Intravenous Tocilizumab versus Standard of Care in the Treatment of Severe and Critical COVID-19-related Pneumonia: A Single-center, Double-blind, Placebo-controlled, Phase 3 Trial.

Background: Severe and critical COVID-19 disease is characterized by hyperinflammation involving pro-inflammatory cytokines, particularly IL-6. Tocilizumab is a monoclonal antibody that blocks IL-6 receptors. Objectives: This study evaluated the efficacy of tocilizumab in Filipino patients with severe to critical COVID-19 disease. Methods: This phase 3 randomized double-blind trial, included patients hospitalized for severe or critical COVID-19 in a 1:1 ratio to receive either tocilizumab plus local standard of care or placebo plus standard of care. Patients were eligible for a repeat IV infusion within 24-48 hours if they deteriorated or did not improve. Treatment success or clinical improvement was defined as at least two categories of improvement from baseline in the WHO 7-point Ordinal Scale of patient status, in an intention-to-treat manner. Results: Forty-nine (49) patients were randomized in the tocilizumab arm and 49 in the placebo arm. There was no significant difference in age, comorbidities, COVID-19 severity, need for mechanical ventilation, presence of acute respiratory distress syndrome, or biomarker levels between groups. Use of adjunctive therapy was similar between groups, with corticosteroid used in 91.8% in tocilizumab group and 81.6% in the placebo group, while remdesivir was used in 98% of participants in both groups.There was no significant difference between groups in terms of treatment success in both the intention-to-treat analysis (relative risk=1.05, 95% CI: 0.85-1.30) and per-protocol analysis (relative risk=0.98, 95% CI: 0.80 to 1.21). There was no significant difference in time to improvement of at least two categories relative to baseline on the 7-point Ordinal Scale of clinical status. Conclusion: The use of tocilizumab on top of standard of care in the management of patients with severe to critical COVID-19 did not result in significant improvement as defined by the WHO 7-point Ordinal Scale of patient status, nor in significant improvement in incidence of mechanical ventilation, incidence of ICU admission, length of ICU stay, and mortality rate.

Isolated tricuspid valve Group B Streptococcal endocarditis with septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries.

A diabetic woman in her 30s was admitted to our medical centre for persistent fever associated with worsening cough, easy fatigability and pleuritic chest pain noted after childbirth. Investigations revealed an isolated tricuspid valve endocarditis from Group B Streptococcus Despite appropriate antibiotic coverage, her symptoms persisted with worsening dyspnoea; hence, a CT pulmonary angiogram was done which showed septic pulmonary embolism and multiple mycotic aneurysms of the pulmonary arteries. She was treated with antibiotics and underwent tricuspid valve replacement and was discharged well with a return to her baseline functional capacity on subsequent follow-ups.

Utility of laboratory and immune biomarkers in predicting disease progression and mortality among patients with moderate to severe COVID-19 disease at a Philippine tertiary hospital.

Purpose: This study was performed to determine the clinical biomarkers and cytokines that may be associated with disease progression and in-hospital mortality in a cohort of hospitalized patients with RT-PCR confirmed moderate to severe COVID-19 infection from October 2020 to September 2021, during the first wave of COVID-19 pandemic before the advent of vaccination. Patients and methods: Clinical profile was obtained from the medical records. Laboratory parameters (complete blood count [CBC], albumin, LDH, CRP, ferritin, D-dimer, and procalcitonin) and serum concentrations of cytokines (IL-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-18, IFN-γ, IP-10, TNF-α) were measured on Days 0-3, 4-10, 11-14 and beyond Day 14 from the onset of illness. Regression analysis was done to determine the association of the clinical laboratory biomarkers and cytokines with the primary outcomes of disease progression and mortality. ROC curves were generated to determine the predictive performance of the cytokines. Results: We included 400 hospitalized patients with COVID-19 infection, 69% had severe to critical COVID-19 on admission. Disease progression occurred in 139 (35%) patients, while 18% of the total cohort died (73 out of 400). High D-dimer >1 µg/mL (RR 3.5 95%CI 1.83-6.69), elevated LDH >359.5 U/L (RR 1.85 95%CI 1.05-3.25), lymphopenia (RR 1.91 95%CI 1.14-3.19), and hypoalbuminemia (RR 2.67, 95%CI 1.05-6.78) were significantly associated with disease progression. High D-dimer (RR 3.95, 95%CI 1.62-9.61) and high LDH (RR 5.43, 95%CI 2.39-12.37) were also significantly associated with increased risk of in-hospital mortality. Nonsurvivors had significantly higher IP-10 levels at 0 to 3, 4 to 10, and 11 to 14 days from illness onset (p<0.01), IL-6 levels at 0 to 3 days of illness (p=0.03) and IL-18 levels at days 11-14 of illness (p<0.001) compared to survivors. IP-10 had the best predictive performance for disease progression at days 0-3 (AUC 0.81, 95%CI: 0.68-0.95), followed by IL-6 at 11-14 days of illness (AUC 0.67, 95%CI: 0.61-0.73). IP-10 predicted mortality at 11-14 days of illness (AUC 0.77, 95%CI: 0.70-0.84), and IL-6 beyond 14 days of illness (AUC 0.75, 95%CI: 0.68-0.82). Conclusion: Elevated D-dimer, elevated LDH, lymphopenia and hypoalbuminemia are prognostic markers of disease progression. High IP-10 and IL-6 within the 14 days of illness herald disease progression. Additionally, elevated D-dimer and LDH, high IP-10, IL-6 and IL-18 were also associated with mortality. Timely utilization of these biomarkers can guide clinical monitoring and management decisions for COVID-19 patients in the Philippines.

The rs1458038 variant near FGF5 is associated with poor response to calcium channel blockers among Filipinos.

ABSTRACT: Genetic variation is known to affect response to calcium channel blockers (CCBs) among different populations. This study aimed to determine the genetic variations associated with poor response to this class of antihypertensive drugs among Filipinos.One hundred eighty one hypertensive participants on CCBs therapy were included in an unmatched case-control study. Genomic deoxyribonucleic acid were extracted and genotyped for selected genetic variants. Regression analysis was used to determine the association of genetic and clinical variables with poor response to medication.The variant rs1458038 near fibroblast growth factor 5 gene showed significant association with poor blood pressure-lowering response based on additive effect (CT genotype: adjusted OR 3.41, P = .001; TT genotype: adjusted OR 6.72, P < .001).These findings suggest that blood pressure response to calcium channels blockers among Filipinos with hypertension is associated with gene variant rs1458038 near fibroblast growth factor 5 gene. Further studies are recommended to validate such relationship of the variant to the CCB response.

Cost-utility analysis of add-on dapagliflozin in heart failure with reduced ejection fraction in the Philippines.

AIM: We aim to determine the cost-effectiveness of dapagliflozin in addition to standard therapy versus standard therapy alone among patients with heart failure with reduced ejection fraction (HFrEF) using the public healthcare provider's perspective in the Philippines. METHODS AND RESULTS: A thousand Filipino patients with HFrEF (with or without type 2 diabetes mellitus) were included in a simulation cohort using a lifetime Markov model. The model, which was developed based on the results of the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial, was composed of three health states. These were 'alive without an event' (chronic heart failure state), 'alive but was hospitalized for heart failure' (worsening heart failure), and 'dead' (death from any cause). Data regarding costs and utilities were obtained from previous studies and local data. These were used to estimate the incremental cost per quality-adjusted life-year (ICER). A 3% annual discount rate was used for both costs and effects. One-way (deterministic) and probabilistic sensitivity analyses as well as scenario analyses were performed. The ICER for the addition of dapagliflozin to standard therapy among HFrEF patients was PHP177 868 (US$3434) and PHP160 983 (US$3108), respectively, if the present price (PHP44.00) and possible negotiated unit cost of dapagliflozin 10 mg tablet (PHP40.00) were used. These were deemed cost-effective because they were both below the threshold ICER which was equivalent to the gross domestic product per capita of the Philippines in 2019, PHP180 500 (US$3485). Using the unit costs of dapagliflozin previously mentioned, the ICERs among HFrEF patients with diabetes were PHP132 582 (US$2560) and PHP120 249 (US$2321), respectively. Doing PSA involving Monte Carlo simulation of 10 000 iterations and plotting the resulting ICERs against the threshold ICER in the cost-effectiveness acceptability curves, these ICERs for HFrEF among diabetics were determined to be 72% and 76% cost-effective. CONCLUSION: Dapagliflozin added to standard therapy for HFrEF patients is likely to be cost-effective using the perspective of the Philippine public healthcare provider.

Executive Summary of the 2020 Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines.

Dyslipidemia is a cardiovascular risk factor that is increasing in prevalence in the country. The need to treat and manage elevated cholesterol levels, both pharmacologic and non-pharmacologic, is of utmost importance. Different medical societies and groups bonded together to formulate the 2020 Philippine Clinical Practice Guidelines for dyslipidemia. The group raised nine clinical questions that are important in dyslipidemia management. A technical working group analyzed the clinical questions dealing with non-pharmacologic management, primary prevention for both non-diabetic and individuals with diabetes, familial hypercholesterolemia, secondary prevention, adverse events of statins and the use of other lipid parameters as measurement of risk for cardiovascular disease. Randomized controlled trials and meta-analyses were included in the GRADE-PRO analysis to come up with the statements answering the clinical questions. The statements were presented to a panel consisting of government agencies, members of the different medical societies, and private institutions, and the statements were voted upon to come up with the final statements of the 2020 practice guidelines. The 2020 CPG is aimed for the Filipino physician to confidently care for the individual with dyslipidemia and eventually lower his risk for cardiovascular disease.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee.

BACKGROUND: Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES: The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY: A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS: A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

A systematic review and meta-analysis on the effectiveness of an invasive strategy compared to a conservative approach in patients > 65 years old with non-ST elevation acute coronary syndrome.

BACKGROUND: Patients 65 years old and older largely represent (>50%) hospital-admitted patients with acute coronary syndrome (ACS). Data are conflicting comparing efficacy of early routine invasive (within 48-72 hours of initial evaluation) versus conservative management of ACS in this population. OBJECTIVE: We aimed to determine the effectiveness of routine early invasive strategy compared to conservative treatment in reducing major adverse cardiovascular events in patients 65 years old and older with non-ST elevation (NSTE) ACS. DATA SOURCES: We conducted a systematic review of randomized controlled trials (RCTs) through PubMed, Cochrane, and Google Scholar database. STUDY SELECTION: The studies included were RCTs that evaluated the effectiveness of invasive strategy compared to conservative treatment among patients ≥ 65 years old diagnosed with NSTEACS. Studies were included if they assessed any of the following outcomes of death, cardiovascular mortality, myocardial infarction (MI), stroke, recurrent angina, and need for revascularization. Six articles were subsequently included in the meta-analysis. DATA EXTRACTION: Three independent reviewers extracted the data of interest from the articles using a standardized data collection form that included study quality indicators. Disparity in assessment was adjudicated by another reviewer. DATA SYNTHESIS: All pooled analyses were initially done using Fixed Effects model. For pooled analyses with significant heterogeneity (I2≥ 50%), the Random Effects model was used. A total of 3,768 patients were included, 1,986 in the invasive strategy group, and 1,782 in the conservative treatment group. RESULTS: Meta-analysis showed less incidence of revascularization in the invasive (2%) over conservative treatment groups (8%), with overall risk ratio of 0.29 (95% CI 0.14 to 0.59). Across all pooled studies, no significant effect of invasive strategy on all-cause mortality, cardiovascular mortality, stroke, and MI was observed. Only one study assessed the outcome of recurrent angina. CONCLUSION: There was a significantly lower rate of revascularization in the invasive strategy group compared to the conservative treatment group. In the reduction of all-cause mortality, cardiovascular mortality, MI, and stroke there was no significant effect of invasive strategy versus conservative treatment. This finding does not support the bias against early routine invasive intervention in patients ≥ 65 years old with NSTEACS. Further studies focusing on these patients with larger population sizes are still needed.

The Klotho Variant rs36217263 Is Associated With Poor Response to Cardioselective Beta-Blocker Therapy Among Filipinos.

A common drug used for hypertension among Filipinos is beta-blockers. Variable responses to beta-blockers are observed, and genetic predisposition is suggested. This study investigated the association of genetic variants with poor response to beta-blockers among Filipinos. A total of 76 Filipino adult hypertensive participants on beta-blockers were enrolled in an unmatched case-control study. Genotyping was done using DNA from blood samples. Candidate variants were correlated with clinical data using χ2 and logistic regression analysis. The deletion of at least one copy of allele A of rs36217263 near Klotho showed statistically significant association with poor response to beta-blockers (dominant; odds ratio (OR) = 3.89; P = 0.017), adjusted for diabetes and dyslipidemia. This association is observed among participants using cardioselective beta-blockers (crude OR = 5.60; P = 0.008) but not carvedilol (crude OR = 2.56; P = 0.67). The genetic variant rs36217263 is associated with poor response to cardioselective beta-blockers, which may become a potential marker to aid in the management of hypertension.

Economic burden of hospitalisation for congestive heart failure among adults in the Philippines.

OBJECTIVES: Hospitalisation for congestive heart failure (CHF) was reported to be 1648 cases for every 100 000 patient claims in 2014 in the Philippines; however, there are no data regarding its economic impact. This study determined CHF hospitalisation cost and its total economic burden. It compared the healthcare-related hospitalisation cost from the societal perspective with the payer's perspective, the Philippine Health Insurance Corporation (PhilHealth). METHODS: This is a cost analysis study. Data were obtained from representative government/private hospitals and a drugstore in all regions of the country. Healthcare costs included cost of diagnostics/treatment, professional fees and other CHF-related hospital charges, while non-healthcare costs included production losses, transportation and food expenses. RESULTS: The overall mean healthcare-related cost for CHF hospitalisation (class III) in government hospitals in the Philippines in 2014 was PHP19 340-PHP28 220 (US$436-US$636). In private hospitals, it was PHP28 370-PHP41 800 (US$639-US$941). In comparison, PhilHealth's coverage/CHF case rate payment is PHP15 700 (US$354). The mean non-healthcare cost was PHP10 700-PHP14 600 (US$241-US$329). Using PhilHealth's case rate payment and the prevalence of CHF hospitalisation in 2014, the total economic burden was PHP691 522 200 (US$15 574 824). Using the study results on healthcare-related cost meant that the total economic burden for CHF hospitalisation would instead be PHP851 850 000-PHP1 841 563 000 (US$19 185 811-US$41 476 644). CONCLUSIONS: The calculated healthcare-related hospitalisation cost for CHF in the Philippines in 2014 demonstrates the disparity between the actual cost and PhilHealth's coverage. This implies a need for policymakers to review its coverage to make healthcare delivery affordable.

Ivabradine Versus Beta-Blockers in Mitral Stenosis in Sinus Rhythm: An Updated Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Symptoms of mitral stenosis (MS) are worsened during tachycardia and exercise. Beta-blockers are used in controlling heart rate (HR) in MS, resulting in symptom improvement, but coming with significant side effects. Ivabradine has a selective action on the sinus node devoid of the usual side effects of beta-blockers. Small studies have recently investigated the role of ivabradine in MS in sinus rhythm. Our aim was to determine the efficacy of ivabradine, compared to beta-blockers, in terms of exercise duration, maximum HR achieved, resting HR, mean gradient, and working capacity among patients with MS in sinus rhythm. METHODS: We conducted a systematic search of studies using MEDLINE, Google Scholar, ScienceDirect, Scopus, Clinical Key, Cochrane, and clinicaltrials.gov databases in all languages and examined reference lists of studies. We included studies if they are: 1) randomized controlled trials comparing ivabradine and beta-blockers; 2) of adults ≥ 19 years old with MS in sinus rhythm; and 3) reported data on exercise duration, maximum HR achieved, resting HR, mean gradient, and working capacity. Studies identified were assessed for risk of bias using the Cochrane Collaboration Tool for Assessing Risk of Bias. We used inverse variance analysis of fixed effects to compute for mean difference, carried out using Review Manager (RevMan) 5.3. RESULTS: Pooled analysis from five identified trials showed that among patients with MS in sinus rhythm, ivabradine was better compared to beta-blockers in total exercise duration (mean difference: 32.73 s (95% CI: 12.19, 53.27; P = 0.002; I2 = 0%)), maximum HR achieved after exercise (mean difference: -3.87 beats per minute (95% CI: -5.88, -1.860; P = 0.0002; I2 = 23%)), and work capacity (mean difference: 0.56 METS (95% CI: 0.33, 0.80; P < 0.00001; I2 = 0%)); inferior to beta-blockers in resting HR achieved (mean difference: 1.83 s (95% CI: 0.39, 3.28; P = 0.01; I2 = 91%)); and comparable to beta-blockers in terms of mean gradient (mean difference: -0.52 mm Hg (95% CI: -1.20, 0.16; P = 0.13; I2 = 6%)). CONCLUSIONS: Ivabradine is better or comparable to beta-blockers in terms of the outcomes measured, and may be considered as an alternative for patients with MS in sinus rhythm who are intolerant to beta-blockers.

Cardiac events occurred commonly among apparently healthy Filipinos with the Brugada ECG pattern in the LIFECARE cohort.

BACKGROUND: Brugada syndrome is the mechanism for sudden unexplained death. The Brugada ECG pattern is found in 2% of Filipinos. There is a knowledge gap on the clinical outcome of these individuals. The clinical profile and 5-year cardiac event rate of individuals with the Brugada ECG pattern were determined in this cohort. METHODS: This is a sub-study of LIFECARE (Life Course Study in Cardiovascular Disease Epidemiology), a community based cohort enrolling healthy individuals 20 to 50 years old conducted in 2009-2010. ECGs of all enrollees were screened independently by three cardiologists. The prevalence of the coved Brugada ECG pattern was ascertained, and the 5-year cardiac event rate was determined among those individuals with this pattern. The participants were contacted to determine the occurrence of cardiac events, which included syncope, presyncope, seizures, cardiac arrest and unexplained vehicular accidents. RESULTS: A total of 3072 ECGs were reviewed, and 14 subjects (0.4%) with the coved Brugada ECG pattern were identified. Four had a cardiac event on follow-up at 5 years, but all remained alive. Most of these 14 coved Brugada individuals were healthy and asymptomatic at baseline. CONCLUSION: Cardiac events occurred commonly among initially asymptomatic Filipinos with the coved Brugada ECG pattern. Such patients need to be followed up closely.

Red Cell Distribution Width and Mortality in Patients With Acute Coronary Syndrome: A Meta-Analysis on Prognosis.

BACKGROUND: Red cell distribution width (RDW), a routine component of the complete blood count (CBC), measures variation in the size of circulating erythrocytes. It has been associated with several clinical outcomes in cardiovascular disease. We sought to strengthen the association between RDW and mortality in patients admitted for acute coronary syndrome (ACS) by pooling together data from available studies. METHODS: Studies that fulfilled the following were identified for analysis: 1) observational; 2) included patients admitted for ACS; 3) reported data on all-cause or cardiovascular (CV) mortality in association with a low or high RDW; and 4) used logistic regression analysis to control for confounders. Using MEDLINE, Clinical Key, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials databases, a search for eligible studies was conducted until January 9, 2017. The quality of each study was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Our primary outcome of interest was all-cause or CV mortality. We also investigated the impact of RDW on major adverse cardiovascular events (MACEs) for the studies that reported these outcomes. Review Manager (RevMan) 5.3 was utilized to perform Mantel-Haenzel analysis of random effects and compute for relative risk. RESULTS: We identified 13 trials involving 10,410 patients, showing that in ACS, a low RDW is associated with a statistically significant lower all-cause or CV mortality (RR 0.35, (95% CI 0.30 to 0.40), P < 0.00001, I2 = 53%), a finding that was consistent both in the short- and long-term. CONCLUSIONS: A low RDW is also associated with lower risk for MACEs after an ACS (RR 0.56, (95% CI 0.51 to 0.61), P < 0.00001, I2 = 91%). A low RDW during an ACS is associated with lower all-cause or CV mortality and lower risk of subsequent MACEs, providing us with a convenient and inexpensive risk stratification tool in ACS patients.

Epidemiologic burden of hospitalisation for congestive heart failure among adults aged ≥19†years in the Philippines.

OBJECTIVES: The study determined the prevalence of hospitalisation due to congestive heart failure (CHF) among adult patients aged 19 years and above in the Philippines and its 17 regions in 2014. It also determined the demographic profile of these patients, aetiology and type of CHF, comorbidities, duration of hospitalisation and the overall in-hospital mortality rate. METHODS: Data collection was done using the hospitalisation claims database of the Philippine Health Insurance Corporation (PhilHealth). All patient claims for CHF, that is, patients who were admitted from 1 January to 31 December 2014, were included. Descriptive statistics were utilised to obtain the results. RESULTS: The prevalence rate was 1.6% or 1648 cases of CHF for every 100 000 patient claims for medical conditions in 2014. The mean age was 52.6±15.1 years. There was no sex predilection. Only 22.67% of the hospitalisation claims for CHF listed possible specific aetiologies, the most common of which was hypertensive heart disease (86.7%). There were more cases of systolic compared to diastolic heart failure. The mean length of hospital stay was 5.9 days (+8.2) days (median 4 days), with an overall in-hospital mortality rate of 8.2%. CONCLUSIONS: There were 16 cases of heart failure for every 1000 Filipino patients admitted due to a medical condition in 2014. Hypertension was possibly the most common aetiologic factor. Compared to western and Asia-Pacific countries, the local mortality rate was relatively higher.

Chronic Heart Failure Clinical Practice Guidelines' Class 1-A Pharmacologic Recommendations: Start-to-End Synergistic Drug Therapy?

BACKGROUND: Chronic heart failure (HF) disease as an emerging epidemic has a high economic-psycho-social burden, hospitalization, readmission, morbidity and mortality rates despite many clinical practice guidelines' evidenced-based and consensus driven recommendations that include trials' initial-baseline data. OBJECTIVE: To show that the survival and hospitalization-free event rates in the reviewed chronic HF clinical practice guidelines' class I-A recommendations as initial HF drug therapy (IDT) is possibly a combination and 'start-to-end' synergistic effect of the add-on ('end') HF drug therapy (ADT) to the baseline ('start') HF drug therapy (BDT). METHODOLOGY: The references cited in the chronic HF clinical practice guidelines of the 2005, 2009, and 2013 American Heart Association/American College of Cardiology (AHA/ACC), the 2006 Heart Failure Society of America (HFSA), and the 2005, 2008, and 2012 European Society of Cardiology (ESC) were reviewed and compared with the respective guidelines' and other countries' recommendations. RESULTS: The BDT using glycosides and diuretics is 79%-100% in the cited HF trials. The survival rates attributed to the BDT ('start') is 46%-89% and IDT ('end') 61%-92.8%, respectively. The hospitalization-free event rate of the BDT group: 47.1% to 85.3% and IDT group 61.8%-90%, respectively. Thus, the survival and hospitalization-free event rates of the ADT is 0.4%-15% and 4.6% to 14.7%, respectively. The extrapolated BDT survival is 8%-51% based on a 38% estimated natural HF survival rate for the time period109. CONCLUSION: The contribution of baseline HF drug therapy (BDT) is relevant in terms of survival and hospitalization-free event rates compared to the HF class 1-A guidelines initial drug therapy recommendations (IDT). Further, the proposed initial HF drug ('end') therapy (IDT) has possible synergistic effects with the baseline HF drug ('start') therapy (BDT) and is essentially the add on HF drug therapy (ADT) in our analysis. The polypharmacy HF treatment is a synergistic effect due to BDT and ADT.

Prediction of Symptomatic Embolism in Filipinos With Infective Endocarditis Using the Embolic Risk French Calculator.

BACKGROUND: Cardioembolic events are life-threatening complications of infective endocarditis (IE). The embolic risk French calculator estimates the embolic risk in IE computed on admission. Variables in this tool include age, diabetes, atrial fibrillation, prior embolism, vegetation length, and Staphylococcus aureus on culture. A computed risk of > 7% was considered high in the development of this tool. Knowledge of this risk applied in our local setting is important to guide clinicians in preventing such catastrophic complications. Among patients with IE, we aim to determine the efficacy of the embolic risk French calculator, using a computed score of > 7%, in predicting major embolic events. METHODS: All adults admitted from 2013 to 2016 with definite IE were included. The risk for embolic events was computed on admission. All were monitored for the duration of admission for the occurrence of the primary outcome (any major embolic event: arterial emboli, intracranial hemorrhage, pulmonary infarcts, or aneurysms). Secondary outcomes were: 1) composite of death and embolic events; and 2) death from any cause. RESULTS: Eighty-seven adults with definite IE were included. Majority had a valvular heart disease and preserved ejection fraction (EF). The mitral valve was most commonly involved. Embolic events occurred in 25 (29%). Multivariate analysis identified a high embolic score > 7% (relative risk (RR): 15.12, P < 0.001), vegetation area ≥ 18 mm2 (RR: 6.39, P < 0.01), and a prior embolism (RR: 5.18, P = 0.018) to be independent predictors of embolic events. For the composite of embolic events and death, independent predictors include a high score of > 7% (RR: 13.56, P < 0.001) and a prior embolus (RR: 13.75, P = 0.002). Independent predictors of death were a high score > 7% (RR: 6.20, P = 0.003) and EF ≤ 45% (RR: 9.91, P = 0.004). CONCLUSION: Cardioembolic events are more prevalent in our study compared to previous data. The embolic risk French calculator is a useful tool to estimate and predict risk for embolic events and in-hospital mortality. The risk of developing embolic events should be weighed against the risks of early preventive cardiac surgery, as to institute timely and appropriate management.

Economic Burden of Community-Acquired Pneumonia among Adults in the Philippines: Its Equity and Policy Implications in the Case Rate Payments of the Philippine Health Insurance Corporation.

OBJECTIVES: To determine 1) the cost of hospitalization, the 1-week postdischarge cost, the total cost, and the economic burden of community-acquired pneumonia among patients aged 19 years or older in the Philippines and 2) the difference between the estimated costs and the Philippine Health Insurance Corporation (PhilHealth) pneumonia case rate payments. METHODS: The study involved two tertiary private hospitals in the Philippines. Using the societal perspective, both health care and non-health care costs were determined. A base-case analysis and sensitivity analyses were performed, and the economic burden of pneumonia was determined using PhilHealth claims. RESULTS: The estimated cost of hospitalization for community-acquired pneumonia-moderate risk (CAP-MR) ranged from Philippine peso (PHP) 36,153 to 113,633 (US $852-2678) and its 1-week postdischarge cost ranged from PHP1450 to 8800 (US $34-207). The cost of hospitalization for community-acquired pneumonia-high risk (CAP-HR) ranged from PHP104,544 to 249,695 (US $2464-5885) and PHP101,248 to 243, 495 (US $2386-5739) using invasive and noninvasive ventilation, respectively. The postdischarge cost for CAP-HR ranged from PHP1716 to 10,529 (US $40-248). If only health care cost was considered, the cost ranged from PHP24,403 to 89,433 for CAP-MR and PHP92,848 to 213,395 for CAP-HR. The present PhilHealth case rate payments are PHP15,000 (US $354) and PHP32,000 (US $754) for CAP-MR and CAP-HR, respectively. Based on the number of PhilHealth claims for 2012 and the estimated health care cost, the economic burden of pneumonia in 2012 was PHP8.48 billion for CAP-MR and PHP643.76 million for CAP-HR. CONCLUSIONS: The estimated health care cost of hospitalization is markedly higher than the PhilHealth case rate payments. As per the study results, the economic burden of pneumonia is, thus, significantly higher than PhilHealth estimates.