Sex differences in Cardiovascular risk factors and management in a preventive Cardiology clinic at a tertiary referral center

Background@#Cardiovascular disease is the leading cause of death in both genders worldwide. Gender differences in clinical presentation and treatment have been reported.@*Objective@#This study aims to describe and compare the cardiovascular risk factors and management strategies for primary prevention among Filipinos.@*Methods@#An analytical cross-sectional study was done on 2,082 patients at the Preventive Cardiology Clinic of a tertiary referral center in Quezon City, Philippines from January 1, 2002 to December 31, 2017.@*Results@# Seventy-two percent of the patients were females with a higher mean age compared to males (57.67 + 10.50 vs 55.66 + 11.82, p 0.002). There were more women who were unemployed (75.2 vs 45.9, p<0.001). There was no significant difference in the prevalence of hypertension (68.6% vs 67.9%, p=0.542) and type 2 diabetes mellitus (19.8% vs 21.5%, p=0.437) in both genders. Beta blockers (24.1%), calcium channel blockers (22.9%) and angiotensin receptor blockers (22.1%) were the most commonly prescribed anti-hypertensive drugs. Biguanides were the most commonly prescribed glucose-lowering drug (11.3%). Compared to men, more women had dyslipidemia (51.8% vs 38.6%, p<0.001). Statins were more commonly prescribed in women (22.4 vs 18.1%, p=0.033).@*Conclusion@#There were significantly more women seen in our Preventive Cardiology clinic. Smoking and alcoholic drinking were higher in males. BMI, total cholesterol and HDL were significantly higher in females than in males.

Prevalence and Factors Associated with Obesity at a Primary Preventive Cardiology Clinic: The Philippine Heart Center Experience

@#INTRODUCTION: Obesity has been linked to the development of type 2 diabetes mellitus (T2DM) and cardiovascular diseases. This study primarily aims to determine the prevalence of obesity among the Filipino patients in our institution since there have been no previous studies on this subset of patients. METHODS: A cross-sectional analytical study of 2,078 patients at the Primary Preventive Cardiology Out-Patient Clinic of the Philippine Heart Center (PHC) was done from January 1, 2002 to December 31, 2017. The prevalence of obesity was determined using the World Health Organization (WHO) and Asian classification. Factors associated with obesity were determined using binary logistic regression analysis. RESULTS: A majority of the patients were females (1499, 71.14%) with a higher mean age compared to the male patients (57.67±10.5 vs 55.66±11.8, p<0.001). Hypertension (68.5%), coronary artery disease (37.1%) and T2DM (20.3%) were the most common co-morbid illnesses in both genders. The mean body mass index (BMI) was 25.8±4.3 kg/m2 for the female patients while it was 25.2±4.1 kg/m2 for the male patients (p<0.001). The prevalence of obesity using the WHO and Asian classifications was 15% (n=312). Compared to the Asian criteria, there were significantly more patients classified as having normal weight (44.09% vs 24.95%, p<0.001) and overweight (37.98% vs 19.13%, p<0.001) using the WHO classification. Pre-obesity, an additional criterion of the Asian classification which was not adopted by WHO was seen in 37.98% of the patients. On multivariate analysis, female gender (OR 1.31, 95% CI [1.08-1.59)] p=0.006) and T2DM (OR 1.25, 95% CI [1.01-1.56], p=0.42) were significant factors associated with obesity while age (OR 0.98, 95% CI [0.98-0.99], p<0.001) was protective of obesity. CONCLUSION: The prevalence of obesity in our cohort was consistent with the worldwide prevalence reported by the WHO which underscores the need for effective weight management programs and primary preventive strategies 7to lower the prevalence and obviate the development of complications related to obesity. Female gender and T2DM were significant factors associated with obesity, while age was a significant protective factor of obesity.

Liver Abscess Harbors Melioidosis: A case report on this rare finding in a potentially endemic community

Introduction@#Melioidosis among Filipinos may be underreported. The causative agent, Burkholderia pseudomallei, thrives in soil and water in tropical regions. Because our country thrives on agriculture as a source of livelihood, occupational exposure through farming needs to be recognized. @*Case Presentation@#We report a case of a 40-year-old male complaining of intermittent fever, progressive weight loss and jaundice for three weeks prompting consult. Whole abdominal ultrasound showed presence of a hepatic mass. Further evaluation using CT scan of the whole abdomen with contrast revealed multiple cystic hepatic nodules with wall/septal enhancement. He was admitted and was initially managed as sepsis secondary to a complicated intra-abdominal infection (liver abscess, pyogenic or amebic). Ciprofloxacin and metronidazole were started. Aspiration of the hepatic abscess showed many pus cells. Culture of the aspirate grew Burkholderia pseudomallei, sensitive to ceftazidime. Antibiotics were shifted accordingly. Defervescence ensued. Patient was discharged improved after two weeks of ceftazidime wo grams every eight hours given intravenously followed by a three-month oral course of cotrimoxazole 160mg/800mg tablet, two tablets every 12 hours and doxycycline 150mg capsule every 12 hours. On follow-up after three months, he had no recurrence of symptoms and was able to resume his usual work.@*Discussion@#Melioidosis is a disease of humans and animals that is geographically restricted to tropical countries since the organism thrives in soil and water. Symptom onset may be delayed due to the ability of the organism to produce latent infection. Isolation of B. pseudomallei from clinical specimens sent for culture and sensitivity testing is the diagnostic gold standard.@*Conclusion@#Melioidosis may present as an intraabdominal infection. A high clinical index of suspicion among those with occupational exposure to contaminated soil and water is important to promptly recognize and treat this infection.

Acute Limb Ischemia: A rare and devastating complication of infective Endocarditis

Introduction@#In contrast to embolic events to the brain, lungs and spleen which have been comprehensively discussed in literature, acute limb ischemia (ALI) due to septic embolism (SE) from infective endocarditis (IE) are uncommonly reported. There have been no reported cases of ALI as a complication of IE among Filipinos to date making this case report the first in our country@*Case Presentation@#We report two cases of communityacquired native valve endocarditis caused by streptococcus spp. and enterococcus faecalis. Both patients had large and mobile vegetations in the mitral valve and aortic valve respectively on transthoracic echocardiography. The first one developed ALI (IIa) on the R leg after the initiation of antibiotics. The second case presented with ALI (IIa) on the R leg on admission. They were given the appropriate antibiotics and received systemic anticoagulation with heparin. The first case underwent successful emergency embolectomy on the R leg but developed new-onset ALI on the L leg and refused further intervention. Embolectomy was also recommended on the second patient who also re-fused any intervention. Despite maximal medical management, both patients subsequently expired@*Conclusion@#Infective endocarditis (IE) patients are at risk to develop SE before or during the initiation of appropriate antibiotics. ALI is a life threatening extra cardiac complication of IE. Early recognition and prompt aggressive management are therefore imperative.

Left Ventricular Non-Compaction in an adult with Patent Ductus Arteriosus

Introduction@#Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy that may occur in isolation or with an associated cardiac anomaly. It presents with a wide array of manifestations, prompting early recognition to be imperative to prevent progression of symptoms.@*Case presentation@#We report a case of a 46-year-old male complaining of palpitations for 10 years who survived sudden cardiac arrest on the same year as symptom onset. Consult was advised but was not done until he had heart failure symptoms. Carvedilol, furosemide and digoxin were given. Initially, some improvement was noted but he later developed dyspnea on exertion prompting consult at our institution. Pertinent physical examination findings include a dynamic precordium, apex beat at sixth left intercostal space-anterior axillary line (LICS AAL), right ventricular heave, distinct heart sounds, normal rate, irregularly irregular rhythm, a grade 4/6 continuous murmur heard best at the left upper sternal border, suggestive of patent ductus arteriosus (PDA), and a grade 3/6 holosystolic murmur at the apex radiating to the axilla, suggestive of mitral regurgitation. Transthoracic echocardiography confirmed presence of a PDA (0.8cm) with left to right shunt and Qp/Qs of 2.7:1. Incidental finding of LVNC was noted characterized by prominent ventricular trabeculations and deep intertrabecular recesses. Optimal medical treatment for heart failure was given with symptomatic relief. Surgical closure of the PDA was contemplated after hemodynamic studies can confirm the absence of irreversible pulmonary hypertension.@*Discussion@#Patients with LVNC may be asymptomatic or may present with heart failure, sudden cardiac death or arrhythmias. The diagnosis of LVNC poses a diagnostic challenge. Echocardiography is a cost-effective diagnostic tool that will allow early diagnosis. Cardiac magnetic resonance (CMR) imaging is an alternative diagnostic modality. Once the diagnosis has been confirmed, prompt initiation of guideline-directed medical treatment for heart failure may prevent progression of disease.@*Conclusion@#Left ventricular non-compaction may occur in isolation or in association with other congenital heart diseases such as patent ductus arteriosus. Closure of a PDA is indicated in the presence of a significant shunt and with confirmation of acute reversibility in the presence of pulmonary hypertension to prevent the possibility of decompensation in a patient with heart failure.

Comparison of the prevalence of Hypertension using three proposed classifications in a single center primary prevention setting

Introduction@#The American College of Cardiology/American Heart Association (ACC/AHA) revised the thresholds for the definition and treatment of hypertension that was recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) while the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure retained their previous classification but revised the recommendations for diagnosis and treatment. The impact of these changes in our setting is uncertain. This study aims to compare the prevalence of hypertension using the three proposed criteria in a primary preventive setting.@*Methods@#This is a cross-sectional analytical study using data at the Primary Preventive Cardiology Clinic of the Philippine Heart Center from January 1, 2002 to December 31, 2017.@*Results@#There were 2,082 patients in this study. The mean age is 57.1±10.9 years with a female predominance (72.5%). Most of the patients were married (67.3%, 1,401) and unemployed (67.1%, 1,398). Comorbid illnesses include dyslipidemia (48.2%) and type 2 diabetes mellitus (20.3%). The prevalence of hypertension using the JNC 7 and the 2018 ESC/ESH blood pressure (BP) classification was 56% (n=1,167). When the 2017 ACC/AHA BP classification was applied, there was a significant increase in the prevalence of hypertension to 80.3% (n=1671) (p<0.001) demonstrating an absolute increase of +24.2%.@*Conclusion@#The study shows a high prevalence of hypertension which further increased when the 2017 ACC/AHA BP classification was applied This can impose a significant public health burden that needs to be addressed to prevent or decrease hypertension-related complications. Use of the new guidelines may affect diagnosis and treatment of hypertension with potential cost implications.

Ten-Year survival analysis of Filipino patients with Systemic Lupus Erythematosus at the National Kidney and Transplant Institute

Introduction@#Systemic lupus erythematosus (SLE) is increasingly being diagnosed in our country. This study aims to describe the clinical features, management strategies and outcome of patients with SLE during a ten-year period.@*Methods@#This is a retrospective cohort study of patients first diagnosed with SLE at the National Kidney and Transplant Institute in 2004 who were then followed up in the next ten years.@*Results@#Eighty-five patients were first diagnosed with SLE in 2004. The mean age was 28.1±12.03 years old. Hypertension (34.12%) was the most common co-morbid illness. Renal involvement (74.12%) was seen in a majority but only those with cardiopulmonary manifestations (mean=0.71 years, p=0.030) significantly affected survival. Eleven patients (12.94%) expired during the study period. Active disease and infection were the most common causes of death. Biopsyproven lupus nephritis had a significantly higher survival rate (mean=10.57 years, p=0.006). Those on hemodialysis had a significantly lower survival time (mean=8.82 years, p=0.040). Discussion: The estimated 10-year cumulative survival rate of patients with SLE in our cohort was 75%. This is comparable to the rates reported in some countries. Regular follow-up at six to eight weeks intervals with more frequent follow-up for patients with an SLE flare and/or on intensive immunosuppression was the most likely reason for studies reporting higher survival rates. The disparity in the survival rates may also be attributed to the frequency of exacerbations with better survival among those who never had exacerbations. The most common cause of death was due to septic shock secondary to pneumonia. The authors believe that one factor that was contributory to death was the degree of immunosuppression as observed in studies describing high doses of corticosteroids on those who have died.@*Conclusion@#The cumulative survival rate decreased from 90% at the time of diagnosis to 75% on the tenth year which was comparable to several countries. Patients with cardiopulmonary manifestations were found to significantly affect survival in this study. Although renal involvement was the most common initial manifestation, it did not significantly affect survival similar to other studies. However, biopsyproven lupus nephritis cases had better survival since this allowed treatment to be streamlined based on the class of lupus nephritis. Active disease and infection were the most common causes of death.

Acute Myocardial Infarction in very young Filipino adults

Introduction@#Acute myocardial infarction (AMI) is rare in “very young” patients and studies among Filipinos are scarce. The objective of this study is to determine the prevalence, clinical, echocardiographic and angiographic features, and outcome of this population.@*Methods@#A retrospective study of patients aged 19 to 30 years old who were diagnosed with AMI at the Philippine Heart Center from 2012 to 2016 was done.@*Results@#The prevalence of AMI in very young Filipino adults at our institution was 0.93% (11/1182). The mean age was 26.5±3.4 years with a male predominance (82%). Chest pain was the most common symptom (91%). More than half of the patients did not have heredofamilial diseases. Eight patients were smokers (72%). There was one case of illegal drug use (methamphetamine) (9%). There were only two cases of non-ST elevation myocardial infarction (NSTEMI) (18%). ST elevation myocardial infarction (STEMI) of the anterior wall was seen in four cases (36%), inferior wall in three cases (27%) and anterolateral wall in two cases (18%). Six patients (45%) had left anterior descending artery (LAD) involvement. Two patients (18%) had right coronary artery (RCA) involvement. Two patients (18%) had both LAD and RCA involvement. The youngest patient, a 19-year-old female with Takayasu arteritis, had three-vessel involvement. Five patients (45%) underwent percutaneous coronary involvement (PCI) of the LAD while two had PCI of the RCA (18%). All patients were discharged improved.@*Discussion@#Acute myocardial infarction (AMI) in the young has not been extensively studied among Asians. Chest pain is the most common clinical presentation with STEMI being more frequent than NSTEMI in this age group. Male gender and smoking were the most common risk factors.@*Conclusion@#Early recognition and prompt management of AMI, particularly revascularization (if indicated), are of paramount importance to optimize outcomes.