The American Heart Association (2006) has identified cardiovascular disease as the leading cause of death in the United States for every year except 1918 since 1900. Cardiac surgery is an increasingly common method of treating this problem (Contrada, Goyal, Cather, Rafalson, Idler et al. , 2004). Researchers have found that depression is associated with serious complications related to cardiac surgery (Connemey, Shapiro, McLaughlin, Bagiella, & Sloan, 2001 ). Many researchers have identified factors associated with depression in these patients. The purpose of this thesis was to identify and synthesize these current research findings. Studies included were published from 1997-2006 and focused on male and female patients 18 years of age and older, primarily undergoing Coronary Artery Bypass Grafting (CABG). The synthesis of these findings includes both the factors associated with developing depression and the complications associated with depression. Common factors associated with its development included female gender, lower socioeconomic status, pessimism, and poorer cognitive and physical functioning. Complications associated with depression included decreased physical functioning, healing, and cognitive functioning, as well as increased hospital stays, readmissions, cardiac events, and mortality. The associated factors may help to identify patients at high risk for developing depression, while the complications emphasize its importance. Limitations were acknowledged and recommendations for nursing research, education, and practice are included.

Yes / Background: Non-adherence to secondary prevention medicines (SPMs) among patients with coronary artery disease (CAD) remains a challenge in clinical practice. This study attempted to identify actual and potential modifiable barriers to adherence that can be addressed in cardiology clinical practice. Methods: This was a cross-sectional, postal survey-based study of the medicines-taking experience of patients with CAD treated at a secondary/tertiary care centre. All participants had been on SPM for ≥3 months. Results: In total, 696 eligible patients were sent the survey and 503 responded (72.3%). The median age was 70 years, and 403 (80.1%) were male; the median number of individual daily doses of all medicines was 6. The rate of non-adherence to at least one SPM was 43.5% (n=219), but 53.3% of reported non-adherence was to only one SPM. Statins contributed to 66.7% and aspirin to 61.7% of overall non-adherence identified by the Single Question (SQ) tool. In 30.8% of non-adherent patients (n=65), this was at least partly intentional. Barriers included forgetfulness (84.9%; n=186), worry that medicines will do more harm than good (33.8%; n=74), feeling hassled about medicines taking (18.7%; n=41), feeling worse when taking medicines (14.2%; n=31) and not being convinced of the benefit of medicines (9.1%; n=20). In a multivariate analysis, modifiable factors associated with overall non-adherence included being prescribed aspirin (OR: 2.22; 95% CI: 1.18 to 4.17), having specific concern about SPM (OR: 1.12; 95% CI: 1.07 to 1.18) and issues with repeat prescriptions (OR: 2.48; 95% CI: 1.26 to 4.90). Different factors were often associated with intentional versus unintentional non-adherence. Conclusions: Using appropriate self-report tools, patients share actual and potential modifiable barriers to adherence that can be addressed in clinical practice. Non-adherence behaviour was selective. Most non-adherence was driven by forgetfulness, concern about the harm caused by SPM and practical barriers. / The study was partially funded by the Leeds Teaching Hospitals Charitable Foundation.

A quantitative research design for a descriptive and contextual study to determine the critical care nurses knowledge and data preferences regarding the central venous and pulmonary artery catheters management and decision making after coronary arte.y bypass graft operations and the utmzation period of the pulmonary artery catheter after coronary artery bypass graft operations. The data was collected through a questionnaire completed by critical care nurses and retrospective analysis of patient records through a structured checklist. Data analysis indicated the following: critical care nurses have a knowledge deficit in the management of the central venous and pulmonary artery catheters and felt more competent and confident in the central venous measurements. The utilization period of the pulmonary artery catheter was 48% compared to the 100% of the central venous catheter. / Advanced Nursing Science / M.A. (Advanced Nursing Science)

Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF.

Introdução: A liberação de biomarcadores de necrose miocárdica após revascularização miocárdica cirúrgica (RM) ocorre com frequência. No entanto, a correlação entre a liberação de biomarcadores e o diagnóstico do infarto agudo do miocárdio (IAM) periprocedimento gera controvérsias, especialmente com o aumento da sensibilidade nos ensaios de troponina (Tn). Neste estudo, objetivou-se quantificar a liberação dos biomarcadores cardíacos em pacientes submetidos à RM, sem o uso de circulação extra corpórea (CEC), que não apresentaram evidências de infarto do miocárdio por meio da avaliação do realce tardio pelo gadolínio (RTG) na ressonância magnética cardíaca (RMC). Métodos: Pacientes portadores de doença arterial coronária estável e função ventricular preservada, com indicação eletiva para RM sem CEC, foram incluídos. RMC com RTG foi realizada em todos os pacientes antes e depois do procedimento. Aferições seriadas de Tn e creatinoquinase fração MB (CK-MB) foram realizadas antes do procedimento e até 72h após. Pacientes com RTG na RMC após o procedimento foram excluídos. Resultados: 73 pacientes foram referenciados para a realização eletiva da RM sem CEC e 20 (27%) foram excluídos, 14 (19%) por causa do surgimento de um novo RTG na RMC. Dentre os 53 pacientes sem evidência de IAM periprocedimento pela RMC, 37 (70%) eram do gênero masculino, a média da idade foi 63 (± 10) anos e o escore SYNTAX médio encontrado foi 20 (±7). Após a RM, todos os pacientes apresentaram um pico de elevação de Tn acima do percentil 99; em 48 (91%) pacientes a elevação foi superior a 10 vezes esse limite. Por outro lado, 41 (76%) pacientes apresentaram pico de CK-MB acima do percentil 99 e em apenas 7 (13%) este pico foi superior à10 vezes o percentil 99. A mediana do pico de liberação da Tn foi 2,0 (0,8 - 3,7) ng/mL, valor 50 vezes superior ao percentil 99. Conclusão: Diferente da CK-MB, a liberação da troponina I ocorre, frequentemente, após procedimento de RM sem CEC na ausência de realce tardio pela RMC / Background: The release of myocardial necrosis biomarkers after off-pump coronary artery bypass grafting (OPCAB) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedurerelated myocardial infarction (MI) (type 5) has been controversial. This study aims to evaluate the amount and pattern of cardiac biomarker release after elective OPCAB in patients without the image of a new MI assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE). Methods: Patients with normal baseline cardiac biomarkers referred for elective OPCAB were prospectively included. CMR with LGE was performed in all patients before and after interventions. Measurements of troponin I (cTnI) and creatinekinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with a new LGE on the post-procedure CMR were excluded. Results: Of the 53 patients without the evidence of a procedure-related MI assessed by the CMR after OPCAB, all patients exhibited cTnI elevation peak above the 99th percentile. In 48 (91%), the peak value was greater than 10 times this threshold. However, 41 (76%) had CK-MB peak above the limit of the 99th percentile, and this peak was greater than 10 times the 99th percentile in only 7 patients (13%). The median peak release of cTnI was 0.20 (0.8 - 3.7) ng/mL, which is 50-fold higher than the 99th percentile. Conclusions: In contrast to CK-MB, cTnI release often occurs after an elective OPCAB procedure, despite the absence of a new LGE on CMR

Kang, Ning. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references. / Abstract also in Chinese. / Abstracts --- p.i / Abbreviations --- p.v / List of Figures and Tables --- p.vii / Contents --- p.viii / Chapter Chapter 1: --- Introduction --- p.1 / Chapter 1. --- Saphenous vein graft patency after coronary artery bypass grafting --- p.1 / Chapter 2. --- Mechanism of vein graft failure and therapeutic strategies --- p.8 / Chapter 2.1 --- Mechanism --- p.15 / Chapter 2.2 --- Therapeutic strategies --- p.18 / Chapter 3. --- Summary --- p.22 / Chapter 4. --- References --- p.23 / Chapter Chapter 2: --- Animal model and laboratory investigations --- p.34 / Chapter 1. --- Surgical procedure --- p.35 / Chapter 2. --- Postoperative management --- p.37 / Chapter 3. --- Adenoviral-mediated gene transfer ex vivo for gene therapy study --- p.38 / Chapter 4. --- Laboratory investigations --- p.39 / Chapter 5. --- Statistical analysis --- p.40 / Chapter 6. --- Summary --- p.41 / Chapter 7. --- References --- p.41 / Chapter Chapter 3: --- "Impact of osteopontin expression in vein grafts on VSMC migration, proliferation, and neointimal formation" --- p.42 / Chapter 1. --- Introduction --- p.42 / Chapter 2. --- Methods and materials --- p.43 / Chapter 3. --- Results --- p.43 / Chapter 4. --- Discussion --- p.49 / Chapter 5. --- Summary --- p.52 / Chapter 6. --- References --- p.53 / Chapter Chapter 4: --- Potential Role of gene therapy in prevention of vein graft failure --- p.56 / Chapter 1. --- Vectors --- p.56 / Chapter 2. --- "Reporter gene, timing and titer" --- p.57 / Chapter 3. --- Candidate genes --- p.58 / Chapter 4. --- Summary --- p.64 / Chapter 5. --- References --- p.66 / Chapter Chapter 5: --- Conclusions --- p.70 / Acknowledgements --- p.72

A quantitative research design for a descriptive and contextual study to determine the critical care nurses knowledge and data preferences regarding the central venous and pulmonary artery catheters management and decision making after coronary arte.y bypass graft operations and the utmzation period of the pulmonary artery catheter after coronary artery bypass graft operations. The data was collected through a questionnaire completed by critical care nurses and retrospective analysis of patient records through a structured checklist. Data analysis indicated the following: critical care nurses have a knowledge deficit in the management of the central venous and pulmonary artery catheters and felt more competent and confident in the central venous measurements. The utilization period of the pulmonary artery catheter was 48% compared to the 100% of the central venous catheter. / Advanced Nursing Science / M.A. (Advanced Nursing Science)

A Tomografia Computadorizada Dual-Source (TCDS) é uma tecnologia de imagem que permite a visualização da estenose coronária de uma maneira não-invasiva. Estudos recentes demonstraram uma alta acuracia deste teste diagnóstico, quando comparado ao padrão de referência, a angiografia coronária invasiva (ACI). O objetivo deste trabalho foi sintetizar as evidências de acurácia desta tecnologia por meio de uma revisão sistemática e uma síntese quantitativa (meta-análise) e avaliar possíveis diferenciais de acurácia relacionados aos seguintes subgrupos de pacientes: com frequência cardíaca elevada, arritmias cardíacas, escore de cálcio elevado e índice de massa corporal (IMC) elevado. Foi realizada uma busca bibliográfica nas bases de dados MEDLINE e LILACS no período de janeiro de 2000 a outubro de 2009. Foram selecionados estudos em inglês, espanhol e português que comparassem a TCDS com a ACI em pacientes com suspeita ou doença arterial coronariana (DAC) e que permitissem a extração de dados suficientes para a construção de uma tabela 2X2. Três avaliadores independentes extraíram as características dos estudos e resultados, com as divergências resolvidas por consenso. Foram incluídos 20 estudos na revisão sistemática, que utilizaram três unidades de análise: paciente, vaso e segmento arterial. Nas unidades de análises paciente, vaso e segmento arterial, os valores das sensibilidades sumárias foram respectivamente de 98% (IC de 95%, 96% a 99%), 94% (IC de 95%, 89-% a 97%) e 93% (IC de 95%, 89% a 95%) e das especificidades sumárias foram respectivamente 84% (IC de 95%, 76% a 89%), 92% (IC de 95%, 87% a 95%) e 96% (IC de 95%, 91% a 98%). Também foi avaliada a acurácia nos subgrupos de pacientes com frequência cardíaca elevada e escore de cálcio aumentado. Na análise por subgrupos de pacientes, a sensibilidade e especificidade se mantiveram altas em pacientes com frequência cardíaca elevada 93% (IC de 95%, 90% a 95%) e 98% (IC de 95%, 95% a 99%), respectivamente. Já em pacientes com elevada calcificação (> 400 unidades de agatston) a especificidade diminuiu bastante, caindo para 79% (IC de 95%, 25% a 98%). A evidência disponível aponta para uma elevada acurácia da TCDS para a detecção da estenose coronária. Entretanto, a população que mais se beneficiaria desta tecnologia população com dor torácica e risco intermediário de DAC geralmente não esteve incluída nos estudos. Foram incluídos pacientes com alta probabilidade pré-teste da doença, já que os estudos foram realizados usualmente em centros de referência, com indivíduos com indicação prévia de angiografia coronária invasiva / Dualsource computed tomography (DSCT) is an imaging technology that enables the visualization of coronary artery stenosis in a non-invasive way. Earlier studies showed high accuracy compared to conventional coronary angiography. The aims of this study were to evaluate the evidence of this technology using a meta-analytic process and its accuracy in different subgroups such as patients with high heart rates, arrhythmia, increased calcium score and high body mass index. A search of the literature in MEDLINE and LILACS was performed and articles published between January 2000 and October 2009. Studies in English, Spanish and Portuguese that compared DSCT with conventional coronary angiography performed for all patients and included sufficient data for compilation of 2 X 2 tables were included. Three investigators independently extracted the characteristics of the studies and differences were settled by consensus. Twenty studies were included in the systematic review, using three units of analysis: patient, vessels and segment. Analysis of patients, vessels and segments yielded a sensitivity of 98% (95% CI, 96% to 99%), 94% (95% CI, 89% to 97%) and 93% (95% CI, 89% to 95%) and a specificity of 84% (95% CI, 76% to 89%), 92% (95% CI, 87% to 95%) and 96% (95% CI, 91% to 98%), respectively. We also analyzed the accuracy of DSCT in subgroups of patients with high heart rate and increased calcium score. The analyses of patients subgroups demonstrated that sensitivity and specificity remained high in patients with high heart rate 93% (CI 95%, 90% to 95%) and 98% (CI 95%, 95% to 99%), respectively. In patients with increased calcium score (> 400 Agatston units) the specificity declined significantly, falling to 79% (95%, 25% to 98%). The available evidence points to a high accuracy of DSCT for the detection of coronary artery stenosis. However, the population who might benefit from this technology - individuals with chest pain and intermediate risk of coronary artery disease, CAD have not generally been included in the retrieved studies since the studies were usually conducted in reference centers where patients usually have an indication for invasive coronary angiography, and consequently a high pretest probability of CAD

A Tomografia Computadorizada Dual-Source (TCDS) é uma tecnologia de imagem que permite a visualização da estenose coronária de uma maneira não-invasiva. Estudos recentes demonstraram uma alta acuracia deste teste diagnóstico, quando comparado ao padrão de referência, a angiografia coronária invasiva (ACI). O objetivo deste trabalho foi sintetizar as evidências de acurácia desta tecnologia por meio de uma revisão sistemática e uma síntese quantitativa (meta-análise) e avaliar possíveis diferenciais de acurácia relacionados aos seguintes subgrupos de pacientes: com frequência cardíaca elevada, arritmias cardíacas, escore de cálcio elevado e índice de massa corporal (IMC) elevado. Foi realizada uma busca bibliográfica nas bases de dados MEDLINE e LILACS no período de janeiro de 2000 a outubro de 2009. Foram selecionados estudos em inglês, espanhol e português que comparassem a TCDS com a ACI em pacientes com suspeita ou doença arterial coronariana (DAC) e que permitissem a extração de dados suficientes para a construção de uma tabela 2X2. Três avaliadores independentes extraíram as características dos estudos e resultados, com as divergências resolvidas por consenso. Foram incluídos 20 estudos na revisão sistemática, que utilizaram três unidades de análise: paciente, vaso e segmento arterial. Nas unidades de análises paciente, vaso e segmento arterial, os valores das sensibilidades sumárias foram respectivamente de 98% (IC de 95%, 96% a 99%), 94% (IC de 95%, 89-% a 97%) e 93% (IC de 95%, 89% a 95%) e das especificidades sumárias foram respectivamente 84% (IC de 95%, 76% a 89%), 92% (IC de 95%, 87% a 95%) e 96% (IC de 95%, 91% a 98%). Também foi avaliada a acurácia nos subgrupos de pacientes com frequência cardíaca elevada e escore de cálcio aumentado. Na análise por subgrupos de pacientes, a sensibilidade e especificidade se mantiveram altas em pacientes com frequência cardíaca elevada 93% (IC de 95%, 90% a 95%) e 98% (IC de 95%, 95% a 99%), respectivamente. Já em pacientes com elevada calcificação (> 400 unidades de agatston) a especificidade diminuiu bastante, caindo para 79% (IC de 95%, 25% a 98%). A evidência disponível aponta para uma elevada acurácia da TCDS para a detecção da estenose coronária. Entretanto, a população que mais se beneficiaria desta tecnologia população com dor torácica e risco intermediário de DAC geralmente não esteve incluída nos estudos. Foram incluídos pacientes com alta probabilidade pré-teste da doença, já que os estudos foram realizados usualmente em centros de referência, com indivíduos com indicação prévia de angiografia coronária invasiva / Dualsource computed tomography (DSCT) is an imaging technology that enables the visualization of coronary artery stenosis in a non-invasive way. Earlier studies showed high accuracy compared to conventional coronary angiography. The aims of this study were to evaluate the evidence of this technology using a meta-analytic process and its accuracy in different subgroups such as patients with high heart rates, arrhythmia, increased calcium score and high body mass index. A search of the literature in MEDLINE and LILACS was performed and articles published between January 2000 and October 2009. Studies in English, Spanish and Portuguese that compared DSCT with conventional coronary angiography performed for all patients and included sufficient data for compilation of 2 X 2 tables were included. Three investigators independently extracted the characteristics of the studies and differences were settled by consensus. Twenty studies were included in the systematic review, using three units of analysis: patient, vessels and segment. Analysis of patients, vessels and segments yielded a sensitivity of 98% (95% CI, 96% to 99%), 94% (95% CI, 89% to 97%) and 93% (95% CI, 89% to 95%) and a specificity of 84% (95% CI, 76% to 89%), 92% (95% CI, 87% to 95%) and 96% (95% CI, 91% to 98%), respectively. We also analyzed the accuracy of DSCT in subgroups of patients with high heart rate and increased calcium score. The analyses of patients subgroups demonstrated that sensitivity and specificity remained high in patients with high heart rate 93% (CI 95%, 90% to 95%) and 98% (CI 95%, 95% to 99%), respectively. In patients with increased calcium score (> 400 Agatston units) the specificity declined significantly, falling to 79% (95%, 25% to 98%). The available evidence points to a high accuracy of DSCT for the detection of coronary artery stenosis. However, the population who might benefit from this technology - individuals with chest pain and intermediate risk of coronary artery disease, CAD have not generally been included in the retrieved studies since the studies were usually conducted in reference centers where patients usually have an indication for invasive coronary angiography, and consequently a high pretest probability of CAD

Introdução – Pouco se publicou na literatura médica a respeito de projeções angiográficas dedicadas às anatomias especiais. Neste cenário, propomos uma projeção angiográfica para a exposição da bifurcação do tronco da artéria coronária esquerda (TCE) quando o conjunto de projeções rotineiras previamente utilizadas foi ineficaz para exibir com clareza essa região. Pacientes e Métodos – 84 pacientes foram submetidos à projeção Lateral Direita (90-120°) associada a Cranial (30-40°). Estudo de reprodutibilidade, realizado com a participação de dois observadores independentes, julgou a eficácia da projeção proposta. O índice kappa, ajustado para a prevalência e viés (PABAK) com IC de 95%, foi utilizado para demonstrar a intensidade da concordância inter e intraobservador: ≤ 0,20 = ruim, 0,21 – 0,40 = fraca, 0,41 – 0,60 = moderada, 0,61 – 0,80 = substancial e 0,81 – 1,0 = quase perfeita. Resultados – A projeção proposta foi eficaz em 79% dos angiografias com concordância de 0,76 (0,6 – 0,9; P ≤ 0,001). A origem e o segmento proximal da artéria coronária descendente anterior foram expostos em 89% com concordância de 0,86 (0,7 – 1,0; P ≤ 0,001), a origem e o segmento proximal da artéria circunflexa foram expostos em 83% com concordância de 0,72 (0,5 – 1,0; p ≤ 0,001) e a origem e o segmento proximal do ramo intermediário, quando presente, foram expostos em 89% com concordância de 0,79 (0,6 – 1,0; p ≤ 0,001). Conclusão – A projeção proposta é eficaz, segura e reproduzível. Em situações especiais, onde projeções rotineiras falham, essa poderá exibir detalhes importantes da anatomia da bifurcação do TCE à cinecoronariografia ou ser a projeção de trabalho durante a intervenção coronariana percutânea. / Objectives – We propose a 90 – 120° right lateral with 30-40° cranial angiographic view to expose the bifurcation of the left main coronary artery (LMCA) when previously used routine projections were inefficient at clearly showing this region. Background – Little has been published in the medical literature regarding angiographic projections dedicated to special anatomies. Methods – A total of 84 patients were subjected to the proposed projections. A reproducibility study, conducted with the participation of two independent observers, judged the effectiveness of the proposed projection. The Prevalence and Bias Adjusted Kappa (PABAK) index, with a 95% confidence interval (CI), was used to demonstrate the intensity of intra- and inter-observer agreement: ≤ 0.20 = poor, 0.21 – 0.40 = slight, 0.41 – 0.60 = moderate, 0.61 – 0.80 = substantial and 0.81 – 1.0 = almost perfect. Results – The proposed projection was efficient in 79% of the angiograms, with agreement of 0.76 (0.6 – 0.9; P ≤ 0.001). The origin and the proximal segment of the anterior descending coronary artery were exposed in 89% of the angiograms, with agreement of 0.86 (0.7 – 1.0; P ≤ 0.001); the origin and the proximal segment of the circumflex artery were exposed in 83% of the angiograms, with agreement of 0.72 (0.5 – 1.0; P ≤ 0.001); and the origin and the proximal segment of the intermediate branch, when present, were exposed in 89% of the angiograms, with agreement of 0.79 (0.6 – 1.0; P ≤ 0.001). Conclusion – The proposed projection is effective, safe and reproducible. In special situations where routine projections fail, this proposed projection can reveal important details of the anatomy of the bifurcation of the LMCA during conventional / Tese (Doutorado)