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

Thesis ( M. Tech. (Clinical Technology )) - Central University of Technology, Free State, 2013 / The best approach to surgical myocardil revascularization remains controversial. It is already known that an inflammatory response exists due to several factors related to the use of CPB. physiological stress response which leads to an increase in pro-inflammatory markers still remains during OPCAB surgery. surgery induces a wide haematological and hemodynamic changes. Hemodynamic and metabolic optimization is of daily importance in the hospital environment. morbidity and mortality. Lactate is also often used to predict clinical outcomes and complications but controversy remains about using this measure because of discrepancies in The aim of the study was to evaluate how metabolic and clinical changes relate to the incidence of complications and clinical outcomes in ACS patients undergoing on-pump and off-pump CABG Sixty patients diagnosed with ACS who received CABG surgery were recruited to participate in the study (30 patients on-pump and 30 patients off-pump). Patients not receiving isolated with reference to the intra-operative and post-operative metabolic data, intra-operative hemodynamic data and post-operative clinical outcomes/complications. lactate levels <5mmol/L or patients with lactate levels >5mmol/L. Comparisons between the two groups were made with reference to the intra-operative and post-operative metabolic data, Intra-operative metabolic data indicated 11 (37.0%) on-pump patients and 6 (20.0%) off-pump patients had peak lactate levels of >5mmol/L during cardiac surgery. The difference between the statistically comparison, the difference cannot be considered clinically relevant. differences (p<0.05) between the lactate < 5mmol/L group and the lactate > 5 mmol/L group. Intra-operative hemodynamic data showed statistically significant differences between the on- Post-operative metabolic data showed statistically significant differences (p<0.05) between the on-pump and off-pump groups for acid-base balance variables, pH, HCO3- and BE (B) from The metabolites, glucose and lactate, showed statistically significant differences (p<0.05) between the on-pump and off-pump groups from admission to ICU until 12 hours post- Despite the fact that elevated lactate levels have been described to be associated with adverse outcomes in paediatric- as well as general intensive care admission, no specific lactate level has surgery. Lactate values for the on-pump group were significantly higher during the immediate post- resulting in vasoconstriction and a redistribution of blood flow away from the peripheral tissue and the splanchnic circulation, creating an environment for increased lactate levels in the tissue. indication of a patient's likelihood of experiencing various complications. Both groups recovered to lactate levels of <2mmol/L by the 24th hour post-operatively. According to operatively this is associated with an increased 60-day mortality. The study did show a statistically significant difference between the on-pump and off-pump comparison, the difference cannot be considered conclusive and we can only make suggestions as to the trends seen in the data. Elevated lactate levels show that they may be poorly correlated with clinical outcomes and in order to see a more definite relationship between peak lactate levels and clinical outcomes, a larger study population will be required or perhaps a different lactate cut-off value should be considered. It may also be more useful to see if there is a positive correlation between the duration of time a patient is subjected to peak lactate levels of >5mmol/L and clinical outcomes. We recommend larger study population and change lactate cut-off value to >10mmol/L.

This dissertation investigated the psychometric properties and clinical applications of the Psychosocial Inventory for Cardiovascular Illness (PICI). The PICI is an inventory developed to measure the psychosocial risk factors for heart disease including anxiety, depression, stress, social isolation, and anger. The inventory was developed to measure the ways that each psychosocial risk factor contributes to the coronary artery disease process through the lifestyle behaviors and pathophysiological mechanisms with which they are associated. The primary purpose of the study was to examine predictive validity for the PICI. With support for predictive validity, the inventory may aid in early identification of individuals at increased risk for coronary artery disease (CAD) so that behavioral, psychosocial, and medical interventions can be implemented. Both healthy and cardiac samples were used in the inventory development and validation process. The PICI was administered in conjunction with similar inventories and physiological markers of CAD were collected including percent of coronary artery blockage and history of heart attacks. Item analysis and factor analysis were used to yield a 20-item PICI comprised of three subscales to include Negative Affect, Social Isolation, and Anger. It was hypothesized that the PICI subscales would predict group membership; whether or not a participant carried a diagnosis of CAD, and would be have a strong relationship to the physiological markers of CAD that were measured. Analysis revealed that the PICI was unable to predict diagnostic status and did not have a strong relationship with the physiological markers of CAD. Results suggest that the PICI has acceptable reliability and construct validity as demonstrated in the current sample, yet further investigation must be conducted to gain support for the instrument’s predictive abilities. / text

A novel technique for saphenous vein (SV) graft harvesting, the No-touch technique (NT), has been developed at the Dept. of Cardiovascular surgery, Örebro University hospital. With NT the SV is harvested with a pedicle of surrounding tissue. This avoids graft spasm and eliminates the need for distension. The surrounding tissue acts as a structural support and is a rich source of vaso-dilating agents. A randomized controlled trial (RCT) has shown a significantly higher patency rate for NT SV grafts compared to SV grafts harvested with conventional technique (CT). This thesis evaluates some of the properties of the surrounding tissue and compares patency rates between NT SV and radial artery (RA) grafts and patency rates for internal thoracic artery (ITA) grafts harvested with and without surrounding tissue. Paper I investigated vasa vasorum (VV) in SV grafts and showed that the NT preserves an intact VV whereas CT does not. This could be one of the mechanisms underlying the improved patency for NT SV grafts. Paper II evaluated VV and associated nitric oxide (NO) in SV and arterial grafts. SV grafts showed a higher number and larger VV, which correlated with NO production, compared to arterial grafts. NT SV grafts showed higher activity for e-NOS compared to CT SV grafts. Paper III is a RCT comparing patency rates between NT SV and RA grafts, three years after surgery, showing a significantly higher patency rate for NT SV grafts. Paper IV is a RCT comparing patency rates for ITA graft harvested with and without surrounding tissue and did not show any difference between graft preparations. In conclusion, the NT for SV graft harvesting preserves an intact vasa vasorum and associated NO production. NT SV grafts show a higher patency rate than RA grafts. Harvesting of ITA with or without surrounding tissue does not affect patency rate.

Although the drug-eluting stent (DES) has dramatically reduced the rate of coronary restenosis, it still occurs in up to 20% of patients with a DES. Monitoring drug delivery could be one way to decrease restenosis rates. We demonstrate real-time photoacoustic imaging and spectroscopy (PAIS) using a wavelength-tunable visible laser and clinical ultrasound scanner to track cardiac drug delivery. The photoacoustic signal was initially calibrated using porcine myocardial samples soaked with a known concentration of a drug surrogate (Dil). Next, an in situ coronary artery was perfused with DiI for 20 min and imaged to monitor dye transport in the tissue. Finally, a partially DiI-coated stent was inserted into the porcine brachiocephalic trunk for imaging. The photoacoustic signal was proportional to the DiI concentration between 2.4 and 120 mu g/ml, and the dye was detected over 1.5 mm from the targeted coronary vessel. Photoacoustic imaging was also able to differentiate the DiI-coated portion of the stent from the uncoated region. These results suggest that PAIS can track drug delivery to cardiac tissue and detect drugs loaded onto a stent with sub-mm precision. Future work using PAIS may help improve DES design and reduce the probability of restenosis. (C) 2017 Society of Photo-Optical Instrumentation Engineers (SPIE)

Este trabalho teve como objetivo comparar as freqüências e concordâncias em percentual os registros de diagnósticos e intervenções de enfermagem entre dois métodos: Sistematização de Assistência de Enfermagem (SAEP) e o Conjunto de Dados de Enfermagem Perioperatória (PNDS) no transoperatório de RM, Os métodos foram empregados por 2 grupos distintos de enfermeiros em 50 pacientes. Os registros encontrados no SAEP foram transcritos, mapeados para o PNDS e então comparados. No PNDS registrou-se 648 diagnósticos e no SAEP 38. A freqüência de intervenções registradas para o PNDS foi 1863 e para SAEP 1587. Não houve concordância em percentual para a presença de diagnósticos entre os métodos estudados. Nas intervenções do domínio segurança, houve concordância acima de 70% em 12 categorias / This study aimed to compare frequency and percentage agreement of nursing diagnosis and interventions documented by two different methods: Perioperative Nursing Care Process (SAEP) and Perioperative Nursing Data Set (PNDS) during intra-operative CABG surgery. The methods were employed by two distinct groups of nurses with 50 patients. SAEP nursing documentation was transcribed, mapped and compared to PNDS. With the PNDS documentation, 648 nursing diagnosis were recorded and 38 with SAEP. Nursing interventions frequency for PNDS were 1863 and SAEP, 1587. There was no percentage agreement of nursing diagnosis between the studied methods. There was over 70% agreement for safety domain interventions, in 12 categories

Introdução:O diabetes mellitus tipo 2 (DM2) está associado ao aumento da mortalidade por doença arterial coronária (DAC). O DM2 afeta o metabolismo de lípides, levando à dislipidemia, caracterizada por hipertrigliceridemia e baixa concentração plasmática de HDL-colesterol. Transferências de lípides entre HDL e outras lipoproteínas são passos cruciais no metabolismo e função da HDL. Objetivo: Investigar se o desenvolvimento de DAC em pacientes com DM2 está associado com alterações na transferência de lípides para HDL. Métodos: Foram estudados 79 pacientes com DM2 portadores de DAC obstrutiva (DM2-DAC) e 76 pacientes com DM2 e artérias coronárias angiograficamente normais (DM2). Foram avaliados o perfil lipídico, apolipoproteínas, composição lipídica da HDL, dosagem de CETP e LCAT. No ensaio de transferência, as amostras de plasma foram incubadas por 1h a 37º com uma nanoemulsão artificial marcada com 3H-éster de colesterol e 14Cfosfolípides ou 3H -triglicérides e 14C-colesterol não esterificado. A quantificação da transferência de lípides da nanoemulsão doadora para a HDL foi feita após a precipitação da fração não HDL. O tamanho da HDL foi medido por laser light scattering. Resultados: Os pacientes DM2-DAC apresentaram maior concentração de colesterol total (DM2-DAC=218±48; DM2=193±36; p < 0,001), LDL-C (147±44 vs 124±33; p < 0,001) e apoB (103,1±20,4 vs 96,0 ± 19,5; p = 0,03) que o grupo sem DAC. Os grupos não mostraram diferença com relação à concentração plasmática de triglicérides (DM2-DAC=171 ± 73; DM2=154 ± 70; p=0,1) e HDL-C (41±9 vs 38±8; p=0,07). A transferência de éster de colesterol (4,0 ± 0,6 vs 4,3 ± 0,7; p=0,005) e de colesterol não esterificado (7,6 ± 1,2 vs 8,2±1,5; p=0,006) foi menor no grupo com DAC, porém esse grupo teve maior concentração de colesterol não esterificado no plasma (36,3 ± 8,0 vs 33,6±6,5 ;p=0,02). A concentração de CETP foi menor no grupo DM2DAC (2,1±1,0 vs 2,5 ±1,1; p=0,02 ). O diâmetro das partículas de HDL não diferiu entre os grupos (8,9 ± 1,2 vs 9,0±0,6; p=0,4), nem a composição lipídica da HDL (éster de colesterol: 52,2 ± 10,8 vs 50,6 ± 10,7; p=0,38; colesterol não esterificado: 9,0 ± 2,8 vs 8,4 ± 2,7; p=0,19; triglicérides: 13,4 ± 3,9 vs 12,4 ± 3,9; p=0,11e fosfolípides:77,2 ± 16,7 vs 78,8 ± 20,5; p=0,60). A atividade da enzima LCAT não diferiu entre os grupos (1,34 ± 0,12 vs 1,33 ± 0,10; p=0,9). As transferências de todos os lípides apresentaram correlação entre si. Na análise multivariada, a presença de DAC influenciou a transferência de éster de colesterol, quando ajustado para HDL-C, apoA1, CETP massa e LDL-C (r2=0,5, p=0,03) e a transferência de colesterol não esterificado, quando ajustado para apoA1, apoB, LCAT, glicemia, idade e sexo (r2 = 0,7, p = 0,003). Conclusão: Na amostra estudada, pacientes diabéticos portadores de DAC apresentam menor transferência de colesterol para HDL comparados com os pacientes diabéticos sem DAC obstrutiva / Aim: Type 2 diabetes mellitus (DM2) is associated with morbidity and mortality secondary to coronary artery disease (CAD). DM2 affects lipid metabolism, and diabetic dyslipidemia is characterized by increased levels of tryglicerides and reduced levels of HDL-cholesterol. Lipid transfer between HDL and the other lipoproteins is a crucial step in HDL function and metabolism. Objective: The purpose of this study was investigate whether the susceptibility of patients with type 2 diabetes mellitus to develop CAD is related with alterations in lipid transfers to HDL. Methods: 79 patients with DM2 and obstructive CAD (DM2- CAD) and 76 with DM2 (DM2 group) and angiographic normal coronary arteries were studied. Lipid profile, apolipoproteins, HDL lipid composition, CETP and LCAT activity were evaluated. In the lipid transfer assay, fasting plasma samples were incubated for 1h at 37°C with a donor artificial nanoemulsion labeled with 3H -cholesteryl-esters and 14C-phospholipids or 3H-triglycerides and 14C-unesterified cholesterol. Radioactive lipids transferred from the donor nanoemulsion to HDL were quantified in the supernatant after chemical precipitation of non-HDL fractions and nanoemulsion. HDL size was measured by laser light scattering. Results: In DM2-CAD, total cholesterol (DM2- DAC=218 ± 48; DM2=193±36; p < 0,001), LDL-C (147 ± 44 vs 124±33; p < 0,001) and apoB (103,1±20,4 vs 96,0±19,5; p=0,03) were higher than in DM2 group. The groups showed no differences with respect to plasma triglycerides levels (DM2-DAC=171± 73; DM2=154 ± 70; p=0,1) nor HDL-C (41 ± 9 vs 38±8; p=0,07). DM2-CAD showed diminished transfer to HDL of esterified cholesterol (4,0±0,6 vs 4,3 ± 0,7; p = 0,005) and unesterified cholesterol (7,6 ± 1,2 vs 8,2 ± 1,5; p=0,006). However, the DM2-CAD group showed higher levels of plasmatic unesterified cholesterol (36,3±8,0 vs 33,6±6,5 ;p=0,02). CETP mass was lower in the DM2- CAD group (2,1 ± 1,0 vs 2,5 ± 1,1; p=0,02 ). HDL particle diameter was not different between groups (8,9±1,2 vs 9,0 ± 0,6; p=0,4) neither its lipid composition (esterified cholesterol: 52,2 ± 10,8 vs 50,6 ± 10,7; p=0,38; unesterified cholesterol: 9,0 ± 2,8 vs 8,4 ± 2,7; p=0,19; triglycerides: 13,4 ± 3,9 vs 12,4 ± 3,9; p=0,11; phospholipids: 77,2 ± 16,7 vs 78,8 ± 20,5; p=0,60). LCAT activity was not different in the two groups (1,34±0,12 vs 1,33±0,10; p=0,9). In multivariate analysis, DAC influenced cholesteryl ester transfer, when adjusted to HDL-C, apoA1, CETP mass and LDL-C (r2=0,5, p=0,03), and unesterified cholesterol transfer, when adjusted to apoA1, apoB, LCAT, glycemia, age and sex (r2=0,7, p=0,003). Conclusion: In these sample, DM2-CAD patients show diminished cholesterol transfer to HDL particles when compared to diabetic patients without obstructive CAD

O objetivo principal deste estudo foi compreender os significados culturais de apoio social e descrever a experiência da enfermidade na perspectiva de um grupo de pessoas submetidas à revascularização do miocárdio (CRVM). O método etnográfico foi utilizado na condução deste estudo bem como os modelos explanatórios, propostos por Arthur Kleinman, foram utilizados para compreender o processo de saúde e doença. Participaram do estudo 11 pacientes moradores de Ribeirão Preto que foram submetidos à CRVM em um hospital terciário e universitário da mesma cidade. Para a coleta de dados, foram utilizados questionário com registro de dados sociodemográficos, entrevista semiestruturada e observações diretas, realizadas na residência dos sujeitos e durante o retorno às consultas médicas. A maioria dos participantes era do sexo feminino (seis), casada, com idade variando entre 49 e 73 anos e ensino fundamental incompleto. A partir da análise e interpretação dos dados, dois temas principais foram identificados: 1) A experiência da revascularização do miocárdio e 2) Significado de apoio social: instrumental e emocional. A notícia da necessidade da CRVM aconteceu de forma inesperada para os pacientes que não relacionavam os sinais e sintomas que apresentavam a qualquer problema de saúde cardiovascular. A necessidade da cirurgia fez com que os pacientes elaborassem diferentes explicações para o problema, como: causas comportamentais (maus hábitos alimentares e tabagismo), físicas (casos na família e consequência de outras doenças crônicas - diabetes e hipertensão arterial), religiosas (desígnio de Deus - provação), sociais (separações, frustrações) e emocionais (muito estresse, nervoso, muitas preocupações, muita ansiedade). Para os pacientes, esse período foi muito difícil, pois não queriam operar, tinham medo de morrer. O apoio dos familiares e de DEUS foi fundamental para tomarem a decisão pela CRVM. Após a CRVM, a principal fonte de apoio para esses pacientes foram os familiares que ofereceram apoio emocional e apoio instrumental. Observamos que o apoio dos profissionais da saúde foi restrito ao ambiente hospitalar e de maneira pontual antes da cirurgia. Para os pacientes, o apoio significou ajuda nas atividades domésticas e de autocuidado, principalmente prestada pelos familiares (cônjuge e filhos). Para os pacientes é muito difícil estar dependente dos familiares, uma vez que antes da doença a situação era inversa. / The main goal of this study was to understand the cultural meanings of social support and to describe the disease experience from the perspective of a group of people submitted to coronary artery bypass graft (CABG). Ethnographic method was used to conduct this study, and the explanatory models proposed by Arthur Kleinman were used to understand the health and disease process. Study participants were 11 patients who lived in Ribeirão Preto and were submitted to CABG at a tertiary teaching hospital in the same city. For data collection, a questionnaire was used to register socio-demographic data, as well as a semi-structured interview and direct observations at the subjects\' homes and during medical return appointments. Most participants were female (six), married, with ages ranging from 49 to 73 years and unfinished primary education. Based on data analysis and interpretation, two main themes were identified: 1) The coronary artery by-pass graft experience and2) Meaning of social support: instrumental and emotional. Most patients unexpectedly received the News about the need for the CABG, who did not relate the signs and symptoms they displayed with any cardiovascular health problem. The need for the surgery made patients elaborate different explanations for the problem, such as: behavioral (bad eating habits and smoking), physical (cases in the family and consequences of other chronic illnesses - diabetes and arterial hypertension), religious (designed by God - probation), social (separations, frustrations) and emotional causes (great stress, nervous, many concerns, great anxiety). For patients, this period was very difficult, as they did not want to operate on, they were afraid of dying. The relatives and God\'s support was fundamental to decide on undergoing the CABG. After the CABG, the main support source for these patients were relatives, who offered emotional and instrumental support. We observed that health professionals\' support was restricted to the hospital environment and happenedpromptly before the surgery. For the patients, support meant help with housework and self-care activities and mainly come from relatives (partner and children). It is very difficult for the patients do depend on their family members, as the situation used to be the opposite before the disease.

Introdução: apesar das recomendações de todas as diretrizes sobre a doença arterial coronária e das evidências científicas de que o tratamento medicamentoso otimizado acrescido de intervenção sobre os fatores de risco e a melhoria do estilo de vida reduzem eventos cardiovasculares fatais não-fatais, essa terapêutica de prevenção secundária continua a ser subutilizada na prática clínica. Objetivos: Primário: demonstrar que a utilização de um programa de otimização da prática clínica em pacientes com doença arterial coronária estável aumenta a prescrição de medicamentos comprovadamente eficazes na prevenção secundária desta doença. Secundários: a) documentar a prática clínica vigente em termos de terapia medicamentosa e de medidas para a mudança do estilo de vida b) identificar as ferramentas utilizadas na estratégia para a otimização da prática clínica quanto à eficácia e aderência à medicação prescrita. Métodos: trata-se de um estudo de corte transversal para documentar a prática clínica vigente, seguido de componente longitudinal em que a utilização das ferramentas para a otimização da prática clínica foi avaliada por meio de novo corte transversal, com nova coleta de dados. Foram identificados retrospectivamente através dos prontuários, 710 pacientes consecutivos portadores de doença arterial coronária (Fase 1). Após a aplicação das ferramentas, foram incluídos 705 pacientes consecutivos atendidos no serviço com a coleta dos mesmos dados, para a análise comparativa. Além disso, foram selecionados do primeiro grupo, de forma aleatória, 318 prontuários de seis a doze meses após a primeira avaliação, para a coleta dos mesmos dados, que foram comparados com as informações iniciais destes mesmos pacientes. (Fase 3). Resultados: comparação entre Fase 1 e Fase 2: as características demográficas eram comparáveis entre os dois grupos. Quanto aos fatores de risco, houve melhora com diferença significativa para o tabagismo (p=0,019), dislipidemia (p<0,001) hipertensão arterial e atividade física regular (p<0,001). Quanto aos exames laboratoriais, não houve diferença estatisticamente significativa entre as duas populações. Comparando a prescrição dos fármacos recomendados, houve diferença significativa para IECA (67,2% versus 56,8%, p<0,001); ARA II (25,4% versus 32,9%, p=0,002) e betabloqueador (88,7% versus 91,9%, p=0,047). Comparação entre Fase 1 e Fase 3: os dados demográficos foram semelhantes, assim como as características clínicas, com exceção da doença arterial periférica obstrutiva: 31 pacientes (9,7%) e 42 (13,3%), p=0,007. Em relação aos fatores de risco, consideramos apenas os modificáveis tabagismo e atividade física. Para o tabagismo, considerando três categorias (nunca, ex-fumante e atual), não houve diferença significativa entre as duas fases. Para a atividade física, a proporção de pacientes sem informação para esta variável era elevada, 83,9% na primeira fase e 72,8% na terceira fase, dificultando a análise estatística. Quanto às medidas de exame físico, houve redução significativa do peso, p=0,044, pressão arterial sistólica e diastólica, p<0,001. Os exames laboratoriais não mostraram diferenças significativas entre as duas fases. Em relação à prescrição de medicamentos recomendados, houve diferença para IECA (64,8% versus 61,6%, p=0,011) e ARA II (27,0% versus 31,3%, p=0,035). Conclusão: com base nos resultados obtidos, o presente estudo permite concluir: não houve mudança significativa na utilização de medicamentos comprovadamente eficazes na prevenção secundária da DAC entre o período pré- e pós-intervenção; houve melhora significativa em relação ao tabagismo e atividade física na Fase 2; melhora substancial nos níveis de pressão arterial, tanto sistólica como diastólica na comparação tanto entre a Fase 1 e 2 como entre a Fase 1 e 3; a inclusão de enfermeiro treinado para gerenciar o processo é fundamental para a eficácia do programa; programas abrangentes de melhoria de qualidade assistencial em hospitais terciários e acadêmicos, provavelmente devem ser continuados por período de seguimento superior a um ano. / Background: despite guidelines recommendations on coronary artery disease treatment and scientific evidence confirming that optimal medical therapy added to risk factors and lifestyle management, reduce both fatal and non-fatal cardiovascular events, these secondary prevention strategies have been underutilized in clinical practice. Objectives: Primary: to demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients would increase the evidence-proved treatment prescription in secondary prevention. Secondaries: a) to describe the ongoing clinical practice on medical therapy and lifestyle change counseling b) to identify tools to be utilized in the strategy to improve clinical practice, assessing efficacy and adherence to prescribed treatment. Methods: cross-sectional study to describe the ongoing clinical practice, followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional crosssectional data collection. 710 consecutive coronary artery disease patients were included after chart review following eligibility criteria (Phase 1). After tools implementation, within 6-month period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3). Results: Phase 1 to Phase 2 comparison: demography was comparable. Concerning to risk factors, there were improvement on smoking (p=0,019), dyslipidemia (p<0,001), hypertension and physical activity (p<0,001). There were no statistical significant differences on laboratory results. By comparing the proven pharmacological treatment prescription, there was significant difference on ACEI (67,2% versus 56,8%, p<0,001); ARB II (25,4% versus 32,9%, p=0,002) and beta-blocker (88,7% versus 91,9%, p=0,047). Phase 1 to Phase 3 comparison: demography was comparable, as well as clinical characteristics, except peripheral artery disease: 31 patients (9,7%) and 42 (13,3%), p=0,007. Regarding risk factors, smoking and physical activity were considered. There was no significant difference on smoking rates taking into account three categories (never, ex-smoker and smoker). The proportion of patients without available data for physical activity was high, 83,9% (Phase 1) and 72,8% (Phase 3), making the data analysis not appropriated. Anthropometric measurement showed significant on weight reduction, p=0,044, both systolic and diastolic blood pressure, p<0,001. Laboratory results did not show significant differences. There was statistical significant difference on ACEI (64,8% versus 61,6%, p=0,011) and ARB II (27,0% versus 31,3%, p=0,035). Conclusion: based upon study results the following might be concluded: there was no significant change on the evidence-based pharmacological treatment utilization on secondary prevention coronary artery disease patients between pre and post-intervention Phases; there was significant improvement concerning smoking and physical activity in Phase 2; substantial improvement on blood pressure levels, both systolic and diastolic in both comparisons (Phase 1 to 2 and Phase 1 to 3); the inclusion of a case-manager for the process management is crucial for program efficacy; comprehensive programs for clinical practice improvement in tertiary academic hospitals should be pursued for longer follow-up period.

OBJETIVO: Avaliar a qualidade de vida em portadores de Doença Arterial Coronária (DAC)submetidos a três tratamentos: clínico, cirúrgico ou por angioplastia, além de comparar possíveis diferenças entre gêneros. CASUÍSTICA E MÉTODO: O estudo incluiu 542 sujeitos com DAC submetidos a um dos tratamentos: cirúrgico, clínico ou por angioplastia. Dos participantes, 376 eram homens (58,5 dp 8,7 anos)e 166 mulheres (61,8 dp 9,2 anos). O instrumento de avaliação foi o Questionário Genérico de Avaliação de Qualidade de vida (SF-36), aplicado no início do tratamento, após seis e doze meses.A análise estatística foi realizada pelo teste ANOVA. RESULTADOS: Em relação aos componentes físicos do SF-36, o grupo cirúrgico exibiu escores de 46, 63 e 68, respectivamente, na fase inicial, seis e doze meses; o clínico 52, 65 e 62 e a angioplastia 57, 66 e 70. Os escores dos componentes mentais do tratamento cirúrgico foram 58, 71 e 74, do clínico 61, 69 e 69 e da angioplastia 64, 74 e 74. As diferenças foram significantes ao longo do tempo e entre os tratamentos (p<0,01). Na comparação entre os gêneros notou-se que os componentes físicos nos homens apresentaram respectivamente escores de 56*, 69 e 77* e nas mulheres 41*, 64 e 62*; os componentes mentais nos homens revelaram 61*, 73 e 80* e nas mulheres 51*, 68 e 62* (*p<0,0001). CONCLUSÕES: Os sujeitos submetidos ao tratamento cirúrgico mostraram evolução mais favorável. Os homens apresentaram melhor qualidade de vida no início e se beneficiaram progressivamente após seis e doze meses dos tratamentos realizados, enquanto nas mulheres a melhora ocorreu aos seis meses, reduzindo-se aos doze. / OBJECTIVE: To analyse the quality of life of people with coronary artery disease (CAD) who underwent distinct therapeutic interventions and to compare the possible differences between genders. METHOD: This study comprised 542 subjects, 376 men (58,5 years) and 166 women (61,8 years)with CAD, who underwent surgical, medical treatment or angioplasty. Quality of life was assessed with The Medical Outcomes Study 36-item short-form health survey (SF-36) that was administered at the beginning of the treatment, after 6 and 12 months; the applied statistical method was the ANOVA test. RESULTS: Those who underwent surgical treatment had scores of 46, 63 and 68, for SF-36 physical components; 52, 65 and 62 for medical treatment and 57,66 and 70 for angioplasty, respectively,in the inicial, 6 and 12 months phases. For mental components, results were 58, 71 and 74 for the surgical intervention; 61, 69 and 69 for the medical treatment and 64, 74 and 74 for angioplasty. The differences among treatments and repeted measures reached statistical significance (p<0,01). When comparing genders, physical components scores in men were 56*, 69 and 77* and 41*, 64 and 62* in women, respectively; mental components scores in men were 61*, 73 and 80* and 51*, 68 and 62* in women (*p<0,0001). CONCLUSIONS: Those subjetcts who underwent surgical treatment had the most favorable evolution. Men had better quality of life in the beginning of the treatment compared with that in women, with a progressive improvement after 6 and 12 months, while women, after an improvement at 6 months, present a decrease at 12 months.