INTRODUÇÃO: Aproximadamente 10% dos pacientes com doença arterial coronária (DAC) apresentam angina refratária, condição crônica causada por insuficiência coronariana, que não pode ser controlada pela combinação de tratamento medicamentoso, angioplastia ou cirurgia de revascularização miocárdica (RM). Os preditores de eventos cardiovasculares neste grupo crescente de pacientes são escassos. Os ensaios para a troponina T cardíaca ultrassensível (TnTc-us) são valiosos biomarcadores que podem ser utilizados para determinar o prognóstico de pacientes com DAC estável, mas não há evidência que esta habilidade se mantenha em indivíduos com doença mais grave e extensa, como ocorre na angina refratária. Os objetivos deste estudo são: avaliar a eficácia de um protocolo de otimização terapêutica para pacientes encaminhados por angina refratária, os preditores de óbito e infarto do miocárdio (IM), assim como o papel da TnTc-us como ferramenta prognóstica neste cenário. MÉTODOS: Estudo prospectivo e observacional que incluiu 117 pacientes (83 homens, 62,7 ± 9,4 anos), por amostragem consecutiva, de Outubro de 2008 a Setembro de 2013. Os critérios de inclusão foram: angina pectoris estável classificada pela Canadian Cardiovascular Society (CCS) de II a IV, evidência de isquemia miocárdica documentada por um teste não invasivo e DAC obstrutiva considerada desfavorável para RM após a avaliação de uma coronariografia recente por um \"Heart Team\". O tratamento medicamentoso foi titulado de acordo com a tolerância dos pacientes durante um período de três meses e a seguir, o seguimento ambulatorial foi semestral. As dosagens de TnTc-us foram obtidas na consulta inicial e após três meses. O desfecho primário foi a incidência combinada de óbito por todas as causas e IM não fatal. RESULTADOS: Houve significativa prevalência de DAC triarterial (75,2%), angina CCS III ou IV (60,7%) e antecedentes de procedimentos de RM prévia (91,5%). A maioria dos pacientes apresentou função ventricular preservada (61,5%). Valores de TnTc-us acima do limite de detecção (3 ng/L) foram encontrados em 79,5% dos pacientes e 27,4% apresentaram concentrações acima do percentil 99 para indivíduos saudáveis (14 ng/L). Os preditores independentes de valores mais elevados de TnTc-us foram: disfunção ventricular esquerda, não usar bloqueadores de canais de cálcio, pressão arterial sistólica elevada, e ritmo de filtração glomerular reduzido. A melhora de ao menos uma classe funcional CCS foi alcançada em 50% dos pacientes (P < 0,001) e 25,9% se apresentaram sem angina ou com angina CCS I após três meses de tratamento. Houve redução significativa nos episódios de angina (P < 0,001) e no consumo de nitrato sublingual (P = 0,029). Não houve redução dos níveis de TnTc-us após 3 meses de otimização terapêutica. Durante um seguimento mediano de 28 meses (intervalo interquartil de 18 a 47,5 meses), a taxa de eventos combinados foi estimada em 13,4% (5,8% para óbito) pelo método de Kaplan-Meier. Preditores univariados para o desfecho composto foram os níveis de TnTc-us e disfunção ventricular esquerda. Após análise de regressão multivariada através do modelo de regressão de risco proporcional de Cox, apenas a TnTc-us foi independentemente associada com os eventos avaliados, tanto como variável contínua (HR por aumento em cada unidade do logarítimo natural: 2,83; IC 95% de 1,62 a 4,92; P < 0,001) quanto como variável categórica (HR para concentrações acima do percentil 99: 5,14; IC 95% de 2,05 a 12,91; P < 0,001). CONCLUSÕES: O protocolo de otimização terapêutica demonstrou ser bem tolerado e eficaz em reduzir os sintomas de angina em grande parte dos pacientes inicialmente considerados refratários. No entanto, esta melhora clínica não foi acompanhada por redução nas concentrações plasmáticas de troponina T ultrassensível, um biomarcador que nosso estudo revelou como o mais forte preditor de óbito e infarto do miocárdio não fatal nos pacientes com angina refratária. A incidência de eventos cardiovasculares neste estudo foi menor do que a relatada anteriormente e se aproximou da taxa observada entre os pacientes com doença arterial coronária complexa passível de revascularização miocárdica / BACKGROUND: Approximately 10% of patients with symptomatic coronary artery disease (CAD) suffer from refractory angina, a chronic condition caused by coronary insufficiency which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. The predictors of cardiovascular events in this growing group of patients are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are valuable biomarkers that may be used to determine the prognosis of patients with stable CAD, but there is no evidence that this ability would be retained in individuals with more severe and extensive disease, as is the case in refractory angina. The aims of this study are to evaluate the effectiveness of a maximally tolerated medical therapy, the predictors of death and nonfatal myocardial infarction (MI), as well as the role of hs-cTnT as a prognostic tool in this setting. METHODS: We prospectively enrolled 117 consecutive patients (83 men, 62.7 ± 9.4 years) in this study between October 2008 and September 2013. All patients had angina as classified by the Canadian Cardiovascular Society (CCS) II to IV at their first visit, and evidence of myocardial ischemia via any stress test. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms. Optimal medical therapy was up-titrated over three months. Patients were followed every 6 months via outpatient visits; plasma hs-cTnT levels were determined at baseline and after three months. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS: There were high prevalence of three-vessel CAD (75.2%), angina CCS class III or IV (60.7%) and history of previous myocardial revascularization (91.5%); most of the patients had preserved left ventricular function (61.5%). Hs-cTnT values were either at or above the limit of detection (3 ng/L) in 79.5% of patients and we noted concentrations either at or greater than the 99th percentile of healthy individuals (14 ng/L) in 27.4% of patients. The independent predictors of higher concentrations of hs-cTnT were as follows: left ventricular dysfunction, no calcium channel blocker use at baseline, elevated systolic blood pressure and reduced glomerular filtration rate. The improvement of at least one CCS functional class occurred in 50% of patients (P < 0.001) and 25.9% were free from angina or were CCS I after three months of medical therapy. There was a significant reduction in the number of angina attacks (P < 0.001) and a reduction in short-acting nitrate consumption (P = 0.029). There was no reduction in hs-cTnT levels after the three-month medical therapy optimization. During a median follow-up period of 28.0 months (interquartile range, 18.0 to 47.5 months), an estimated 28.0-month cumulative event rate of 13.4% (5.8% for allcause death) was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were as follows: hs-cTnT levels and left ventricular dysfunction. Following a multivariate analysis via a Cox proportional-hazards regression model, only hs-cTnT was independently associated with the events in question, either as a continuous variable (HR per unit increase in the natural logarithm, 2.83; 95% CI, 1.62 to 4.92; P < 0.001) or as a categorical variable (HR for concentrations above the 99th percentile, 5.14; 95% CI, 2.05 to 12.91; P < 0.001). CONCLUSIONS: In patients initially diagnosed with refractory angina, the optimal medical therapy protocol was well tolerated and effective in reducing the symptoms of angina in most patients. However, such clinical improvement was not accompanied by a decrease in plasma concentrations of high-sensitivity troponin T, a biomarker that our study identified as the strongest predictor of death and nonfatal myocardial infarction in patients with refractory angina. The incidence of cardiovascular events in this study was lower than that previously reported, leading to outcomes approaching those of patients with complex coronary artery disease who are suitable for myocardial revascularization

Introdução: O tratamento da Síndrome Coronária Aguda (SCA) sem supradesnivelamento do segmento ST (SSST) sofreu grandes avanços nos últimos 20 anos, com a introdução de novos medicamentos e intervenções invasivas, que reduziram significativamente os eventos clínicos graves como morte e re(infarto), em curto, médio e longo prazos, a despeito dessa entidade ainda representar uma alta taxa de mortalidade no mundo ocidental. Entre os medicamentos, os inibidores da enzima conversora da angiotensina (IECA) tiveram um papel fundamental, demonstrando redução desses eventos em pacientes com alto risco cardiovascular. Nesse período, as troponinas cardíacas consolidaram-se como os biomarcadores de necrose miocárdica de escolha para o diagnóstico e avaliação prognóstica nesses pacientes, devido às suas altas sensibilidade e especificidade. Objetivo: Determinar o efeito do uso prévio de IECA na mensuração da troponina I cardíaca em pacientes com SCASSST, e avaliar os desfechos clínicos em até 180 dias. Casuística e métodos: Estudo prospectivo, observacional, em um único centro de cardiologia, realizado entre 8 de setembro de 2009 e 10 de outubro de 2010, com 457 pacientes, consecutivamente internados no Pronto-Socorro com SCASSST. Os pacientes deveriam apresentar sintomas isquêmicos agudos, nas últimas 48 horas. Foram excluídos os que apresentassem elevação do segmento ST, ou qualquer alteração confundidora ao ECG, como ritmo de marcapasso, bloqueio de ramo esquerdo ou fibrilação atrial. Foram selecionados para análise exploratória, dados de história clínica, exame físico, eletrocardiográficos e laboratoriais, com ênfase à troponina I cardíaca. As variáveis com nível de significância menor que 10% nesta análise, foram submetidas a um modelo de regressão logística múltipla. Resultados: Na população estudada, observou-se que a idade média era de 62,1 anos (DP=11,04) e 291 pacientes (63,7%) do gênero masculino. Fatores de risco como hipertensão arterial sistêmica (85,3%) e dislipidemia (75,9%) foram os mais prevalentes, além da presença de SCA prévia em 275 (60,2%) pacientes; com 49,5% dos pacientes já submetidos a alguma revascularização prévia (Intervenção Coronária Percutânea(ICP) ou Revascularização do Miocárdio (RM), além de 35,0% de diabéticos. Na avaliação de eventos em 180 dias, ocorreram 28 óbitos (6,1%): 11 por choque cardiogênico, 8 por infarto agudo do miocárdio, 3 por choque séptico, além de outras causas. Foi elaborado um modelo de análise estatística, onde foram analisadas as variáveis que interferiam com a liberação de troponina. Por esse modelo, observou-se que cada 1mg/dL a mais na glicemia de admissão, aumentava a chance da troponina ser maior que 0,5 ng/mL em 0,8% (p=0,0034);o uso de IECA previamente à internação reduzia a chance da troponina ser maior que 0,5 ng/mL em 40,6% (p=0,0482) e a presença de infradesnivelamento do segmento ST igual ou maior a 0,5 mm, em uma ou mais derivações, aumentava a chance da troponina ser maior que 0,5 ng/mL em 2,6 vezes (p=0,0016). A estatística C para este modelo foi de 0,77. Conclusão: Os dados apresentados nesta pesquisa em um centro terciário de cardiologia, mostraram uma correlação inequívoca entre o uso de IECA e a redução do marcador de necrose miocárdica troponina I cardíaca, utilizado como medida qualitativa.Porém, ainda não há dados disponíveis para se afirmar que esta redução poderia levar a um número menor de eventos clínicos graves como morte e re(infarto), no período de 180 dias. / Introduction: The last 20 years have seen great advances in the management of non-ST elevation acute coronary syndrome (NSTE-ACS). The introduction of novel drugs and invasive interventions significantly reduced major clinical events such as death and (re)infarction in the short, medium and long term. Yet, mortality rates remain high in the Western world. Among these drugs, angiotensin-converting enzyme (ACE) inhibitors have played a critical role in reducing these events in patients at high cardiovascular risk. In the meantime, cardiac troponins became firmly established as the myocardial necrosis biomarkers of choice to make the diagnosis and prognosis of these patients, due to their high sensitivity and specificity. Objective: To determine the effect of prior use of ECA inhibitors in serum levels of cardiac troponin I in patients with NSTE-ACS and to assess the clinical outcomes up to 180 days. Patients and methods: This was a prospective, observational study conducted at a single tertiary cardiology center from September 8, 2009 to October 10, 2010 with 457 consecutive patients admitted to the emergency department for NSTE-ACS. Only patients with acute ischemic symptoms within the past 48 hours were included in the study. Those with ST-segment elevation or any confounding ECG factor, such as pacemaker rhythm, left bundle branch block, or atrial fibrillation, were excluded. Study population underwent exploratory analysis, clinical history, physical examination, ECG, and laboratory tests, particularly for cardiac troponin I. Variables with a significance level less then 10% were entered into a multiple logistic regression model. Results: The mean age of the study population was 62.1 years (SD = 11.04), and 291 patients (63.7%) were male. Risk factors such as hypertension (85.3%) and dyslipidemia (75.9%) were the most prevalent, followed by previous ACS in 275 (60.2%) patients; 49.5% of the patients had already undergone previous revascularization procedures (either percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]). Diabetes was present in 35% of the patients. At the 180-day assessment, 28 patients (6.1%) had died: 11 as a result of cardiogenic shock, 8 of acute myocardial infarction, and 3 of septic shock, among other causes. In this study, a statistical model was developed to determine which variables affected troponin release. This model showed that each 1mg/dL increase in admission blood glucose increased the likelihood of troponin being higher than 0.5 ng/mL by 0.8% (p=0.0034); the use of ACE inhibitors prior to admission reduced the likelihood of troponin being higher than 0.5 ng/mL by 40.6% (p=0.0482), and the presence of ST-segment depression >= 0.5 mm in one or more ECG leads increased 2.6 times the likelihood of troponin being higher than 0.5 ng/mL (p=0.0016). The C-statistic for this model was 0.77. Conclusion: The data from this study conducted at a tertiary cardiology center show an unequivocal relationship between the use of ACE inhibitors and decreased levels of cardiac troponin I, a biomarker of myocardial necrosis used as a qualitative measure. However, there is no available data to determine whether or not this decrease would result in a lower number of major clinical events, such as death and re(infarction) within 180 days.

A doença aterosclerótica coronariana tem um grande impacto na morbidade e mortalidade em todo mundo. A terapia cardíaca com ondas de choque consiste em uma nova opção potencial para o tratamento de pacientes com doença coronariana crônica e angina refratária. No presente estudo, avaliamos os efeitos das ondas de choque na mecânica do ventrículo esquerdo, avaliados pela ecocardiografia com speckle tracking, assim como nos sintomas clínicos e isquemia miocárdica em pacientes com angina refratária. Estudamos, prospectivamente, 19 pacientes com angina refratária submetidos à terapia com ondas de choque com 3 sessões de tratamento por semana, realizados na primeira, quinta e nona semanas, totalizando 9 semanas de tratamento. A mecânica do ventrículo esquerdo foi avaliada por meio da determinação do strain longitudinal global e segmentar. A perfusão miocárdica foi analisada por cintilografia de perfusão miocárdica com Tecnécio-99m Sestamibi, para determinação do summed stress score (SSS). Parâmetros clínicos foram mensurados pelo escore de angina da Canadian Cardiovascular Society (CCS), escore de insuficiência cardíaca da New York Heart Association (NYHA) e qualidade de vida pelo Seattle Angina Questionnaire (SAQ). Todos os dados foram mensurados antes do início do tratamento e 6 meses após a terapia com ondas de choque. Os nossos resultados demonstraram que as ondas de choque não ocasionaram efeitos colaterais importantes e os pacientes apresentaram melhora significativa dos sintomas. Antes do tratamento, 18 (94,7%) pacientes se apresentavam com angina CCS classe III ou IV, e 6 meses após houve redução para 3 (15,8%) pacientes (p = 0,0001), associada à melhora no SAQ (38,5%; p < 0,001). Treze (68,4%) pacientes estavam em classe funcional III ou IV da NYHA antes do tratamento, com redução significativa para 7 (36,8%); p = 0,014. Nenhuma alteração foi observada no SSS global basal no acompanhamento de 6 meses (15,33 ± 8,60 versus 16,60 ± 8,06, p = 0,155) determinado pela cintilografia miocárdica. No entanto, houve redução significativa no SSS médio dos segmentos isquêmicos tratados (2,1 ± 0,87 pré versus 1,6 ± 1,19 pós-terapia, p = 0,024). O strain longitudinal global do ventrículo esquerdo permaneceu inalterado (-13,03 ± 8,96 pré versus -15,88 ± 3,43 pós-tratamento; p = 0,256). Também não foi observada alteração significativa no strain longitudinal segmentar do ventrículo esquerdo pela ecocardiografia com speckle tracking. Concluímos que a terapia com ondas de choque é um procedimento seguro para tratamento de pacientes com angina refratária, que resulta em melhor qualidade de vida, melhora na perfusão miocárdica dos segmentos tratados e preservação da mecânica ventricular esquerda / Coronary atherosclerotic disease represents a major impact on morbidity and mortality worldwide. Cardiac shock wave therapy is a new potential option for the treatment of patients with chronic coronary disease and refractory angina. In the present study, we sought to determine the effects of shock wave therapy on the left ventricular mechanics, evaluated by speckle tracking echocardiography, as well as on myocardial perfusion and symptoms of patients with refractory angina. We prospectively studied 19 patients undergoing shock wave therapy with 3 sessions per week, on the 1st, 5th and 9th weeks, for a total of 9 weeks of treatment. The left ventricular mechanics was evaluated by global longitudinal strain using the speckle tracking echocardiography. Myocardial perfusion was assessed by myocardial scintigraphy with Technetium-99m Sestamibi, for determination of summed stress score (SSS). Clinical parameters were evaluated by the Canadian Cardiovascular Society (CCS) angina score, New York Heart Association (NYHA ) heart failure score and quality of life by the Seattle Angina Questionnaire (SAQ). All data were measured prior to the treatment and 6 months after shock wave therapy. Our results demonstrated that shock wave therapy did not cause significant side effects and improved symptoms. Before treatment, 18 patients (94.7%) had CCS class III or IV angina, and 6 months later there was a reduction to 3 (15.8%), p = 0.0001, associated with improvement in SAQ ( 38.5%, p < 0.001). Thirteen (68.4%) were in NYHA class III or IV before treatment, with a significant reduction to 7 (36.8%); p = 0.014. No change was observed in the global SSS at 6-months follow-up (from 15.33 ± 8.60 baseline to 16.60 ± 8.06 post-treatment, p = 0.155). However, there was a significant reduction in the mean SSS of the treated ischemic segments (2.1 ± 0.87 pre versus 1.6 ± 1.19 post therapy, p = 0.024). The global longitudinal strain remained unchanged (-13.03 ± 8.96 pre versus -15.88 ± 3.43 6 months post-treatment, p = 0.256). In the same way, no significant difference was observed in the longitudinal strain of the left ventricular segments. We concluded that shock wave therapy is a safe procedure for the treatment of patients with refractory angina, resulting in better quality of life, improved myocardial perfusion of the treated segments, and preservation of left ventricular mechanics

Angina pectoris är bröstsmärta orsakat av myokardischemi, till följd av kranskärlsjukdom med eller utan stenoser eller icke kranskärlsjukdom. Arbetsprov är den vanligaste undersökningen för angina pectoris. Diffusa symtom och angina pectoris varianter utan stenoser med låg sensitivitet för elektrokardiografi (EKG) sänker den diagnostiska säkerheten i arbetsprov på kvinnor. Litteraturstudiens syfte var att utreda om hemodynamiska parametrar och riskbedömning med Pre-test sannolikhet (PTP) samt Dukes Löpbands Index (DTS, Dukes Treadmill Score) kan öka den diagnostiska säkerheten i arbetsprov på kvinnor. Inklusionskriterierna var vetenskapligt granskade kliniska studier på engelska, med information om etiskt godkännande eller samtycke. Snowballing metoden, PUBMED, MEDLINE och CINAHL användes. Studier som inkluderades i resultatet granskades återigen och jämfördes med varandra. Hemodynamiska parametrar, PTP och DTS ökar den diagnostiska säkerheten i arbetsprov på kvinnor. Denna diagnostiska säkerhet beror dock också på PTP metod, PTP riskgrupp, etnicitet och angina pectoris variant. Vidare forskning behövs om etnicitetspecifika PTP metoder, mekanismen bakom blodtrycksreaktionen, DTS på icke kranskärlsjukdomar samt metoder som kan skilja mellan olika icke kranskärlsjukdomar. Utan studier om Systematic COronary Risk Evaluation (SCORE) och Diamond Forrester Score (DFS) samt deras påverkan på arbetsprov, kan inte resultatet i litteraturstudien generaliseras till arbetsprov i Sverige. / Angina pectoris is chest pain and myocardial ischemia due to Coronary Artery Disease (CAD) or Non-Coronary Artery Disease (non-CAD). Exercise stress test (EST) is the most common diagnostic procedure for angina pectoris. Non-CAD, low sensitivity for exercise electrocardiography (ex-ECG) and diffuse symptoms lower the diagnostic accuracy for females. This review’s aim was to study whether haemodynamic parameters and risk stratifications with Pre-test probability (PTP) or Duke Treadmill Score (DTS) improves the diagnostic accuracy of EST for females. Inclusion criterions were English peer reviewed, clinical studies with mentioned ethical approval or consent. Snowballing, PUBMED, MEDLINE and CINAHL were used. Articles that were included in the results, were reviewed once again, and compared to one another. Hemodynamic parameters, PTP and DTS increase the diagnostic accuracy of EST in women. This diagnostic accuracy depends on PTP method, risk group, ethnicity, and angina pectoris variant. Further research regarding ethnic specific PTP methods, mechanism behind the blood pressure reaction, DTS for diagnosis of non-CAD and methods for differentiation of subtypes of non-CAD, would be valuable. Without studies about the Systematic Coronary Risk Evaluation (SCORE), Diamond Forrester Score (DFS), and their impact on ex-ECG, the result of this review cannot be generalized to ex-ECG in Sweden.

Introduction: Acute coronary syndromes (ACS) belong to cardiovascular diseases and contribute significantly to mortality, morbidity and disability in developed countries. Therefore the aim of current therapy is to reduce the risk of subsequent complications, including early death, and to increase patients' quality of life. For successful therapy it is necessary to follow regimen and dietary principles which are along with pharmacotherapy an integral part of treatment. Therefore sufficient knowledge of these principles by patients is a basic precondition for their successful treatment. Objectives: The aim of the diploma thesis was to assess dietary and regime knowledge in patients diagnosed with ACS. The specific objectives were: to determine an effect of sex or previous education on the knowledge; to describe patients' dietary habits; to specify their knowledge of nutrition; and to identify which knowledge is the most deficient. Methods: The research was carried out as a questionnaire survey. The questionnaire was compiled directly for the purposes of this thesis and was approved by the VFN Ethics Committee for use in inpatient wards at II. and III. internal clinics and at the Coronary unit of II. internal clinics of VFN. A total of 80 patients diagnosed with ACS were included in the study....

Mirbazel SH. Jämförelse mellan kvinnor och mäns överlevnad baserad på resultat från arbetsprov och myokardscintigrafi. Examensarbete i Biomedicinsk Laboratorievetenskap, 15 högskolepoäng. Malmö högskola: Hälsa och Samhälle, utbildningsområde för Biomedicinsk Laboratorievetenskap, 2011.En av de vanligaste orsakerna till död både i utvecklingsländerna och i västvärlden är hjärtinfarkt som drabbar vanligtvis individer över 65 år. Hjärtischemi är den vanligaste orsaken till hjärtinfarkt/ plötsligt hjärtstopp. För diagnostik av hjärtischemi används oftast arbetsprov som förstahandsval, eftersom metoden är billig, icke-invasiv och relativt ofarlig. Myokardscintigrafi utförs ofta efter arbetsprovet, om detta varit inkonklusivt. Syftet i denna retrospektiva studie var att ta reda på om prognosen och överlevnaden skiljer sig åt mellan kvinnor och män beroende på undersökningsresultat från arbetsprov och myokardscintigrafi. I denna studie analyserades 2045 patienter som var registrerade att utföra arbetsprov för misstänkt eller tidigare känd koronarkärlssjukdom under 2006 & 2007. Patienternas resultat delades i tre grupper: normalt, patologiskt och intermediärt enligt bestämda kriterier. Intermediärgruppen analyserades också om de hade utfört ett myokardscintigrafi inom 6 månader. Intermediärgruppen delades därefter in i tre grupper: de med normal myokardscintigrafi, de med patologisk och de som inte hade utfört någon. Patienter med normalt arbetsprov var 1110, med intermediärt arbetsprov 540 och med patologiskt arbetsprov 254 personer. Det finns statistiskt signifikanta skillnader av antal levande och avlidna mellan män och kvinnor i intermediärt arbetsprov (p < 0,001) och i undergruppen, intermediär utan utförd myokardscintigrafi (p < 0,001). Det finns också en statistiskt signifikant skillnad i överlevnad i huvudgruppen med intermediärt arbetsprov(p < 0,01). Inga analyser av överlevad utfördes för undergrupperna. Sammanfattningsvis har denna studie visat att det inte finns några statistiskt säkerställda skillnader i överlevnad mellan män och kvinnor med normalt och patologiskt arbetsprov däremot finns det en signifikant skillnad i intermediärgruppen. / Mirbazel SH. Comparison between men and women’s survival based on the results from the exercise tests and myocardial perfusion imaging. Degree Project in Biomedical Laboratory Science, 15 points. Malmö University: Health and Society, Department of Biomedical Laboratory Science, 2011.One of the most common causes of death in both developing countries and in the Western world is heart attack that hits usually individuals over 65 years. Cardiac ischemia is the most common cause of myocardial infarction/sudden cardiac arrest. For the diagnosis of cardiac ischemia, exercise test is the first choice, because the method is inexpensive, non-invasive and relatively harmless. Myocardial perfusion imaging is often performed after an inconclusive exercise test. The purpose of this retrospective study was to determine if the prognosis and survival differ between women and men depending on the outcome of the investigation from the exercise test, and the myocardial perfusion imaging. In this study 2045 patients were analyzed who were registered to perform the exercise tests for a suspected or previously known coronary artery disease in 2006/2007. Patient’s results were divided into three groups: normal, pathological and intermediate findings. The intermediary group was further divided according to results of myocardial perfusion imaging within 6 months of the exercise test: those with normal, those with pathologic and those who had not carried out any myocardial perfusion imaging. Patients with normal exercise test were 1110, with intermediate exercise test 540 and with pathologic exercise test were 254 people. There are statistically significant differences in the number of living and deceased between men and women in intermediate exercise tests (p < 0, 001) and in the subgroup, intermediary without myocardial perfusion imaging (p < 0,001). There is also a statistically significant difference in survival in the main group with the intermediate exercise tests (p < 0.01). No analysis was performed for sub-groups. In conclusion, this study has shown that there are no statistically significant differences in survival between men and women with normal and pathological exercise test. However there is a significant difference in intermediary group.

In the UK angina affects 2 million people (BHF, 2010b) and unfortunately secondary prevention interventions such as Cardiac Rehabilitation (CR) are not widely available for this population (NACR, 2011). This doctoral research project examined the effectiveness and feasibility of an alternative intervention for this population; CR delivered via the internet. The programme was interactive and comprised personalised goal setting orientated around exercise, diet, emotions, and smoking with support available through an online email link or synchronised chat room. A randomised controlled trial (RCT) and semi-structured interviews were used to evaluate the intervention. Primary care patients with angina were randomised to either an intervention group (n=48) or to a control group that did not receive any intervention other than treatment as usual (n=47). Outcome measures were taken at baseline, 6 week and 6 month follow ups. The primary outcome measure was daily steps (measured objectively using Sensewear Pro 3® accelerometer technology). Secondary outcome measures included daily energy expenditure (EE), daily duration of sedentary activity (DDSA), daily duration of moderate activity (DDMA), daily duration of vigorous activity (DDVA), weight, diastolic blood pressure (DBP), systolic blood pressure (SBP), body fat %, fat intake, fibre intake, anxiety, depression, self-efficacy, and health related quality of life (HRQOL). At the 6 week follow up the intervention group had greater improvements than the control group in daily steps, daily EE, DDSA, DDMA, weight, self-efficacy, emotional quality of life and frequency of angina symptoms. In addition, at the 6 month follow up there were significantly greater improvements in anxiety, and frequency of angina symptoms among the intervention group compared to the control group. Semi-structured interviews were also conducted with a subsample of intervention group participants at the 6 week follow up (n=16). Themes resulting from these interviews indicated a high level of programme acceptability and feasibility; ‘self reported improvements’ and ‘programme facilitators’. However, the theme labelled ‘programme barriers’ illustrated intervention related challenges which should be taken into account when delivering the programme. Overall the study demonstrated that a new web based CR programme was effective at improving lifestyle related cardiac risk factors for a primary care angina population in both the short-term (significantly improved daily steps, DDSA, DDMA, weight, self-efficacy, emotional QOL and frequency of angina) and medium-term (significantly improved anxiety, and frequency of angina). These findings on the whole suggest that the programme could be offered to a primary care angina population who are not routinely included within conventional CR. However, there is a need to consider the factors described to affect engagement of the programme; family and work commitments, bad weather, older age, receiving the programme late in angina diagnosis and levels of self-motivation.

Chong Lung-wun. / Thesis (M.Sc.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 49-58). / Abstracts in English and Chinese. / Acknowledgement --- p.1 / Contents --- p.2 / Abstract --- p.4 / Chapter I. --- Introduction --- p.6 / Chapter 1. --- Nitrate therapy for angina patients --- p.7 / Chapter 1.1 --- The mode of action of nitrates --- p.8 / Chapter 1.2 --- Hypotheses for the nitrate tolerance --- p.9 / Chapter 1.2.1 --- The Sulfhydryl depletion hypothesis --- p.9 / Chapter 1.2.2 --- Neurohormonal hypothesis --- p.10 / Chapter 1.2.3 --- Plasma volumc expansion hypothesis --- p.10 / Chapter 1.2.4 --- Free-radical hypothesis --- p.11 / Chapter 2. --- Testosterone therapy for angina patients --- p.12 / Chapter 3. --- Nitric Oxide and Steroidogenesis --- p.13 / Chapter II. --- Materials and Methods --- p.14 / Chapter 1. --- Subjects --- p.14 / Chapter 2. --- Method for measuring nitrite and nitrate in plasma --- p.16 / Chapter 3. --- Method for the determination of total and free testosterone in blood --- p.24 / Chapter 3.1 --- Reagent preparation --- p.24 / Chapter 3.2 --- Assay procedure for total testosterone --- p.28 / Chapter 3.3 --- Assay procedure for free testosterone --- p.29 / Chapter 3.4 --- Determination of working antiserum for free testosterone assay --- p.30 / Chapter 4. --- Method for the determination of serum Cortisol --- p.31 / Chapter III. --- Result --- p.33 / Chapter 1. --- Summary of nitric oxide assay performance --- p.33 / Chapter 2. --- Summary of total testosterone assay performance --- p.34 / Chapter 3. --- Summary of free testosterone assay performance --- p.34 / Chapter 4. --- Data analysis --- p.35 / Chapter IV. --- Discussion --- p.43 / Chapter V. --- Conclusion --- p.47 / Chapter VI. --- References --- p.49

ABSTRACT The non-steroidal anti-inflammatory drug (NSAID), diclofenac, has been associated with a high risk for cardiovascular events in observational studies. However, majority of studies identifying this association were conducted when diclofenac was the only NSAID that could be obtained as a combination product (i.e., formulated with misoprostol). As a result, channelling bias might have resulted if prescribers selected the combination of diclofenac/misoprostol (Diclo-Miso) in patients with poor health status frequently than other NSAID products. The main purpose of this study was to identify evidence for channelling bias in a cohort of patients with coronary heart disease (CHD) prescribed NSAIDs. Three independent, retrospective analyses were carried out using Saskatchewan’s health administrative databases. Patients were eligible if they were hospitalized with CHD event between January 1, 1994 and December 31, 2008. In the first analysis, a time series was conducted to examine trends in the use of NSAIDs following discharge from original hospitalization. In the second analysis, multivariate logistic regression models were constructed to identify characteristics of patients prescribed with Diclo-Miso in comparison to single-entity diclofenac. Finally, a nested case-control study was conducted to examine the risk for recurrent myocardial infarction (MI)/ Unstable Angina (UA) or death among patients prescribed with Diclo-Miso versus single-entity diclofenac. For each case, up to five controls were matched by age and sex. Between 1994 and 2008, NSAIDs were used by 20.1% (3,099/15,393) of patients in the year following discharge from their original MI/UA hospitalization. Use of these agents was relatively stable until 2004 when the COX-2 selective agent rofecoxib was withdrawn from the market. Following this date (i.e., September 30, 2004), the use of Diclo-Miso and single-entity diclofenac appeared to follow different trends. However, available patient and disease specific factors could not explain diverging utilization trends. Further, no differences were observed in the risk of experiencing recurrent MI/UA between patients receiving Diclo-Miso (OR 0.88, 95% CI 0.72-1.08, p=0.22) or single-entity diclofenac (OR 0.78, 95% CI 0.60-1.00, p=0.06) versus patients not exposed to NSAIDs. Based on the study’s result, channelling bias does not appear to be a major threat to the analysis of cardiovascular toxicity of diclofenac products.

Diss. (sammanfattning)--Stockholm : Karol. inst., 2002. / Härtill 5 uppsatser.