Der akute Myokardinfarkt ist eine der Haupttodesursachen weltweit. Nach aktueller Studienlage reduziert eine schnelle perkutane Koronarintervention (PCI) die Sterblichkeit und verbessert das Outcome bei Patienten mit ST-Hebungsinfarkten (STEMI). Gleichwohl ist es in vielen Fällen schwierig, die von den nationalen und internationalen Gesellschaften geforderten Zeitintervalle einzuhalten. In der vorliegenden prospektiven Erhebung wurde untersucht, ob sich durch den Aufbau eines Infarktnetzwerkes und durch systematische Datenerfassung und Feedback, Behandlungszeiten bei Patienten mit STEMI verkürzen und somit die Behandlungsqualität verbessern lassen. Die hier ausgewerteten Daten wurden im Rahmen des deutschlandweiten, multizentrischen „Feedback-Intervention and Treatment-Times“ (FITT STEMI)-Projektes erhoben. Therapie- und Behandlungszeiten wurden bei Patienten mit STEMI (n=465) in einem Zeitraum von 18 Monaten standardisiert erfasst und systematisch analysiert. Nach einer Analyse des Status-quo in den ersten drei Monaten wurde durch Interventionsmaßnahmen versucht, eine Prozessoptimierung in der Behandlung von ST-Hebungsinfarkten zu erreichen. Zu den Interventionsmaßnahmen zählten: 1. die Einführung eines Herznotrufhandys für eine direkte Kommunikation der einweisenden (Not-)Ärzte und umliegenden peripheren Krankenhäuser mit dem diensthabenden Interventionskardiologen 2. ein systematischer Bypass der Notaufnahme im Interventionskrankenhaus zugunsten eines direkten Transportes in das Herzkatheterlabor 3. der direkte Transport von Patienten in das Interventionszentrum unter Umgehung von peripheren Krankenhäusern (Primärtransport) 4. die quartalsweise Rückkoppelung von Ergebnissen der Datenerhebung im Rahmen von Feedbackrunden an alle Beteiligten des Herzinfarktnetzwerkes. Es zeigte sich, dass die durchgeführten Interventionsmaßnahmen zu einer Reduzierung der Transport- und Behandlungszeiten und einer Prozessoptimierung führten. Die Rate der Primärtransporte in das Interventionszentrum war deutlich erhöht - auf über 70% im letzten Quartal. Die durchschnittlichen „door-to-balloon“ (D2B)-Zeiten konnten global um 13 min reduziert werden, die „contact-to-balloon“ (C2B)-Zeiten von 182 min zu Beginn der Erhebung um 50 min auf 132 min gesenkt werden. Auch der Anteil der Patienten, die innerhalb der von den Leitlinien formulierten Zeitintervalle therapiert wurden, konnte gesteigert werden. Nach Beginn des Projektes wurden doppelt so viele Patienten innerhalb der geforderten C2B-Zeit von < 90 bzw. <120 min therapiert, der Anteil der Patienten mit einer D2B-Zeit < 30 min konnte signifikant gesteigert werden. In der weiteren Analyse der Daten zeigte sich, dass insbesondere die telefonische Anmeldung der Patienten und die Umgehung der Notaufnahme wesentliche Faktoren in der Verbesserung des Behandlungsprozesses darstellen. Auffällig waren die langen Prähospitalzeiten (S2C). Diese Zeitspanne birgt erhebliches Verbesserungspotential, gerade im Hinblick auf die zeitliche Dringlichkeit in der Therapie. Ein direkter Einfluss der S2C auf die Mortalitätsraten konnte in dieser Erhebung allerdings nicht festgestellt werden. Zum Ende der Erhebung stiegen in einigen Bereichen die Behandlungszeiten wieder an. Es bleibt im weiteren Verlauf des Projektes abzuwarten, ob diese Beobachtung ein zufälliges Ereignis oder einen langfristigen Trend darstellt. Unbestritten ist, dass ein bestmöglicher Therapieprozess eine hohes Engagement aller Beteiligten, eine ständige Reevaluation und das kontinuierliche Bestreben, Prozesse zu verbessern, erfordert.

Background: Alcohol consumption has been causally related to the incidence of coronary heart disease, but the role of alcohol before the event has not been explored in depth. This study tested the hypothesis that heavy drinking (binge drinking) increases the risk of subsequent acute myocardial infarctions (AMI), whereas light to moderate drinking occasions decrease the risk. Methods: Case-crossover design of 250 incident AMI cases in Switzerland, with main hypotheses tested by conditional logistic regression. Results: Alcohol consumption 12 h before the event significantly increased the risk of AMI (OR 3.1; 95% CI 1.4–6.9). Separately, the effects of moderate and binge drinking before the event on AMI were of similar size but did not reach significance. In addition, AMI patients showed more binge drinking than comparable control subjects from the Swiss general population. Conclusions: We found no evidence that alcohol consumption before the event had protective effects on AMI. Instead, alcohol consumption increased the risk. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

La posición socioeconómica y la práctica de actividad física (AF), como estilo de vida, son dos determinantes que influyen en la salud individual y poblacional. En esta tesis se ha analizado la relación y la tendencia en el periodo 1995-2005 de estos dos determinantes con los factores de riesgo cardiovascular (FRCV) y el riesgo de infarto agudo de miocardio (IAM). Se han utilizado datos de tres estudios transversales de base poblacional (1995-2000-2005) realizados en la población de Girona y que incluyen más de 9.000 individuos y datos de un estudio caso-control que incluye más de 1.000 casos de IAM y 1.000 controles. Se ha demostrado que las clases sociales menos favorecidas tienen mayor prevalencia de FRCV, no obstante, las diferencias entre clases en relación al conocimiento, tratamiento y control de los FRCV clásicos que existían en 1995, han desaparecido. Sin embargo, las diferencias entre clases están aumentando durante el periodo analizado respecto a los estilos de vida (tabaquismo, sobrepeso/obesidad y sedentarismo). En relación a la práctica de AF, la prevalencia de sedentarismo ha disminuido de 1995 a 2005. La edad, el género femenino y la clase social menos favorecida se asocian con mayor prevalencia. Al analizar la relación dosis-respuesta de la AF y la salud cardiovascular, se ha observado que la AF ligera no se asocia con un mejor perfil de FRCV pero si con menor riesgo de IAM en mayores de 64 años. La AF moderada-intensa mejora los perfiles de los FRCV con un beneficio máximo en 600-700 MET•minuto/semana y disminuye el riesgo de IAM con un beneficio máximo en 1.500-2.000 MET•minuto/semana. / Socioeconomic status and physical activity practice (PA) (as lifestyle) are two major factors in individual and population health. In this thesis, we analyzed the relationship and the trend in the period 1995-2005 of both two determinants with cardiovascular risk factors and myocardial infarction risk. We used data from three independent population-based cross-sectional studies performed in Girona across 1995-2005 period with 9,546 individuals and data from population based age- and sex-matched case-control study with 1,000 cases and 1,000 controls. This thesis shows that the lower social classes have higher prevalence of cardiovascular risk factors, however, differences in awareness, treatment and control of classical cardiovascular risk factors between groups have disappeared and the disparities in healthy lifestyles between groups are widening. The prevalence of sedentary lifestyle has decreased in the period. Age, female gender and lower educational level were associated with a higher prevalence of physical inactivity. Light intensity PA reduced myocardial infarction risk in subjects older than 64 years and moderate-high intensity PA were associated with a better cardiovascular risk factors profile with a maximum benefit around 600-700 MET・min/week and also with a lower myocardial infarction risk with a maximum benefit around 1500-2000 MET・min/week.

Coronary heart disease (CHD) is a leading cause of morbidity and mortality in the industrialised world, and places a heavy burden on society in terms of personal disability and health care costs. The first signs of CHD often present acutely as a myocardial infarction (AMI), commonly known as a heart attack. Survivors of a heart attack remain vulnerable to poor health-related quality of life (HRQOL), further cardiac events, and increased morbidity due to a progression of CHD. Thus, the implementation of interventions to reduce these risks is an important public health strategy. To date, secondary prevention and rehabilitation efforts post-AMI focus primarily on the patient. However, it is argued that recovery from AMI occurs within a social context, and that risk reduction strategies are likely to be enhanced if interventions take into account the impact of the event on the quality of life of patients and their partners. Evidence from a review of couple relationship literature indicates that a significant proportion of couples experiences poor HRQOL (i.e., physical and emotional wellbeing) when coping with stressful life events, and that interactive aspects of a couple relationship (i.e., dyadic functioning and behaviour) are associated with individual well-being at such a time. Information from studies of couples dealing with recovery from heart attack is sparse, but tends to reflect the findings from the broader literature. Further research is required with post-AMI couples, though, as there are a number of shortcomings associated with the existing evidence. For instance, it is derived from studies conducted with, mostly small, samples of convenience; many different instruments are used to collect the data; and no studies specifically measure HRQOL. Analytically, most evidence is obtained with univariate and bivariate statistics, and data are analysed as groups of patients or partners, as opposed to dyads. Where multivariable analyses are undertaken a number of bivariate relationships are no longer significant after accounting for covariates such as age and gender; and few researchers investigate predictive associations between dyadic functioning/behaviour and HRQOL outcomes. Finally, there is a paucity of information from comparative analyses. Thus, it is not known whether the well-being of post-AMI couples over time is better than, similar to, or worse than, for example, that in the general population. The research program underpinning this thesis, the QUT-AMI Project, comprised two studies designed to address these methodological issues. The first was an observational, cross-sectional, pilot study conducted in 1998 with 26 post-AMI couples. The main investigation was a prospective cohort study of 93 post-AMI couples undertaken in 1999-2000. In both studies the samples comprised a consecutive series of adult males younger than 75 years who had experienced a first AMI, and their female partners. The average couple in both studies was middle-aged, had been married for many years, and both members of the dyad were working at the time of the heart attack. Prospective participants were identified in major clinical centres that admit cardiac patients, and couples were recruited to the project soon after the patient's heart attack. Clinical data were collected in hospital. Further data were collected with self-administered questionnaires during a home visit at 1 month (pilot and main study), and by mailed questionnaire or during a home visit at 6 months(main study) after the heart attack. The pilot study was undertaken to test recruitment and data collection procedures in preparation for the second (main) study, measure couples' HRQOL at 1 month after the event using the SF-36, and qualitatively investigate life issues for couples coping with recovery from AMI. In the main study couples' HRQOL outcomes were measured at 1 and 6 months post-AMI using the SF-36, and examined for changes over that time. The outcomes were also compared with those from matched population norms to estimate the impact of a heart attack on couples' HRQOL during the early and later recovery period. Additionally, the following relationships were investigated to determine the extent to which:* patients' dyadic functioning (e.g. happiness/satisfaction with relationship, measured with the Marital Adjustment Scale) and use of dyadic behaviour (e.g., hiding concerns and negative feelings from the other member of the dyad, measured with the Protective Buffering Scale) at 1 month predicted patients' emotional well-being at 6 months post-AMI;* partners' dyadic functioning and behaviour at 1 month predicted partners' emotional well-being at 6 months post-AMI;* patients' and partners' dyadic functioning at 1 month predicted patients' or partners' emotional well-being at 6 months post-AMI; and* patients' and partners' dyadic behaviour at 1 month predicted patients' or partners' emotional well-being at 6 months post-AMI. Exploratory analyses were also undertaken to determine the effect of dyadic discrepancies in functioning and behaviour, at 1 month after the heart attack, on patients' and partners' emotional well-being at 6 months after the event. Important findings were as follows:* At 1 month after an AMI the HRQOL of couples is impaired. The major impact is on physical well-being for patients, and emotional well-being for their partners.* In general, couples' HRQOL improves between 1 and 6 months after an AMI.* At 6 months after an AMI, the HRQOL of average couples is similar to that of their peers in the normal population.* There are subgroup variations in the quality of life of post-AMI couples, and these are associated with age, clinically poor physical health, and depression.* The combination of patients' and partners' use of dyadic behaviour at 1 month after an AMI explains 7% of the variation in patients' emotional well-being at 6months after the event, after adjustment for patients' concurrent physical wellbeing and prior levels of emotional well-being, as well as duration of couple relationships.* The combination of partners' perceptions of dyadic functioning and use of dyadic behaviour at 1 month after an AMI explains 5% of the variation in partners' emotional well-being at 6 months after the event, after adjustment for partners' concurrent physical well-being and prior levels of emotional well-being, as well as duration of couples' relationships.* Patients have poorer emotional well-being at 6 months after an AMI if partners use dyadic behaviour infrequently at 1 month after the event.* Partners have poorer emotional well-being at 6 months after an AMI if they are not satisfied/unhappy with the functioning of their relationships at 1 month after the event. Adjusted exploratory analyses, undertaken to determine the extent to which dyadic discrepancies in perceptions of functioning or use of protective buffering behaviour, predict emotional well-being, show that patients who are less satisfied/unhappier with functioning than their partners at 1 month after an AMI have poor emotional wellbeing at 6 months after the event; patients who use the behaviour more frequently than their partners at 1 month after an AMI have poor emotional well-being at 6months after the event; and partners who are less satisfied/unhappier with functioning than their patients at 1 month after an AMI have poor emotional well-being at 6months after the event. The evidence from the QUT-AMI Project supports the proposition that the interaction that occurs within a couple relationship, combined with individual characteristics of members of a dyad, influences the extent to which a heart attack impacts on couples' HRQOL. It is argued that it is not enough to merely focus on implementing secondary prevention strategies with post-AMI patients. Given that poor emotional well-being is known to predict adverse cardiac events, and premature mortality due to cardiac disease, it is recommended that a couple-focused intervention designed to meet specific needs should be implemented with at-risk couples as a public health strategy to improve not only the patients' quality of life but also that of his partner. Further research is recommended to determine the extent to which such an intervention improves post-AMI couples' quality of life.

Diss. (sammanfattning) Umeå : Umeå universitet, 2010.

Made available in DSpace on 2016-06-02T20:18:19Z (GMT). No. of bitstreams: 1 4875.pdf: 19049146 bytes, checksum: c54256037244fb411763a05e459a625a (MD5) Previous issue date: 2011-02-28 / There are very few published studies evaluating the effect of a protocol of graded exercise of short duration, during phase I cardiac rehabilitation (CR) on the cardiac autonomic modulation in patients after acute myocardial infarction (AMI), thus three investigations were undertaken in order to evaluate the safety of the protocol of cardiovascular therapy (CPT) phase I, as well as observing the behavior of heart rate (HR), blood pressure (BP) and autonomic modulation of HR through HR variability (HRV) in time domain (TD) and frequency (DF) in patients undergoing phase I protocol CPT after the 1st AMI. Physical therapy in phase I of the CR can be initiated 12 to 24 hours after AMI, however, it is common to prolonged bed rest due to fears of instability of the patient. So the goal of the 1st study was to evaluate the hemodynamic and autonomic responses to post-AMI patients undergoing day 1 of phase I protocol of CPT, as well as their safety. We studied 51 patients with first AMI uncomplicated, 55&#61617;11 years, 76% men and submitted to the 1st day of the protocol CPT Stage I, on average, 24 hours after AMI, consisting of 10 minutes of rest before and after exercises, followed by 4 min of breathing exercises and 5 min of dynamic exercise. The results indicate that the exercise was safe because it caused hemodynamic and autonomic modulation in these patients, without causing any medical complications. The 2nd study aimed to characterize the autonomic and hemodynamic responses to CPT in patients with stage I of an AMI. We studied 21 patients with first uncomplicated AMI, age 52&#61617;12 years, 81% men, six days a progressive exercise program (phase I CPT), consisting of a daily standard protocol (10 min rest in supine position pre-and post-exercise and 4 min of breathing exercises) and a protocol for dynamic graded exercise, progressing to active-assisted movements of the legs in the first days after AMI, even walking in the last days of hospitalization. The protocol applied CPT promoted hemodynamic and autonomic changes during the course of the year, allowing early mobilization of the patient and gradually preparing to return to their activity of daily living after discharge from hospital, without being observed the presence of any sign and / or symptoms of exercise intolerance. The 3rd study was to evaluate the effects of a progressive exercise protocol used in phase I of RCV on HRV at rest in patients after AMI. We studied thirty-seven patients who were admitted to hospital with first uncomplicated AMI. The treated group (TG) (n= 21, age= 52±12 years) conducted a five-day program of progressive exercises during phase I of the RCV, while the control group (CG) (n= 16, age= 54±11 years) had only breathing exercises. The progressive exercise program performed during the first phase of cardiac rehabilitation associated with clinical treatment increased cardiac vagal modulation and reduced cardiac sympathetic modulation in patients after AMI. Overall Conclusion: The results of the three studies suggest that the protocol is safe when applied CPT started after 24 hours of AMI not complicated, and allows early mobilization of patients and gradually prepare them to return their activity of daily living after discharge, without being observed the presence of any sign and / or symptoms of exercise intolerance. In addition the progressive exercise program that compose the physiotherapy intervention associated with clinical treatment caused an increase in cardiac vagal modulation and reduction of cardiac sympathetic modulation at rest in the patients studied. / Há carência de estudos na literatura que avaliem o efeito de um protocolo de exercício físico progressivo (EFP) de curta duração, durante fase I da reabilitação cardiovascular (RCV), sobre a modulação autonômica cardíaca em pacientes pós-infarto agudo do miocárdio (IAM), deste modo, uma investigação dividida em três partes foi desenvolvida no intuito de avaliar a segurança do protocolo de fisioterapia cardiovascular (FTCV) fase I, bem como, observar o comportamento da frequência cardíaca (FC), da pressão arterial (PA) e da modulação autonômica da FC, por meio da variabilidade da FC (VFC) nos domínios do tempo (DT) e da freqüência (DF), em pacientes submetidos ao protocolo de FTCV fase I após o 1º IAM. A fisioterapia na fase I da RCV pode ser iniciada de 12 a 24 horas após o IAM, no entanto, é comum o repouso prolongado no leito devido ao receio de instabilização do paciente. Assim o objetivo do 1º estudo foi avaliar as respostas autonômicas e hemodinâmicas de pacientes pós-IAM submetidos ao 1º dia de protocolo de FTCV fase I, bem como, sua segurança. Foram estudados 51 pacientes com 1o IAM não-complicado, 55&#61617;11 anos, 76% homens e submetidos ao 1º dia do protocolo de FTCV fase I, em média, 24 horas pós-IAM, composto de 10 min de repouso pré e pós-exercícios, 4 min de exercícios respiratórios e 5 min de exercícios físicos dinâmicos (EFD) de membros inferiores (MMII). Os resultados obtidos indicam que o exercício realizado foi seguro, pois promoveu alterações hemodinâmicas e na modulação autonômica da FC nestes pacientes, sem ocasionar qualquer intercorrência clínica. O 2º estudo teve como objetivo caracterizar as respostas autonômicas e hemodinâmicas a FTCV fase I em pacientes com 1º IAM. Foram estudados 21 pacientes com 1o IAM não-complicado, idade 52&#61617;12 anos, 81% homens, durante 6 dias de um programa de EFP (FTCV fase I), composto por um protocolo padrão diário (10 min de repouso na posição supina pré e pós-exercícios e 4 min de exercícios respiratórios) e um protocolo de EFD gradativos, progredindo de movimentos ativo-assistidos de MMII no 1o dia pós-IAM até deambulação nos últimos dias de internação. O protocolo de FTCV aplicado promoveu alterações autonômicas e hemodinâmicas durante a realização do exercício, permitindo a mobilização precoce do paciente e gradativamente o preparando para o retorno a sua atividade de vida diária (AVD) após a alta hospitalar, sem ser observada presença de qualquer sinal e/ou sintoma de intolerância ao esforço. O 3º estudo teve por objetivo avaliar os efeitos de um protocolo de EFP utilizado na fase I da FTCV sobre a VFC de repouso de pacientes pós-IAM. Foram estudados 37 pacientes com 1º IAM não complicado. O grupo tratado (GT) (n=21, idade=52±12 anos) realizou 5 dias de um programa de EFP durante a fase I da FTCV, enquanto o grupo controle (GC) (n=16, idade=54±11 anos) realizou somente exercícios respiratórios. O programa de EFP realizado durante a fase I da FTCV associado ao tratamento clínico aumentou a modulação vagal cardíaca e reduziu a modulação simpática cardíaca em pacientes pós-IAM. Conclusão geral: Os resultados obtidos nas três partes do estudo sugerem que o protocolo de FTCV aplicado é seguro quando iniciado após 24 horas do IAM não complicado, além de permitir a mobilização precoce dos pacientes e gradativamente os preparar para o retorno as suas AVDs após a alta hospitalar, sem ser observada presença de qualquer sinal e/ou sintoma de intolerância ao esforço. Em adição o programa de EFP que compõem a FTCV fase I associado ao tratamento clínico promoveram aumento da modulação vagal cardíaca e redução da modulação simpática cardíaca em repouso nos pacientes estudados.

Made available in DSpace on 2016-06-02T20:19:28Z (GMT). No. of bitstreams: 1 DissMDBS.pdf: 1917686 bytes, checksum: 9d2cd0affae35c5474a851d16fe9b2e0 (MD5) Previous issue date: 2006-03-23 / Universidade Federal de Minas Gerais / The purpose of the present study was to evaluate the effects of physiotherapeutic intervention on the autonomic control of heart rate through heart rate variability (HRV) indices at rest (supine and seated positions), during deep breath test (DBT), during an exercise protocol and during walking, in patients with acute myocardial infarction (AMI) submitted to phase I of cardiac rehabilitation. Second, evaluate the effects of an inspiratory muscle training (IMT) on the maximal inspiratory pressure (PImax) and on the magnitude of respiratory sinus arrhythmia (RSA). Initially, thirty five patients of both genders were studied in the 1st stage of the cardiovascular physiotherapy (CPT), however, only eighteen of them performed all six stages of treatment (mean = 56± 13 year). These patients, who were admitted to the Coronary Care Unit (CCU) (two days) and the ward (four days) of the Santa Casa de Misericórdia de São Carlos with noncomplicated AMI, were hemodynamically stable and used conventional medications. The 1st stage was initiated 22± 5 hours after the CCU admission and the progression to other 5 stages was done based in the daily clinical evolution of each patient. This stage included 10 minutes of rest (pre and post-exercise protocol), 4 minutes of deep breathing test and 5 minutes of exercise protocol (active-assisted low extremities exercises) in the supine position. Furthermore, the 6th stage included 10 minutes of rest in the supine position (pre and post-intervention), 4 minutes of deep breathing test, 5 minutes of rest in the seated position (pre and post-intervention), 5 minutes of active low extremities exercises in the orthostatic position and 15 minutes of walking. The instantaneous heart rate (HR) and the R-R interval (RRi) were acquired by a HR monitor (Polar S810) during all stage and the blood pressure (BP) was measured before and after each stage. Additionally, the PImax was measured (in the seated position) through a manuvacuometer at the pre and post-IMT, which was performed at the 2nd to 6th stages. The intensity of IMT was settled at 40% of PImax pressure load. The HRV was analyzed by time (RMSSD and RMSM indices) and frequency (Fast Fourier Transform) domain methods. The power spectral density was expressed as normalized units (nu) at low (LF) and high (HF) frequencies, and as the LF/HF. Results: The cumulative effect of physiotherapeutic intervention caused increase of AFnu (p<0.05) and decrease of LFnu (p<0.05) when they were evaluated at the rest pre-intervention in the supine position and during exercise protocol of 1st and 6th stages. Additionally, decreased LF/HF was also observed at rest pre-intervention in the supine position. However, no changes were observed for these indices when the 1st and 6th stages were compared to during the RSA, in the rest post-intervention (supine position) and in the rest pre and post-intervention (seated position), and the 4th and 6th stages were compared to during the walking. In the time domain, RMSM and RMSSD diminished at 1st to 6th stages for rest post-intervention in supine position. The IMT augmented the PImax in 46% (P<0.05), but increased PImax and the RSA magnitude did not correlate among them. Conclusion: The CPT realized in the phase I of the cardiac rehabilitation caused increase in the vagal activity and decrease the sympathetic activity during rest and exercises conditions, since the beta-blockade and IECA medications dosages were not altered. Additionally, the intensity used in the IMT was able to improve the PImax, but it did not influence on the RSA magnitude. Financial support: FAPESP (04/05788-6) and CNPq (478799/2003-9). / O presente estudo teve como principal objetivo avaliar a modulação do sistema nervoso autônomo no coração, por meio do comportamento da variabilidade da freqüência cardíaca (VFC) em repouso, supino e sentado, durante manobra para acentuar a arritmia sinusal respiratória (ASR), exercício e deambulação em pacientes com infarto agudo do miocárdio (IAM) antes e após serem submetidos à fisioterapia: fase I da reabilitação cardiovascular. Como objetivo secundário foi avaliada a pressão inspiratória máxima (PImáx) antes e após um programa de treinamento muscular inspiratório (TMI), bem como, a influência do TMI na magnitude da ASR. Foram estudados 35 pacientes na 1ª etapa (controle) e 18 antes e após a fisioterapia cardiovascular (FTCV), com idade média de 56±13 anos, de ambos os sexos, internados na Unidade Coronariana (UCO) (2 dias) e enfermaria da Irmandade Santa Casa de Misericórdia de São Carlos (4 dias) com IAM não complicado. Todos estavam hemodinamicamente estáveis e em uso de medicações convencionais. Foram submetidos a 1ª etapa após 22±5 horas da chegada na UCO e progrediram na FTCV até a 6ª etapa, diariamente, baseado na evolução clínica. A 1ª etapa foi composta de 10 minutos (min) de repouso supino pré (R1) e pós-intervenção (R2), 4 min da manobra para acentuar a ASR (MASR) e 5 min de exercícios ativos-assistidos de membros inferiores (MMII) na postura supina. Já a 6ª etapa foi composta de 10 min de R1 e R2, 4 min da MASR, 5 min de repouso sentado pré (RS1) e pós-intervenção (RS2), 5 min de exercícios ativos de MMII na postura em pé e 15 min de deambulação. Os intervalos R-R (iRR) e a freqüência cardíaca (FC) foram obtidos, batimento a batimento, pelo freqüencímetro Polar® S810i e a pressão arterial (PA) foi aferida antes, durante e após a FTCV. A medida da PImáx foi realizada com um manovacuômetro, na posição sentada, na 2ª etapa e reavaliada na 6ª etapa. O TMI foi realizado, na posição sentada, da 2ª até a 6ª etapa, sendo que a carga pressórica foi de 40% da PImáx obtida na 2ª etapa. A VFC foi analisada nos domínios do tempo (DT - índices RMSSD e RMSM dos iRR em ms) e da freqüência (DF por meio da análise espectral), a qual forneceu as bandas de baixa freqüência (BF) e alta freqüência (AF), expressas em unidades normalizadas (un), e a razão BF/AF. Resultados: Com relação ao efeito cumulativo das seis etapas da FTCV, no DF, houve diminuição da BFun e aumento da AFun no R1 e durante o exercício e diminuição da razão BF/AF no R1 da 1ª para a 6ª etapa, não havendo alterações destas variáveis durante a MASR e no R2 da 1ª para a 6ª etapa, no RS1 e RS2 da 2ª para 6ª etapa e durante a deambulação da 4ª para 6ª etapa. No DT, os índices RMSSD e RMSM diminuíram no R2 da 1ª para a 6ª etapa. Houve aumento de 46% da PImáx com o TMI (p<0,05) e não houve correlação entre o aumento da PImáx e a magnitude de resposta da ASR. Conclusões: A FTCV fase I aplicada aos pacientes com IAM promoveu aumento da atuação vagal e redução da atuação simpática tanto na condição de repouso supino como durante a execução de exercício, uma vez que a dosagem das medicações betabloqueadores e inibidoras da enzima conversora de angiotensina permaneceram inalteradas durante o estudo. Ainda, o TMI promoveu aumento da PImáx na intensidade aplicada, no entanto, não influenciou a magnitude de resposta da ASR Suporte Financeiro: FAPESP Proc. 04/05788- 6, CNPq Proc. 478799/2003-9.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / In this work was realized characterization studies of a new material, poly (3- hidroxyphenylacetic acid) and its application for the construction of an amperometric immunosensor for detection of Acute Myocardial Infarction (AMI). Initially, it was carried out the electropolymerization of 3-hidroxyphenylacetic acid at three different pH's (0.0, 6.5 and 12.0) which could be assessed, electrochemically, the relationship between the behavior of the polymer and the reaction s pH. It was found that in the acid solutions (pH 0.0) the formation of electrochemically active material is more evident. Moreover, using electrochemical techniques, were carried out investigations on the structure of the polymeric material by using cationic and anionic probes. Monomer and polymer were characterized by infrared spectroscopy (FTIR), Ultra-Violet (UV/Vis.) and fluorescence; thermal analysis (DTA and TGA) and structural analysis (XDR). These studies were extremely important to highlight the main differences between the starting material (monomer) and electropolymerized material (polymer), and in particular assess the main characteristics of the polymer in order to enable its use as a platform to the proposed immunosensor. Studies of the immunosensor were conducted using two substances that acted as indicators of the reaction between the specific antibody for the AMI (anti-troponin T) and specific antigen for AMI (troponin T), hexaaminruthenium chloride and ferro/ferricyanide potassium. The results showed that the hexaaminruthenium chloride showed the best performance to indicate the formation of antibody-antigen complex wich occurs in the AMI. / Neste trabalho foram realizados estudos de caracterização de um novo material, o poli(ácido 3-hidroxifenilacético) e sua aplicação para construção de um imunossensor amperométrico para detecção do Infarto Agudo do Miocárdio (IAM). Inicialmente, foi realizada a eletropolimerização do ácido 3-hidroxifenilacético em três pH s diferentes (0,0; 6,5 e 12,0) onde foi possível avaliar, eletroquimicamente, a relação entre o comportamento do polímero formado e o pH do meio reacional. Foi possível constatar que em meio ácido (pH 0,0) a formação do material eletroquimicamente ativo é mais evidenciada. Além disso, com o auxílio de técnicas eletroquímicas, foram realizadas investigações sobre a estrutura do material polimérico formado, utilizando sondas catiônicas e aniônicas. Monômero e polímero foram caracterizados por técnicas espectroscópicas de Infravermelho (FTIR), Ultra-Violeta (UV/Vis.) e Fluorescência; análises térmicas (TGA e DTA) e análises estruturais (DRX). Estes estudos foram de extrema importância para destacar as principais diferenças entre o monômero e o material eletropolimerizado e, principalmente, avaliar as principais características do polímero, no sentido de viabilizar a sua utilização como plataforma do imunossensor proposto. Os estudos do imunossensor foram conduzidos utilizando-se duas substâncias que atuaram como indicadores da reação entre anticorpo específico para o IAM (antitroponina T) e antígeno específico para o IAM (troponina T), o cloreto de hexaaminrutênio II e o ferro/ferricianeto de potássio. Os resultados obtidos mostraram que o cloreto de hexaaminrutênio II teve melhor desempenho para indicar a formação do complexo anticorpo-antígeno, característico no evento do IAM. / Mestre em Química

Abstract In the Czech Republic there is no doubt about the tendency of gradual increase in median life expectancy, which is significantly affected by the fact that mortality from cardiovascular diseases, especially from acute coronary syndromes, has been decreasing. Besides the provable effect of a healthy lifestyle, diet and, by all means, a quality and effective pharmacotherapy, a significant development in the field of interventional cardiology contributes to this accomplishment. The number of coronographies, coronary angioplasties and implanted stents have multiplied, and today the invasive coronarographic diagnostics and percutaneous myocardial revascularization belong to the the most common diagnostic and therapeutic methods in treatment of acute forms of ischemic heart diseases. An obvious prerequisite for such a rapid development in the field of intervention coronary angiography was the establishment of a sufficiently dense network of catheter laboratories and specialized facilities, which provide a highly professional and intensive care for patients. This thesis is focused on three basic objectives: ? To survey and characterize differences in nursing care concerning various complications in patients after SKG / PCI ? To survey bio / psycho / social impacts of complications after SKG / PCI on a patient ? To identify and summarize personal and material prerequisites and requirements to ensure quality nursing care for these complicated conditions The research was conducted by using a qualitative methodology. The methods used were observation, non-standardized interviews and medical and nursing records analyses. The research survey samples on which the investigation was focused were patients with the acute coronary syndrome hospitalized in the coronary care unit in the Cardio Center in České Budějovice, their family members and also the nursing staff providing the comprehensive nursing care. The outcomes of this survey were eleven descriptive case reports characterizing the occurrence of the most frequent complications in patients with ACS after SKG / PCI. To ensure clarity, each case study is complemented by a thought map with an account of the most important nursing interventions in the management of specific acute conditions. The paper also contains a framework analysis of bio / psycho / social impacts of complicated situations on patients. It is interesting to compare this matter from the perspective of nurses and patients, which is seen in correlation graphs. The section describing the organizational and personnel provision is introduced with the characteristics of the medical process and it also contains the list of medical personnel with their qualifications and the length of experience in the Coronary care unit in České Budějovice. Summarization of the instrumental medical equipment is also based on the analysis of previous cases and is accompanied by photographs of the equipment typical and indispensable for the care of patients in the Coronary care unit, which primarily has an informative and complementary character to get an integrated view of the Coronary care unit running and the nursing staff work.

Introdução: Alguns autores estudaram o valor prognóstico do eletrocardiograma inicial na sobrevida em longo prazo dos pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. O valor prognóstico de outros traçados eletrocardiográficos na fase intra-hospitalar do tratamento foi menos estudado. Objetivos: Avaliar o papel no prognóstico clínico dos registros eletrocardiográficos obtidos durante o evento índice dos participantes do estudo Estratégia de Registro de Insuficiência Coronariana (ERICO) com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Métodos: Foram analisados e classificados, de acordo com o Código de Minnesota, os traçados eletrocardiográficos intra-hospitalares de 634 participantes do estudo ERICO com síndrome coronariana aguda sem supradesnivelamento do segmento ST, no período de fevereiro de 2009 a dezembro de 2013. Foram classificados como alterados os traçados eletrocardiográficos com infradesnivelamento do segmento ST > 1mm e/ou com onda T negativa > 1mm. Foram construídos modelos de regressão de Cox brutos e ajustados, para estudar se o padrão eletrocardiográfico foi um preditor independente de desfechos clínicos (morte por qualquer causa, morte por causa cardiovascular, morte por infarto agudo do miocárdio, e desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal). Resultados: A mediana de seguimento foi de 3 anos. Encontramos uma tendência não significativa para a associação entre a presença de alteração de segmento ST no eletrocardiograma inicial com o desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal [Hazard Ratio (HR) ajustado: 1,64, intervalo de confiança de 95% (IC 95%): 1,00-2,70, p = 0,052]. Encontramos um risco significativamente maior de morte por infarto do miocárdio em indivíduos com alterações do segmento ST no eletrocardiograma final (HR ajustado: 2,04; IC 95%: 1,06-3,92). Os indivíduos com alterações do segmento ST em qualquer traçado durante o evento índice apresentaram risco significativamente maior para desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal (HR ajustado: 1,71; IC 95%: 1,04-2,79). Quando as alterações de onda T foram incluídas na classificação dos traçados, não houve associação significativa com o prognóstico a longo prazo. Conclusões: Encontramos associações significativas entre as alterações de segmento ST e pior prognóstico em longo prazo. A avaliação sequencial dos traçados eletrocardiográficos durante o evento índice parece adicionar informação prognóstica ao ECG inicial / Introduction: Some authors have studied the prognostic value of initial electrocardiogram in long-term survival of patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The prognostic value of other in-hospital electrocardiographic tracings has been less studied. Objectives: To describe the association between electrocardiogram abnormalities (in ST-segment and T wave) during the index event and outcomes in patients with NSTE ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort. Methods: We analyzed and classified, according to the Minnesota Code, in-hospital ECG tracings of 634 ERICO participants with NSTE-ACS, from February 2009 to December 2013. We considered as altered electrocardiographic tracings with ST-segment depression > 1 mm and / or negative T wave > 1 mm. We built crude and adjusted Cox regression models to study if ECG pattern was an independent predictor for clinical outcomes (death from any cause, death from cardiovascular causes, death from acute myocardial infarction, and combined outcome of fatal or new nonfatal myocardial infarction). Results: Median follow-up was 3 years. We found a trend for the association between initial ECG tracing and the combined outcome of fatal or new nonfatal myocardial infarction [Hazard Ratio (HR) adjusted: 1,64, confidence interval 95% (95% CI): 1,00-2,70, p = 0,052]. We found a significantly higher risk of death due myocardial infarction in patients with ST-segment abnormalities in the final ECG tracing (adjusted HR: 2,04; 95% CI: 1,06 to 3,92). Individuals with ST-segment abnormalities in any tracing had significant higher risk for fatal or new nonfatal myocardial infarction (adjusted HR: 1,71; 95% CI: 1,04 2,79). When the T wave changes were included in the classification, there was no significant association with long-term prognosis. Conclusions: We found significant associations between ECG patterns and worse long-term prognosis. Sequential evaluation of electrocardiographic tracings during the index event seems to add prognostic information to the initial ECG