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

Background: Early post-percutaneous coronary intervention chest pain (EPPCP) appears to be a common clinical phenomenon. EPPCP has not been fully explained or studied in the literature despite the abundance of clinical trials on percutaneous coronary intervention (PCI). The objective of this questionnaire-based survey is to assess the current perception of EPPCP among practicing interventional cardiologists nationwide. Methods: A survey questionnaire was designed utilizing the Survey Monkey tool to address the perceptions and current practices regarding key aspects of EPPCP among interventional cardiologists. The survey was sent to the interventional cardiologists via email. Results: The survey questionnaire regarding EPPCP was provided to 2615 practicing interventional cardiologists and resulted in 623 total survey responses, with 503 of those respondents completing all eight survey questions. A total of 50.2% of the interventional cardiologists perceive that the incidence of EPPCP is 5–10%, and 57.5% consider that repeat angiography or PCI is rarely needed (1 in 1000 cases). A total of 47.1% of the participants think that EPPCP is due to transient microvascular dysfunction, while 39% perceive it as a different entity requiring a different approach. When asked about developing a standardized labeling for the phenomenon of EPPCP, 34.8% of responders indicated that they believe EPPCP should be labeled as a benign form of chest pain/angina, and 28% preferred to describe EPPCP in non-standardized terms. Among interventional cardiologists, 80% thought that the treatment of this entity is a combination of reassurance and vasodilators and, without ischemic ECG changes, medical management is appropriate. Conclusion: A total of 72% of interventional cardiologists in our survey preferred to label EPPCP as standard nomenclature to facilitate communication between healthcare providers, patients and families in a consistent way. There is a diversity of opinion regarding EPPCP, no standard nomenclature, and no guideline to standardize practice. Further large-scale prospective studies are needed to better understand the pathophysiological mechanisms, optimal management strategies, prognostic implications, and clinical reporting of EPPCP.

Estudo descritivo, desenvolvido por método de estudo de caso, de múltiplos casos, enfocando o fenômeno da ansiedade. Objetivos: identificar a presença e quantificar o nível de ansiedade em cardíacos isquêmicos antes e após, dez minutos, das orientações ao procedimento de angioplastia coronariana transluminal percutânea (ACTP); mensurar o nível de ansiedade desses clientes, dez minutos antes do indivíduo entrar em sala de procedimentos para sua realização, e identificar a presença de sintomas de ansiedade. Aprovado pelo Comitê de Ética em Pesquisa, com coleta de dados realizada por demanda espontânea conforme conveniência do pesquisador. A amostra compôs-se de vinte sujeitos cardíacos isquêmicos, adultos, encaminhados via Sistema Único de Saúde ao primeiro procedimento de ACTP. Composto por observação participativa e três momentos de mensuração da pressão arterial, freqüência cardíaca e respiratória e aplicação do Inventário de Ansiedade Traço–Estado de Spielberger (IDATE) para Estado, no primeiro momento também foi aplicado o IDATE–Traço. Para obtenção dos resultados aplicou-se métodos de análise estatística simples. Os resultados encontrados foram que a pressão arterial sistólica se manteve acima dos valores limites, segundo a Sociedade Brasileira de Cardiologia, nas três etapas em mais de 60% dos casos, sendo realizado o tratamento anti-hipertensivo; os padrões observados para freqüência cardíaca se mantiveram na faixa de normalidade para 85% dos casos, porém, em 70% dos casos faziam-se uso associado de betabloqueadores; a freqüência respiratória mostrou-se ascendente durante o evoluir das etapas, com taquipnéia em 50% dos casos no segundo momento e em 70% no terceiro momento. Os valores, segundo categorização do IDATE, tiveram as médias do estado de ansiedade em faixa moderada nos três momentos, sendo que entre o segundo e terceiro momentos houve variação de, mais ou menos, seis pontos, levando alguns clientes ao nível elevado. Para ansiedade traço a faixa também foi moderada. As orientações de enfermagem realizadas por cinco profissionais diferentes produziu, em 60% dos clientes, aumento da pontuação do IDATE, sendo percebido e relatado por alguns como aumento do nervosismo após as orientações. O conteúdo das observações demonstra que comportamentos característicos à ansiedade foram mantidos em todos os clientes, tendo maior número e variedade sem relação ao tempo de espera. Conclui-se que a ansiedade, provocada pela ACTP, já vem alterada (moderada), mantendo-se ou agravando-se ao longo da espera, e as orientações de enfermagem não produzem a redução da ansiedade, em alguns casos a eleva mais. Mesmo utilizando medicações anti-hipertensivas, os clientes desenvolvem hipertensão leve a severa, acompanhada por elevação da freqüência respiratória e manutenção da freqüência cardíaca na normalidade nos três momentos. O ambiente ao qual o indivíduo é exposto contribui para desencadear ansiedade, agravando-a também. Considera-se a amostra do estudo pequena, permitindo apenas a generalização naturalística. Expôs-se a realidade vivida pelo cardíaco, suscitando novos questionamentos e demonstrando a necessidade de intervenções ambientais locais. Espera-se com este trabalho o desencadear de outros estudos com populações maiores, aprofundando-se na compreensão da ansiedade. / This descriptive study was developed by mens of the case study method, of various cases, focusing the anxiety phenomena. Goals: identify the presence and qualify the level of anxiety in ischemic cardiac patients before and after (ten minutes) giving out instructions about the procedure of the percutaneous transluminal corornary angioplasty (PTCA); measure the level of anxiety of these clients ten minutes before they entered in the procedure room for itscompletion. The Research EthicsCommittee approved this study, and data collection was performed through spontaneous demand according to researcher’s convenience. The sample: considered of twenty ischemic cardiac patients, all adults, which had been forwarded by the Single Health Sistem for the first PTCA proceduce. The study was compound which a structured partivipative observation and three moments for measuring arterial pressure, cardiac and respiratory frequency, and the application of Spielberger’s (STAXI) State-Trait Anxiety Inventory. In the first moment there was also the application of the STAXI-Trait. Methods of simple statistical analisys were used to obtain the results. Results: showed that the sytolic arterial pressure was maintained above limit values, according to the Cardiology Brazilian Society, in all threee moments for more than 60% of the cases, anti-hypertensive treatment was performed; the observed satandarts for cardiac frequency were kept within the normality rank for 85% of the cases, however, 70% of the individuals form the sample made use of beta-blockers; the respiratory frequency showed to rise during the evolutionof the moments. With increased respitation rate in 50% of the cases in the second moment and 70% in the third. The values, according to the score and categorization of STAXI, had the measures of state of anxiety in a moderate rank in the three moments, being that there was a variation between the sencond and third moments of up to approximately six points, whichled some clientsto wrong level. For trait anxiety, the rank was also moderate. The nursing instructions were performed by five different professionals and produced an increase of STAXI pontuaction in 60% of the clients. This was obseved and reported by someas an increase of nervousness after the instruction. The content of the observations shows that the characteristic behaviors related to anxiety were maintained in all clients, with a higher number and variety disproportional to the waiting time. The study allows us to conclude that the anxiety caused by PTCA is already altered (moderate), and is kept at this level or worsens during the waiting period, and the nursisng instructions do not make this anxiety decrease, and, in some cases, it even increase. Despite using anti-hypetensive medication, the clientdevelop slight to severe hypertension accompained by an elevation of respiratory frequency and maintenance of cardiac frequency at normal rates from the first to the third moment. The environment to which the individual is exposed contributes to the manifestation of anxiety, worsening it was well. The study’s sample is considerate to be small, allowing only the naturalistic generalization. The realy experienced by cardiac patient has been exposed, raising new questionings and showing the need for local environmental interventions. It is hoped to, throught this study, incite new studieswith larger populations, increasing the comprehension of anxiety.

Coronary artery disease is a leading cause of morbidity and mortality in developed countries. Percutaneous transluminal coronary angioplasty (PTCA) is an important treatment option when intervention is required; namely for patients with relatively severe occlusions. However, adverse events including recurrence of angina pectoris and restenosis of the treated artery limit patient prognosis, with subsequent re-vascularisation often necessary. Platelet activation accompanies PTCA, with platelet adhesion and aggregation involved in thrombus formation during restenosis. During platelet activation, highly coagulant platelet-derived microparticles (PMPs) are formed, and it is likely that these PMPs will also be produced during PTCA. While platelet aggregation inhibitors used during PTCA limit platelet aggregation and decrease the incidence of restenosis, they do not prevent PMPs being formed. PMPs are capable of adhesion and aggregation, and adhere to PTCA treated arteries in an animal model. Therefore, in order to understand the phenomenon of restenosis and its improved limitation, it is necessary to investigate PMP formation during PTCA. The field of PMP study is in its infancy, with conflicting results from the substantial inequities in methods of PMP measurement, which may be exacerbated by PMP heterogeneity. The current literature on this topic is reviewed in Chapter 2, where the PMP surface and possible functions are considered, and the PMP size and morphology examined. To conclude, the relationship between PMPs and PTCA is explored, with a focus on the potential role of PMPs in restenosis. The knowledge deficiencies in this field are highlighted at the conclusion of this chapter. Very little is known regarding the production of PMPs with PTCA. The level of PMPs during PTCA was monitored in paired arterial blood samples obtained from seventy-five patients undergoing the procedure (Chapter 3). A significant increase in PMPs from baseline to completion of PTCA was clearly demonstrated for the first time. This indicated that procoagulant PMPs are produced during PTCA and may contribute to subsequent restenosis. Furthermore, administration of the platelet aggregation inhibitor abciximab to a group of thirty-eight high risk patients limited PMP formation; given that abciximab patients required more rigorous PTCA, the protective benefit of this medication for PMP production is underlined. Although few patients in this study experienced restenosis, it is interesting to note that of those treated with abciximab, all patients suffering subsequent restenosis were revascularised using PTCA. This demonstrates that their occlusions were comparatively mild as the need for coronary artery bypass grafting was avoided, and suggests that minimisation of PMP levels may assist in limiting the progression of severe restenosis. The increased peripheral level of PMPs predicated investigation of the coronary circulation to determine local events. Although the level of PMPs increased significantly within the coronary arteries of PTCA patients, there was no corresponding increase in the coronary sinus (Chapter 4). This important finding indicated that significant levels of PMPs remained within the coronary circulation, where their ability to adhere, aggregate and accelerate haemostasis may allow them to contribute directly to restenosis. During the time when increased levels of PMPs were being formed, there was no evidence of platelet lysis, which refuted the hypothesis that PMPs are merely membrane fragments of lysed platelets. A wide variation in reported PMP sizes has contributed to the hypothesis that PMPs are heterogeneous. As morphological information can assist in understanding physiology, the final study was designed to investigate platelet morphology from PTCA patients (Chapter 5). Most platelets were activated prior to and following PTCA, with a slight decrease in body size occurring due to PTCA, presumably due to loss of cytoplasm in PMPs being shed as reported in the previous chapter. Importantly, platelet distal pseudopod buds were observed, and these did not alter significantly with PTCA. These buds were probably unformed PMPs, although the exact mechanism of PMP formation remains undetermined. The platelet pseudopods were longer and significantly thinner distally with PTCA, which may be due to movement of cytoplasm into these terminal swellings. In addition, buds or swellings directly on the platelet body were smaller following PTCA, and it is likely these may also be PMPs prior to detachment from the parent platelet. This work has contributed substantially to knowledge of PMPs produced during PTCA. The level of PMPs increased significantly in peripheral arterial samples, with the platelet aggregation inhibitor abciximab preventing this occurrence. This may indicate that functional aggregation receptors are an essential requirement for PMP formation under these conditions. However, it is possible for PMPs to be formed when aggregation is inhibited, and therefore the molecular mechanisms of PMP formation remain unconfirmed. The examination of PMPs from the coronary circulation provided valuable data indicating that PMPs are produced during PTCA but remain within the coronary circulation. As PMPs are capable of adhesion and aggregation, this strongly suggests that PMPs within the coronary circulation would contribute directly to pathogenesis of restenosis, although further investigation on PMPs with PTCA is necessary to confirm this association. The examination of platelet morphology during PTCA indicated that platelets possessed terminal pseudopod swellings, and cell surface swellings. Importantly, the terminal swellings, which are likely to be unformed PMPs, were observed for the first time during PTCA.

Os resultados tardios com os stents farmacológicos são melhores do que com stents convencionais, principalmente no que se refere à reestenose. Entretanto, no mundo real, os stents farmacológicos são implantados em pacientes de maior complexidade, o que teoricamente já diminui a diferença dos resultados. Comparar resultados da utilização de stents com paclitaxel (Grupo I) em pacientes complexos com stents convencionais (Grupo II) implantados em pacientes menos graves. A partir dos resultados realizar análise para estimar a razão de custo-efetividade nos dois grupos. Foram analisados 220 pacientes prospectivamente durante aproximadamente dois anos (média de 17 meses): 111 do Grupo 1 (GI) e 109 do Grupo II (GII). Foram avaliadas a sobrevida e a sobrevida livre de eventos através do método de Kaplan-Meier. Usando-se os critérios da Organização Mundial de Saúde, calculou-se a razão custo-efetividade incremental (RCEI) para cada reestenose evitada. O escore de propensão foi usado para reduzir diferenças entre os dois grupos. Foi observado predomínio do sexo masculino nos dois grupos (n=174 66,8%), mas sem diferenças entre eles. Também não houve diferenças em relação à idade, que variou de 42 anos a 91 anos (65,9 anos). As diferenças que ocorreram, com maior incidência no GI foram: diabetes: GI=60 (50,4%) e GII=19 (17,4%), p=0,0001; história familiar para doença arterial coronariana (DAC): GI=43 (38,7%) e GII=24 (22,1%), p=0,007; infarto prévio: GI=54 (48,6%) e GII=31 (28,4%), p=0,002; cirurgia de revascularização prévia: GI=24 (21,7%) e GII=6 (5,5%), p=0,0005; angioplastia prévia: GI=28 (25,2%) e GII=17 (15,5%), p=0,077; síndromes coronarianas agudas: GI=48 (43,3%) e GII=35 (32,0%), p=0,088. Os pacientes triarteriais foram mais presentes no GI=21 (18,9%) do que no GII=11 (10,1%), p=0,029. No entanto, os pacientes do GII apresentaram mais frequentemente função normal do VE: GI=51 (45,9%) e GII=85 (77,9%), p=0,0001. Não houve diferença no número de lesões tratadas e entre o número de artérias por paciente, entre os dois grupos. O grupo dos stents convencionais abordou lesões mais simples: Tipo A GI=43 (25,6%); GII=65 (45,5%), p=0,0002; Tipo B: B1 GI=50 (29,7%) e GII=35 (24,5%), p=0,30; e B2 GI=51 (30,4%) GII=26 (18,1%), p=0,53; e Tipo C: GI=24 (14,3%) e GII=17 (11,9%), p=0,53. O número de reestenoses por paciente foi menor no GI=7 (6,3%) vs GII=14 (12,8%), mas sem significância estatística (p=0,099). Entretanto, a reestenose por lesão foi menor no GI=7 (4,1%) vs GII=14 (9,8%) p=0,0489. A sobrevida geral em dois anos foi 96,2% no GI e 89,3% no GII (p=0,76) e as sobrevidas livres de eventos foram similares: eventos maiores (p=0,35) e livre de reestenose (p=0,82). O escore de propensão demonstrou que pacientes com idade >72 anos, os diabéticos, as lesões com diâmetro <3,2mm e com o comprimento >18mm foram as variáveis que melhor classificaram pacientes para receber SF. Avaliando-se todos os fatores clínicos, angiográficos e técnicos através da curva de regressão logística, o único item de destaque foi o tamanho dos stents (OR=6,75 e RR=4,37). Com valor corrigido o GII tem 4,3 vezes maior chance de reestenose do que o GI. No que se refere aos custos, a árvore de decisão foi modelada na reestenose dos dois grupos GI=6,3% vs GII=12,8% em 17 meses (média). O benefício líquido do implante do stent com paclitaxel foi 6,3% de redução de reestenose, com incremento de custo de R$9.590,00. A razão custo-efetividade incremental (RCEI) foi R$147.538,00 por reestenose evitada, cujo valor incremental encontra-se acima do limiar sugerido pela OMS. Conclusões: Os resultados foram similares no GI e GII, mesmo o GI atendendo uma população mais grave, com mais diabéticos e outras comorbidades. A reestenose por lesão foi maior no GII. O tamanho do stent foi a única variável importante para a reestenose. O implante dos stents farmacológicos, em pacientes do mundo real, revelou-se uma estratégia não custo-efetiva. / Long term outcomes for drug eluting stents are better than those for bare metal stents, especially for restenosis. However, drug eluting stents are usually implanted in more complex patients, theoretically lessening the difference in the outcomes. To compare the outcomes of paclitaxel stents (GI) in complex patients and bare metal stents (GII), in less complex patients. For some two years (mean: 17 months), 220 patients were analyzed prospectively: 111 in GI and 109 in GII. Their general survival and cardiovascular event-free survival rates were assessed through the Kaplan-Meier method. Using the criteria of the World Health Organization (WHO), the incremental cost-effectiveness ratio (ICER) was calculated for each restenosis avoided. Propensity scores was used to reduce selection bias by equating both groups based on these covariates. Men predominated in both groups (n=174 66.8%), with no differences between them, including age, ranging from 42 to 91 years (65.9 years). The main differences, with higher rates in GI, were diabetes: GI=60 (50.4%) and GII=19 (17.4%), p=0.0001; family history: GI=43 (38.7%) and GII=24 (22.1%), p=0.007; previous acute myocardial infarction: GI=54 (48.6%) and GII=31 (28.4%), p=0.002; previous coronary artery bypass graft: GI=24 (21.7%) and GII=6 (5.5%), p=0.0005; previous angioplasty: GI=28 (25.2%) and GII=17 (15.5%), p=0.077; acute coronary syndrome: GI=48 (43.3%) and GII=35 (32.0%), p=0.088. Multivessel patients were more frequent in GI=21 (18.9%) than in GII=11 (10.1%), p=0.029. However, the GII patients presented normal left ventricle functions more frequently: GI=51 (45.9%) and GII=85 (77.9%), p=0.0001. There were no differences between the groups for the number of lesions treated and number of arteries per patient. The bare metal stent group presented simpler lesions: Type A GI=43 (25.6%); GII=65 (45.5%), p=0.0002; Type B: B1 GI=50 (29.7%) and GII=35 (24.5%), p=0.30; and B2 GI=51 (30.4%) GII=26 (18.1%), p=0.53; and Type C: GI=24 (14.3%) and GII=17 (11.9%), p=0.53. The restenosis per patient was lower in GI=7 (6.3%) than in GII=14 (12.8%), but without statistical significance (p=0.099). However, restenosis by lesion was lower in GI=7 (4.1%) than in GII=14 (9.8%) p=0.0489. The general two-year survival rate was 96.2% in GI and 89.3% in GII (p=0.76) with similar event-free survival rates: major events (p=0.35) and restenosis (p=0.82). The propensity score showed that it was better to receive SF in patients: age >72, diabetics and lesions with diameter <3,2mm and length >18mm. Assessing all the clinical, angiographic and technical factors through the logistic regression curve, the only the major predictor was stent size. With the value corrected, GII has 4.3 times more chances of restenosis than GI. In terms of costs, the decision tree was modeled on the restenosis in the two groups: GI=6.3% versus GII=12.8% in 17 months (mean). The net benefit of implanting of paclitaxel stents was a 6.3% reduction in restenosis, with a cost increase of R$ 9,590.00. The incremental cost-effectiveness ratio (ICER) was R$ 147,538.00 for avoided restenosis, whose incremental value exceeds the threshold suggested by the WHO (World Health Organization). The results were similar in GI and GII, despite more diabetes and other co-morbidities in GI. Restenosis by lesion was higher in GII. The size of the stent was the only important variable for restenosis. The use of drug eluting stents in patients is not a cost-effective strategy in actual practice.

Submitted by FERNANDA CRISTINA BASQUES null (ferbasques@fmb.unesp.br) on 2017-01-07T20:11:54Z No. of bitstreams: 1 MestradoFerBasques.pdf: 2100437 bytes, checksum: ea4eef96d0c26544ece6a714e13edb07 (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2017-01-11T13:22:30Z (GMT) No. of bitstreams: 1 basques_fc_me_bot.pdf: 2100437 bytes, checksum: ea4eef96d0c26544ece6a714e13edb07 (MD5) / Made available in DSpace on 2017-01-11T13:22:30Z (GMT). No. of bitstreams: 1 basques_fc_me_bot.pdf: 2100437 bytes, checksum: ea4eef96d0c26544ece6a714e13edb07 (MD5) Previous issue date: 2016-12-07 / Introdução. O cateterismo cardíaco é um teste diagnóstico invasivo utilizado para detecção de alterações cardíacas dos pacientes com queixas cardiovasculares como anginas e infartos previamente detectados. Este ocorre por meio de um cateter arterial percutâneo, podendo ser escolhida a via radial ou femoral. Objetivo Obter por meio da revisão integrativa e validação de conteúdo, os principais cuidados para a retirada do introdutor arterial pelo enfermeiro com segurança. Metodologia. Estudo de abordagem quantitativa realizado em duas etapas: primeiro a realização de uma revisão integrativa para elaboração de dois Procedimentos Operacionais Padrão (POP’s) preliminar, utilizando as Bases de Dados BVS (Biblioteca Virtual da Saúde-BVS), Scopus, Embase, Web of Science e Pubmed e numa segunda etapa a submissão para apreciação de 8 peritos para obter um parecer sobre o conteúdo apresentado, utilizando a Técnica Delphi. E a partir destes, em posse das observações feitas pelos peritos, obter os POP’s definitivos. Resultados e Discussão. Estudos mostram que o enfermeiro tem papel fundamental na equipe multidisciplinar, garantindo a segurança na técnica de retirada do introdutor arterial com segurança garantida ao paciente. Importante, porém, protocolizar e dispor a informação para a equipe de enfermagem contribuindo para autonomia do enfermeiro e segurança do paciente. Produtos elaborados. Procedimento Operacional Padrão (POP) sobre a Retirada de Introdutor Arterial mecanicamente e manualmente pelo enfermeiro e um Ebook que ficará disponível na Biblioteca Virtual do Hospital das Clinicas de Botucatu. Conclusão. Cabe ao enfermeiro à prevenção de complicações vasculares como hematomas e sangramentos locais na retirada de introdutor arterial em via femoral, mecanicamente ou manualmente. O protocolo é um recurso técnico para o enfermeiro desenvolver sua prática com maior qualidade e segurança ao paciente. / Introduction. The cardiac catheterization is an invasive diagnostic test used for the detection of changes of cardiac patients with cardiovascular complaints as angina and heart attacks previously detected. This occurs through a percutaneous arterial catheter, can be chosen via the femoral or radial. Objective. Obtain through integrative review and validation of content, the main introducer removal care nurse blood safely. Methodology. Quantitative approach study carried out in two steps: first the realization of a integrative review for development of two standard operating procedures (POP's), using the VHL (Virtual Health Library-BVS), Scopus, Embase, Web of Science and Pubmed and in a second step the submission for consideration of 8 experts for an opinion on the content presented, using the Delphi Technique. And from these, in possession of the observations made by the experts, get the POP's definitive. Results and Discussion. Studies show that the nurse has a fundamental role in the multidisciplinary team, ensuring the technical security of withdrawal of arterial introducer with guaranteed safety to the patient. Importantly, however, Docketing and disposal information for nursing staff contributing to autonomy of nurse and patient safety. Products produced. Standard operating procedure (POP) on withdrawal of Arterial Introducer mechanically and manually by the nurse and an Ebook that will be available in the Virtual Library of the Hospital das Clinicas of Botucatu. Conclusion. It is the responsibility of the nurse to prevent vascular complications such as hematoma and bleeding sites in withdrawal of blood via femoral introducer, mechanically or manually. The Protocol is a technical resource for the nurse to develop their practice with higher quality and patient safety.

Os resultados tardios com os stents farmacológicos são melhores do que com stents convencionais, principalmente no que se refere à reestenose. Entretanto, no mundo real, os stents farmacológicos são implantados em pacientes de maior complexidade, o que teoricamente já diminui a diferença dos resultados. Comparar resultados da utilização de stents com paclitaxel (Grupo I) em pacientes complexos com stents convencionais (Grupo II) implantados em pacientes menos graves. A partir dos resultados realizar análise para estimar a razão de custo-efetividade nos dois grupos. Foram analisados 220 pacientes prospectivamente durante aproximadamente dois anos (média de 17 meses): 111 do Grupo 1 (GI) e 109 do Grupo II (GII). Foram avaliadas a sobrevida e a sobrevida livre de eventos através do método de Kaplan-Meier. Usando-se os critérios da Organização Mundial de Saúde, calculou-se a razão custo-efetividade incremental (RCEI) para cada reestenose evitada. O escore de propensão foi usado para reduzir diferenças entre os dois grupos. Foi observado predomínio do sexo masculino nos dois grupos (n=174 66,8%), mas sem diferenças entre eles. Também não houve diferenças em relação à idade, que variou de 42 anos a 91 anos (65,9 anos). As diferenças que ocorreram, com maior incidência no GI foram: diabetes: GI=60 (50,4%) e GII=19 (17,4%), p=0,0001; história familiar para doença arterial coronariana (DAC): GI=43 (38,7%) e GII=24 (22,1%), p=0,007; infarto prévio: GI=54 (48,6%) e GII=31 (28,4%), p=0,002; cirurgia de revascularização prévia: GI=24 (21,7%) e GII=6 (5,5%), p=0,0005; angioplastia prévia: GI=28 (25,2%) e GII=17 (15,5%), p=0,077; síndromes coronarianas agudas: GI=48 (43,3%) e GII=35 (32,0%), p=0,088. Os pacientes triarteriais foram mais presentes no GI=21 (18,9%) do que no GII=11 (10,1%), p=0,029. No entanto, os pacientes do GII apresentaram mais frequentemente função normal do VE: GI=51 (45,9%) e GII=85 (77,9%), p=0,0001. Não houve diferença no número de lesões tratadas e entre o número de artérias por paciente, entre os dois grupos. O grupo dos stents convencionais abordou lesões mais simples: Tipo A GI=43 (25,6%); GII=65 (45,5%), p=0,0002; Tipo B: B1 GI=50 (29,7%) e GII=35 (24,5%), p=0,30; e B2 GI=51 (30,4%) GII=26 (18,1%), p=0,53; e Tipo C: GI=24 (14,3%) e GII=17 (11,9%), p=0,53. O número de reestenoses por paciente foi menor no GI=7 (6,3%) vs GII=14 (12,8%), mas sem significância estatística (p=0,099). Entretanto, a reestenose por lesão foi menor no GI=7 (4,1%) vs GII=14 (9,8%) p=0,0489. A sobrevida geral em dois anos foi 96,2% no GI e 89,3% no GII (p=0,76) e as sobrevidas livres de eventos foram similares: eventos maiores (p=0,35) e livre de reestenose (p=0,82). O escore de propensão demonstrou que pacientes com idade >72 anos, os diabéticos, as lesões com diâmetro <3,2mm e com o comprimento >18mm foram as variáveis que melhor classificaram pacientes para receber SF. Avaliando-se todos os fatores clínicos, angiográficos e técnicos através da curva de regressão logística, o único item de destaque foi o tamanho dos stents (OR=6,75 e RR=4,37). Com valor corrigido o GII tem 4,3 vezes maior chance de reestenose do que o GI. No que se refere aos custos, a árvore de decisão foi modelada na reestenose dos dois grupos GI=6,3% vs GII=12,8% em 17 meses (média). O benefício líquido do implante do stent com paclitaxel foi 6,3% de redução de reestenose, com incremento de custo de R$9.590,00. A razão custo-efetividade incremental (RCEI) foi R$147.538,00 por reestenose evitada, cujo valor incremental encontra-se acima do limiar sugerido pela OMS. Conclusões: Os resultados foram similares no GI e GII, mesmo o GI atendendo uma população mais grave, com mais diabéticos e outras comorbidades. A reestenose por lesão foi maior no GII. O tamanho do stent foi a única variável importante para a reestenose. O implante dos stents farmacológicos, em pacientes do mundo real, revelou-se uma estratégia não custo-efetiva. / Long term outcomes for drug eluting stents are better than those for bare metal stents, especially for restenosis. However, drug eluting stents are usually implanted in more complex patients, theoretically lessening the difference in the outcomes. To compare the outcomes of paclitaxel stents (GI) in complex patients and bare metal stents (GII), in less complex patients. For some two years (mean: 17 months), 220 patients were analyzed prospectively: 111 in GI and 109 in GII. Their general survival and cardiovascular event-free survival rates were assessed through the Kaplan-Meier method. Using the criteria of the World Health Organization (WHO), the incremental cost-effectiveness ratio (ICER) was calculated for each restenosis avoided. Propensity scores was used to reduce selection bias by equating both groups based on these covariates. Men predominated in both groups (n=174 66.8%), with no differences between them, including age, ranging from 42 to 91 years (65.9 years). The main differences, with higher rates in GI, were diabetes: GI=60 (50.4%) and GII=19 (17.4%), p=0.0001; family history: GI=43 (38.7%) and GII=24 (22.1%), p=0.007; previous acute myocardial infarction: GI=54 (48.6%) and GII=31 (28.4%), p=0.002; previous coronary artery bypass graft: GI=24 (21.7%) and GII=6 (5.5%), p=0.0005; previous angioplasty: GI=28 (25.2%) and GII=17 (15.5%), p=0.077; acute coronary syndrome: GI=48 (43.3%) and GII=35 (32.0%), p=0.088. Multivessel patients were more frequent in GI=21 (18.9%) than in GII=11 (10.1%), p=0.029. However, the GII patients presented normal left ventricle functions more frequently: GI=51 (45.9%) and GII=85 (77.9%), p=0.0001. There were no differences between the groups for the number of lesions treated and number of arteries per patient. The bare metal stent group presented simpler lesions: Type A GI=43 (25.6%); GII=65 (45.5%), p=0.0002; Type B: B1 GI=50 (29.7%) and GII=35 (24.5%), p=0.30; and B2 GI=51 (30.4%) GII=26 (18.1%), p=0.53; and Type C: GI=24 (14.3%) and GII=17 (11.9%), p=0.53. The restenosis per patient was lower in GI=7 (6.3%) than in GII=14 (12.8%), but without statistical significance (p=0.099). However, restenosis by lesion was lower in GI=7 (4.1%) than in GII=14 (9.8%) p=0.0489. The general two-year survival rate was 96.2% in GI and 89.3% in GII (p=0.76) with similar event-free survival rates: major events (p=0.35) and restenosis (p=0.82). The propensity score showed that it was better to receive SF in patients: age >72, diabetics and lesions with diameter <3,2mm and length >18mm. Assessing all the clinical, angiographic and technical factors through the logistic regression curve, the only the major predictor was stent size. With the value corrected, GII has 4.3 times more chances of restenosis than GI. In terms of costs, the decision tree was modeled on the restenosis in the two groups: GI=6.3% versus GII=12.8% in 17 months (mean). The net benefit of implanting of paclitaxel stents was a 6.3% reduction in restenosis, with a cost increase of R$ 9,590.00. The incremental cost-effectiveness ratio (ICER) was R$ 147,538.00 for avoided restenosis, whose incremental value exceeds the threshold suggested by the WHO (World Health Organization). The results were similar in GI and GII, despite more diabetes and other co-morbidities in GI. Restenosis by lesion was higher in GII. The size of the stent was the only important variable for restenosis. The use of drug eluting stents in patients is not a cost-effective strategy in actual practice.