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Thesis (M.D.)—Boston University

Abstrakt Bakgrund: Hjärtinfarkt kan vara livshotande och kräver omedelbar sjukhusvård. För att reducera skada på hjärtat är det viktig att patienten kommer till omedelbar reperfusionsbehandling. Om symtom inte känns eller relateras till hjärtat, kan det göra att personen avvaktar med att söka vård och därmed försenas diagnos och behandling vilket kan leda en till ökad risk för att dö. För att öka kunskapen inom detta område vill vi med vår analys undersöka patienters upplevelse av symtom vid en akut hjärtinfarkt. Syfte: Att undersöka patientens upplevelse av symtom vid en akut hjärtinfarkt. Metod: En integrativ litteraturöversikt genomfördes vilken baserades på sökningar i Cinahl och Pubmed. Nio vetenskapliga artiklar med både kvalitativ och kvantitativ ansats valdes ut. Resultat: Studierna visade stor variation av patienternas upplevda symtom och symtomdebutens karaktär. Det fanns även skillnader mellan förväntade och upplevda symtom och resultatet visade att det råder en generell kunskapsbrist om AMI symtom bland allmänheten. Detta sammantaget leder till fördröjning i patienternas beslutsprocess för att uppsöka vård och behandling. Slutsats: Om tiden till behandling kortas, kan det leda till stora förbättringar vad gäller personens hälsa, välmående och livskvalitet. Det borde därmed finnas ett stort intresse att investera i strategier för att öka kunskapen om de olika och varierande symtom vid akut hjärtinfarkt hos allmänheten och även hos yrkesverksamma inom vård- och omsorg.

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Background: The goal of this study was to improve upon methodological limitations of previous studies to determine the existence and source of differences in the cardiac care of individuals with a history of depression or schizophrenia. The selected outcomes were three cardiac procedures: catheterization, percutaneous transluminal coronary angiography (PTCA), and coronary artery bypass graft (CABG); and three cardiac pharmaceuticals: beta-blockers, angiotensin converting enzyme (ACE) inhibitors and statins. Methods: This population-based retrospective cohort study consisted of 309, 790 individuals diagnosed with an AMI and admitted to an acute care hospital in Ontario between April 1, 1995 and March 31, 2009. The time-to-intervention for the depression and schizophrenia was estimated and compared to those without a mental disorder using Cox Proportional Hazards regression. Subgroup analyses were performed to evaluate the interaction between well-established confounders and the receipt of a cardiac intervention. Results: Persons with a history of depression were found to be more likely to receive a catheterization (HR=1.42, 95% CI=1.34-1.50) or PTCA (HR=1.48, 95% CI=1.40-1.57) if they had no previous CVD history, but were less likely to receive a catheterization (HR=0.71, 95% CI=0.51-0.99) or PTCA (HR=0.64, 95% CI=0.39-1.06) if they had a CVD history. In addition individuals with depression were less likely to receive a CABG, especially if they had a history of CVD (HR=0.38, 95% CI=0.24-0.60). Persons with a history of schizophrenia were found to be just as likely to receive a catheterization (HR=0.90, 95% CI=0.70-1.15) or a PTCA (HR=0.83, 95% CI=0.62-1.11). The likelihood of receiving a beta-blocker or statin was comparable or higher for persons with a history of depression (HR=1.07, 95% CI=1.03-1.11; 1.27, 95% ii i CI=1.22-1.32, respectively) and comparable for persons with a history of schizophrenia (HR=0.90, 95% CI=0.79-1.02; HR=0.97, 95% CI=0.83-1.14, respectively), with a small but significant prior drug use effect modification. Interpretation: Persons with depression or schizophrenia with no CVD history are just as likely to receive most recommended cardiac care interventions compared to those without a mental disorder. The source of the differences in care for individuals with a CVD history with depression and schizophrenia needs to be further explored. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-01-26 11:17:27.964

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Background and aims: Heart failure (HF) is a common health problem worldwide. Despite its importance, the epidemiology of HF is incompletely understood. Frequent references to an ‘epidemic of HF’ are at odds with recent reports of a decline in mortality from heart failure. In addition, reports based on admissions to hospital with a diagnosis of HF show that an earlier upward trend levelled off in the late 1990s in most developed countries. However, HF is a heterogeneous condition with multiple underlying causes. A decline in the severity of acute myocardial infarction (AMI), one of the major underlying causes of HF, and improvement in the treatment of patients with AMI as well as of hypertension are factors that might produce contradictory effects on the epidemiology of HF. Recent claims of a major contribution of improved survival after AMI to the reported epidemic of HF in the United States of America need to be examined in other populations. This thesis aims to define more precisely the epidemiological features of heart failure in Australia, and how these have evolved over the last decade. It examines secular trends in mortality, hospital admissions, incidence and survival related to HF. Methods: Trends in mortality from HF and admission to hospital with a diagnosis of HF are examined using computerized records of all deaths occurring in Australia for calendar years 1997-2003 and National Hospital Morbidity Data for financial years 1996-1997 to 2003-2004, obtained from the Australian Institute of Health and Welfare. A death or admission to hospital was defined as involving HF if at least one of the causes of death or one of the diagnoses of each separation was coded to any of the relevant rubrics within the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) or 10th Revision, Australian Modification (ICD-10-AM). The analyses are based on age- and sex-specific death and hospital separation rates for HF either as underlying cause (or principal diagnosis) or mentioned anywhere on the death certificate (or recorded in any diagnostic position in the hospital electronic file) for each calendar or financial year. The investigation of trends in incidence and outcome of early-onset HF (HF complicating an index AMI within 28 days) and late-onset HF after AMI (HF developing 28 days after an index AMI) was based on the World Health Organization MONItoring trends and determinants of CArdiovascular disease (MONICA) register in Western Australia. The study included all residents aged 25-64 years of Perth, the capital city of Western Australia, who were admitted to hospital between 1988 and 1993 with non-fatal definite AMI and who had no history of AMI or HF in the hospital record. Trends in incidence and outcome of early- and late-onset HF were investigated using appropriate statistical methods. Results: From a total of 907,242 deaths occurring in Australia between 1997 and 2003, heart failure was coded as the underlying cause of death (UCD) for 29,341 (3.2%) and was mentioned anywhere on the death certificate in 135,268 (14.9%). Over this period, in both sexes, there were decreases in the absolute numbers of deaths and in the age-specific and age-standardized mortality rates for HF either as UCD or mentioned anywhere on the death certificate. HF was mentioned in 24.6% and 17.8% of deaths attributed to ischaemic heart disease and circulatory disease respectively, and these proportions remained unchanged over the period of study. In addition, HF as UCD accounted for 8.3% of deaths due to circulatory disease and this did not change from 1997 to 2003. From a total of 48,562,285 separations from hospital between 1996-7 and 2003-4, HF was coded as the principal diagnosis for 344,081 (0.8%) and was mentioned anywhere on the hospital record in 1,212,109 (2.5%). While the number of separations with HF remained stable, the age- and sex-standardized separation rate for HF recorded as principal diagnosis decreased from 2.0 per 1000 population in 1996-1997 to 1.7 per 1000 population in 2003- 2004. The corresponding values for HF recorded in any diagnostic position were 7.8 and 5.0 per 1000 population. From all patients (N = 4006) who met the criteria for first-ever, non fatal ‘definite’ AMI in the Perth MONICA Register, 897 (22.4%) had early-onset HF complicating the index event. After adjustment for age and sex, the odds of developing HF declined by 13% (odds ratio for the period 1989-1993 relative to 1984-1988 = 0.87, 95% confidence interval (95%CI): 0.75 to 1.01). After adjustment for age and history of diabetes and hypertension, the hazard of death in patients with early-onset HF (i.e. case fatality) declined by 26% (HR for the period 1989-1993 relative to 1984-1988 = 0.74, 95%CI: 0.57 to 0.96). Of 3109 patients who did not develop early-onset HF, 406 (13.1%) had at least one subsequent hospital admission with a diagnosis of HF (defined as late-onset HF). Following adjustment for age and sex, the hazard ratio for late-onset HF for the period 1989-1993 relative to 1984-1988 was 0.85 (95% confidence interval (95%CI): 0.69-1.04). History of diabetes and hypertension, current smoking, length of initial admission for AMI, recurrent acute coronary syndrome and coronary artery revascularization procedures were predictors of late-onset HF. After a median follow-up of 3.2 years and adjustment for age (≥70 years) and history of diabetes, the hazard of death in patients with late-onset HF did not change over the period of study (HR for year = 1.02, 95%CI: 0.98 to 1.06). Conclusion: For reasons discussed in the body of the thesis, the observed decline in mortality from HF measured as either number of deaths or rate probably reflects a real change in the epidemiology of HF. In addition, there was no increase in the number of hospital admissions involving HF and standardized rates of hospital separations fell in Australia between 1996 and 2004. These results do not support a major increase in the caseload of HF over recent years. In addition, a decline in the risk of early- and late-onset HF after AMI as well as all the evidence on decline in incidence and severity of coronary artery disease and hypertension argue against an increase in inflow from these two important risk factors of HF. However, taking all of the influences on the epidemiology of HF together, it is likely that because of the increasing number of older people, the number of new cases of HF will rise over the next few years, even if the incidence rate falls.

Aproximadamente 5% dos pacientes com infarto agudo do miocÃrdio tÃm idade inferior a 45 anos. As caracterÃsticas especÃficas, epidemiolÃgicas e clÃnicas desta populaÃÃo ainda nÃo estÃo bem esclarecidas. O objetivo do presente estudo à caracterizar a apresentaÃÃo clÃnica, epidemiolÃgica e cinecoronariogrÃfica em jovens submetidos à angioplastia coronariana primÃria (ATC). Foi realizada uma anÃlise retrospectiva de 150 prontuÃrios de pacientes com idade inferior a 45 anos submetidos à ATC entre janeiro de 2006 e dezembro de 2010. Foram analisados os fatores de risco, a apresentaÃÃo clÃnica e eletrocardiogrÃfica, a funÃÃo ventricular esquerda, caracterÃsticas da anatomia coronariana, o tratamento mÃdico e a evoluÃÃo hospitalar. Observou-se que a idade mÃdia dos pacientes foi de 40,1 Â5 anos, com predominÃncia do sexo masculino (68,7%). Os fatores de risco mais associados com o IAM foram o tabagismo (65%), a hipertensÃo arterial sistÃmica (50%), a histÃria familiar de doenÃa arterial coronariana (40%) e os baixos nÃveis de HDL - colesterol (60%). A prevalÃncia de diabetes mellitus foi de 19,3%. O acometimento da artÃria descendente anterior (DA) ocorreu em 53% dos indivÃduos e em 75% foi observada doenÃa em uma Ãnica artÃria. O tempo mÃdio de chegada ao hospital apÃs o inÃcio dos sintomas (delta T) foi de 5,5  3,4 horas e a permanÃncia hospitalar foi de 10,36  14,1 dias. Em 58% dos pacientes, a fraÃÃo de ejeÃÃo do ventrÃculo esquerdo foi superior a 55%. Houve apenas um Ãbito. A taxa de sucesso da ATC foi de 91%. Quanto ao tratamento do IAM, os pacientes receberam globalmente Ãcido acetilsalicÃlico (99,3%), clopidogrel (98%), inibidores da enzima de conversÃo da angiotensina (IECA) (85,3%), betabloqueadores (66%), estatinas (97,3%) e a prescriÃÃo de inibidores da glicoproteÃna IIb-IIIa foi observada em somente 10% dos pacientes. ConcluÃmos que o IAM em jovens apresenta-se como uma entidade tipicamente masculina e de bom prognÃstico na evoluÃÃo precoce, desde que instituÃdo tratamento adequado em tempo hÃbil. O tratamento mÃdico destinado a estes pacientes no Hospital de Messejana Dr. Carlos Alberto Studart Gomes contempla o que à proposto pela IV Diretriz Brasileira para tratamento do IAM com supradesnivelamento do segmento ST. / Approximately 5% of patients with acute myocardial infarction under the age of 45 years. The specific characteristics, clinical and epidemiological this population are not well understood. The aim of this study is to characterize the clinical, epidemiological and coronary cineangiography in young people undergoing primary coronary angioplasty (PTCA). We performed a retrospective analysis of 150 medical records of patients under the age of 45 years who underwent PCI between January 2006 and December 2010. We analyzed the risk factors, clinical presentation and electrocardiographic left ventricular function, characteristics of the coronary anatomy, medical treatment and hospital course. It was observed that the average age of patients was 40.1  5 years, predominantly male (68.7%). The risk factors associated with AMI were smoking (65%), hypertension (50%), family history of coronary artery disease (40%) and low levels of HDL - cholesterol (60%). The prevalence of diabetes mellitus was 19.3%. Involvement of the anterior descending artery (AD) occurred in 53% of individuals and 75% was observed in the disease in a single vessel. The average time of arrival at the hospital after symptom onset (delta T) was 5.5  3.4 hours and hospital stay was 10.36  14.1 days. In 58% of patients, the ejection fraction of left ventricle was greater than 55%. There was one death. The success rate of PTCA was 91%. Regarding the treatment of AMI patients received aspirin overall (99.3%), clopidogrel (98%), angiotensin-converting enzyme inhibitors (ACEI) (85.3%), beta blockers (66%), statins ( 97.3%) and prescription of glycoprotein IIb-IIIa was observed in only 10% of patients. We conclude that in young AMI presents itself as an entity typically masculine and good prognosis in early evolution, provided that appropriate treatment instituted in a timely manner. Medical treatment for these patients at the Hospital of Messejana Dr. Carlos Alberto Studart Gomes contemplates what is proposed by the IV Brazilian Guideline for the treatment of AMI with ST-segment elevation

Abstract Several studies have shown that altered cardiovascular autonomic regulation is associated with hypertension, diabetes, aging, angiographic severity of coronary artery disease (CAD), and increased mortality after acute myocardial infarction (AMI). The purpose of this study was to assess the temporal changes and prognostic significance of various measures of heart rate (HR) behaviour and their possible associations to coronary risk variables, and the progression of CAD in different populations. This study comprised five patient populations. The first consisted of 305 patients with recent coronary artery bypass graft surgery (CABG) and lipid abnormalities, the second of 109 male patients with recent CABG, the third of 53 type II diabetic patients with CAD, the fourth of 600 patients with recent AMI, and the fifth of 41 elderly subjects. HR variability and non-linear measures of HR dynamics were analysed. Among the patients with prior CABG, a significant correlation existed between the baseline HR variability (standard deviation of N-N intervals, SDNN) and the progression of CAD (r = 0.26, p < 0.001)). In the longitudinal study of patients with prior CABG, only the fractal indexes of HR dynamics, such as the power law slope (β) and the short-term fractal exponent (α1), decreased significantly. In diabetic patients, SDNN decreased significantly (p < 0.001) during the three-year period. The reduction of SDNN was related to cholesterol, triglyceride, and glucose levels, and also to progression of CAD (r = 0.36, p < 0.01). In the longitudinal follow-up study of patients with recent AMI, reduced fractal indices (α1 and β), and reduced HR turbulence predicted cardiac death when measured at the convalescent phase after AMI. Reduced β and turbulence slope predicted cardiac death when measured at 12 months after AMI. In the elderly population, β (p < 0.001) and α1 (p < 0.01) reduced significantly. Low-frequency power spectra were the only traditional measure of HR variability that decreased significantly during the 16-year period. HR variability is associated with many risk factors of atherosclerosis and with progression of CAD among patients with ischemic heart disease. Fractal HR dynamics are more sensitively able to detect age-related changes in cardiovascular autonomic regulation. Altered fractal HR dynamics and HR turbulence are associated with increased mortality after AMI.

The objective of the dissertation is analysis of costs that are connected with acute myocardial infarction in the Znojmo Hospital. It is about the bill of costs of this diagnosis with the use of analysis "Cost of Illness". Cost of Illness is one of many kinds of analysis examining the costs of illnesses. At work, I have tried to capture all relevant costs of this diagnosis, especially the cost of diagnosis, therapy and hospitalization of patients with the diagnosis of acute myocardial infarction.