Lauro L. Abrahan

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.

A Rare Case of Pneumopericardium in the Setting of Tuberculous Constrictive Pericarditis

A 28-year-old Filipino male was admitted due to high-grade fevers and dyspnea on a background of chronic cough and weight loss. Due to clinical and echocardiographic signs of cardiac tamponade, emergency pericardiocentesis was performed on his first hospital day. Five days after, chest radiographs showed new pockets of radiolucency within the cardiac shadow, indicative of pneumopericardium. On repeat echo, air microbubbles admixed with loculated effusion were visualized in the anterior pericardial space. Constrictive physiology was also supported by a thickened pericardium, septal bounce, exaggerated respiratory variation in AV valve inflow, and IVC plethora. A chest CT scan confirmed the presence of an air-fluid level within the pericardial sac. The patient was started on a quadruple antituberculosis regimen and IV piperacillin-tazobactam to cover for superimposed acute bacterial pericarditis. Pericardiectomy was performed as definitive management, with stripped pericardium measuring 5–7 mm thick and caseous material extracted from the pericardial sac. Histopathology was consistent with tuberculosis. This report highlights pneumopericardium as a rare complication of pericardiocentesis. We focused on the utility of echocardiography for diagnosing and monitoring this condition on a background of tuberculous constrictive pericarditis, ultimately convincing us that pericardiectomy was necessary, instead of the usual conservative measures for pneumopericardium.

PS 02-23 ASSOCIATION OF THE PLATELET–LYMPHOCYTE RATIO (PLR) WITH OUTCOMES IN PATIENTS ADMITTED FOR ACUTE CORONARY SYNDROME

Objective: Patients with acute coronary syndromes exhibit a wide spectrum of early risk of death (1–10%). High platelet counts may indicate a propensity for platelet-rich thrombi. A low lymphocyte count has been linked to poor general health. Combining these two markers, recent studies have found that the platelet-to-lymphocyte ratio (PLR) is associated with adverse cardiac events among patients with ACS, but local data is limited. We aim to determine if an elevated PLR taken on admission is associated with higher rates of adverse cardiac events. Design and Method: 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 of these patients was 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 include development or worsening of heart failure, and the development of 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 < 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. Conclusions: Among Filipino patients with ACS, an elevated PLR taken within 24 hours of presentation is a useful marker to predict in-hospital mortality, thus providing useful information for risk stratification.

PS 14-78 RENAL ARTERY STENOSIS IN TAKAYASUʼS ARTERITIS CAUSING EARLY-ONSET HYPERTENSION: A REPORT OF FOUR CASES AT THE UP-PHILIPPINE GENERAL HOSPITAL

Objective: In foreign literature, 90% of renal artery stenosis (RAS) is atherosclerotic and 10% secondary to fibromuscular dysplasia (FMD). However, an important differential for hypertension in the young Asian population is Takayasus arteritis. We present four young patients who initially presented with hypertension due to RAS. Clinical criteria coupled with non-invasive studies in all four cases led to the diagnosis of Takayasus arteritis. All four patients had good outcomes. Design and Method: Four patients (1 male and 3 females) all presented with early-onset hypertension in the third decade of life. Two of the females were pregnant at the time they were seen by the Cardiology service of our institution. Physical examination of the abdomen and peripheral pulses provided clinical clues that suggested the diagnosis of Takayasus arteritis. All four patients had confirmed significant RAS on CT aortogram studies, thus explaining their elevated blood pressures. None had significant elevations in serum creatinine. Results: Although two patients were initially misdiagnosed as FMD, and one was initially managed just as preeclampsia, utilizing the Ishikawa and American College of Rheumatology (ACR) criteria led to the proper diagnosis of Takayasus arteritis. The patients were given varying combinations of anti-hypertensives with or without prednisone to control vasculitic flares/disease activity. The two pregnant inpatients were successfully discharged after their emergency Caesarean sections, and all four are on regular follow-up at the outpatient clinic with controlled blood pressure levels. Conclusions: This case series highlights that even with the rarity of Takayasus arteritis, a thorough history and physical examination are crucial in raising our index of suspicion for this disease as a possible cause of RAS and secondary hypertension. This report also emphasizes the complexity of managing pregnant patients with Takayasus arteritis. Early recognition, a multidisciplinary team, and optimal medical management were the keys to a successful outcome.