited. The objective of this study is to determine if an elevated PLR taken on admission is associated with higher rates of adverse cardiac events.</p><p style="text-align: justify;"><strong>METHODS:</strong> A retrospective cohort of adult patients with ACS admitted at the UP-Philippine General Hospital was analyzed. Leukocyte and platelet counts were measured by an automated hematology analyzer. The PLR values of these patients were computed, and they were stratified into two groups after determining the optimal cut-off from the receiver operating characteristic curve (ROC) curve. The primary outcome was in-hospital mortality. Secondary outcomes included development of heart failure, cardiogenic shock, reinfarction, and significant arrhythmias.</p><p style="text-align: justify;"><strong>RESULTS:</strong> A total of 174 Filipinos with ACS were included. In-hospital mortality occurred in 30 patients (17%). These patients had a higher PLR compared to those who were discharged alive (p-value <0.0001). The optimal cutoff value of PLR to predict in-hospital mortality is 165, with a sensitivity of 77% and specificity of 70% (area under the ROC curve of 0.766). On multiple logistic regression analysis, a high PLR was an independent predictor of in-hospital mortality (RR 8.52; p 0.003) after controlling for the effect of other variables. The development of the predetermined secondary outcomes did not correlate with PLR on multivariate analysis.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> Among Filipino patients with ACS, an elevated PLR taken within 24 hours of admission is a useful marker to predict in-hospital mortality, thus providing vital information for risk stratification and more aggressive management strategies.</p>

Association of the platelet-lymphocyte ratio (PLR) with outcomes in patients admitted for acute coronary syndrome: The PLACS study

INTRODUCTION: Patients with acute coronary syndrome (ACS) exhibit a wide spectrum of early risk of death (one to 10 percent). High platelet counts may indicate a propensity for platelet-rich thrombi. Lymphocyte counts drop during ACS due to stress-induced cortisol release. Combining these two markers, recent studies have found that the platelet-tolymphocyte ratio (PLR) is associated with adverse cardiac events among patients with ACS, but local data is limited. The objective of this study is to determine if an elevated PLR taken on admission is associated with higher rates of adverse cardiac events.METHODS: A retrospective cohort of adult patients with ACS admitted at the UP-Philippine General Hospital was analyzed. Leukocyte and platelet counts were measured by an automated hematology analyzer. The PLR values of these patients were computed, and they were stratified into two groups after determining the optimal cut-off from the receiver operating characteristic curve (ROC) curve. The primary outcome was in-hospital mortality. Secondary outcomes included development of heart failure, cardiogenic shock, reinfarction, and significant arrhythmias.RESULTS: A total of 174 Filipinos with ACS were included. In-hospital mortality occurred in 30 patients (17%). These patients had a higher PLR compared to those who were discharged alive (p-value CONCLUSION: Among Filipino patients with ACS, an elevated PLR taken within 24 hours of admission is a useful marker to predict in-hospital mortality, thus providing vital information for risk stratification and more aggressive management strategies.