M.Cur. / Coronary stenting as a treatment method for the "in-between" patient with atherosclerosis was instituted in October 1991. It was initially used as secondary treatment to balloon angioplasty as "bail-out", when dissection or secondary closure of the coronary artery occurred. It has now become the primary method of treatment for atherosclerosis. It is apparent that there is a deficit in the information available to patients who have received a coronary stent. The objective of this study was therefore firstly to compile an information booklet for the patient who has received a coronary stent and secondly to set nursing guidelines for use on the implementation of this booklet. A literature study was undertaken on the following topics: atherosclerosis and its associated risk factors; the patient as an adult learner; coronary stents and the function of the nurse. This study showed that the literature covered the procedure of coronary stenting but not patient education. Interviews were conducted with two doctors that do coronary stenting as a method of treatment s as to determine what they see as import ant information to be given to these patients. Further interviews were conducted with patients that have received coronary stents to determine what they wanted and needed to know. From all the information gathered from the literature review and interviews, the information booklet was compiled, as well as the guidelines set for the nurse on how to implement the booklet.

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13435号 / 論医博第2234号 / 新制||医||1054(附属図書館) / (主査)教授 石見 拓, 教授 佐藤 俊哉, 教授 湊谷 謙司 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Les traitements antiplaquettaires représentent la pierre angulaire du traitement des patients admis pour syndrome coronaire aigu et/ou bénéficiant d’une angioplastie coronaire. L’association d’une bithérapie antiplaquettaire par aspirine et clopidogrel représente aujourd’hui le gold standard dans la prise en charge de ces patients. Malgré l’efficacité de ces molécules, les récidives d’événements ischémiques restent fréquentes, de l’ordre de 10% dans l’année suivant l’épisode clinique, et le concept de mauvaise réponse biologique au clopidogrel a été proposé comme une des hypothèses à ces récidives. En effet, de nombreuses études biologiques ont fait état d’une large variabilité interindividuelle de réponse biologique au clopidogrel, avec environ 20 à 30% des patients présentant un niveau d’inhibition plaquettaire sous traitement insuffisant. Dans ces travaux, cette réponse biologique a été évaluée par différents tests plaquettaires, les plus utilisés étant les tests de laboratoires (test d’agrégation et test VASP) et le test ‘minute’ Verify Now. Les mécanismes expliquant cette variabilité de réponse restent imparfaitement connus, mais des facteurs ont pu être clairement identifiés : polymorphismes génétiques, interactions médicamenteuses et facteurs cliniques comme le poids ou le diabète. Plus récemment, cette entité biologique a pu être reliée au pronostic clinique de nos patients avec un pronostic ischémique péjoratif chez les patients identifiés biologiquement comme mauvais répondeurs, et à l’inverse, un risque de complications hémorragiques accru chez les patients présentant la plus forte inhibition plaquettaire sous traitement. Devant ces constations, des solutions ont été proposées pour lutter contre cette mauvaise réponse comme une augmentation des doses de clopidogrel ou l’utilisation d’inhibiteurs de la glycoprotéine IIbIIIa. Ces stratégies ont apportés des résultats encourageants dans des études monocentriques, d’assez faibles effectifs. Toutefois, l’individualisation du traitement antiplaquettaire sur la base de ces tests n’est pas d’actualité, et devra attendre les résultats de larges essais multicentriques, actuellement en cours. Dans ce cadre, l’arrivée de nouveaux inhibiteurs de la voie de l’ADP, comme le prasugrel et le ticagrelor, pourront représenter des alternatives intéressantes chez ces patients à haut risque de récidive ischémique. / Antiplatelet therapy is the cornerstone therapy for patients admitted for acute coronary syndrome and/or undergoing percutaneous coronary intervention. Dual antiplatelet therapy with aspirin and clopidogrel is now the gold standard therapy for these patients. In spite of this effective association, recurrent events still occur and low response to clopidogrel has been proposed as one of the responsible factors. Indeed, numerous biological studies have described a broad interindividual variability of platelet response to clopidogrel, assessed with various platelet function tests such as light transmittance aggregometry, VASP phosphorylation index and the bed-side Verify Now assay. Mechanisms underlying this variability of response remain unclear and probably multifactorial, but factors have been clearly identified: genetic polymorphisms, medications interactions and clinical factors (diabetes, weight…). More recently, the clinical impact of this biological entity has been described with worse clinical outcome in patients non responder to clopidogrel, presenting a higher rate of recurrent ischemic events, including stent thrombosis. Meanwhile, a higher rate of bleeding complications have been found in patients with the highest on-treatment platelet inhibition, suggesting a ‘soft’ therapeutic window to avoid both types of recurrent events. Thus, several strategies have been proposed to overcome this poor response to the drug such as higher clopidogrel doses or additional GPIIbIIIa inhibitors in non responders. However, benefit of tailored therapy has been yet established in properly sized, prospective, randomized trial, which are currently ongoing. New comers in the class of P2Y12 inhibitors, prasugrel and ticagrelor, might represent a good alternative for these high-risk patients.

Background: Cerebral complications of coronary catheterizations are transient ischemic attack (TIA) and stroke. Silent stroke (SCI) does not cause acute neurological dysfunction. It might cause many disorders including dementia. Sonolysis is therapeutic method. Sonolysis should be the method for reducing the risk of symptomatic and asymptomatic brain ischemic lesions in patients undergoing elective coronary angioplasty or stenting. Aims: To analyse patients with cardiac disease indicated for elective coronary catheterization: 1) Assess the incidence of acute/subacute SCI on brain magnetic resonance (MR) imaging; 2) Investigate factors influencing the frequency and type of microembolic signals (MES) detected using transcranial Doppler (TCD) in patients undergoing elective coronary intervention, and to correlate the frequency and type of MES with detection of new brain ischemic lesions using MR. Examine changes in cognitive function at 30 days post procedure in relation to pretreatment scores; 3) Test the clinical efficacy and safety of perioperative sonolysis in patients undergoing elective coronary catheterization. Methods: 1) 144 patients were enrolled to the study. Brain MR was performed before cardiac intervention. The presence of acute and subacute SCI was evaluated, SCI volume was measured and risk...