Personcentrerad vård är en av sjuksköterskans kärnkompetenser. Att lindra lidande och att främja hälsa som är ett föränderligt mångdimensionellt fenomen ingår i sjuksköterskans ansvarsområden. Hjärtinfarkt kräver akut behandling och kan påverka vardagliga livet såväl som sex- och samlivet. Det sekundärpreventiva arbetet innefattar bland annat att stödja patient och närstående. Sjuksköterskor har svårigheter att diskutera sexuell hälsa och deras kunskap om hjärtinfarktens inverkan på sexuell hälsa är bristfällig. Syftet var att beskriva upplevelser av sexuell hälsa hos personer som har insjuknat i hjärtinfarkt. Metoden var en litteraturöversikt som utfördes med en systematisk sökstrategi. En integrerad analys av 16 vetenskapliga artiklar genomfördes i syfte att identifiera likheter och skillnader i artiklarnas resultat, vidare för att finna underkategorier och kategorier för att slutligen sammanställa till ett syntetiserat resultat. I resultatet identifierades fyra kategorier; Upplevelser av sexuell funktion, Upplevelser av att samtala om sexuell hälsa, Upplevelser av information från sjukvårdspersonal och Upplevelser av nära relationer. Det framkom minskad lust och lubrikation, svårigheter att få orgasm samt erektil dysfunktion. Det framkom även oro och rädsla för att återuppta sexuella aktiviteter, vilket kunde leda till förändrade sexuella aktiviteter. Det fanns också svårigheter att samtala om sexuell hälsa med sin partner, närstående och sjukvårdspersonal. Informationen framkom som bristfällig och det fanns ökat behov av information om sexuell hälsa. Det framkom också att sexuella relationer förändrades och det fanns ett ökat behov av intimitet med icke sexuella relationer. Även den kroppsliga uppfattningen förändrades och hjärtinfarkten upplevdes påverka existensen. Slutsatsen är att den sexuella hälsan kan påverkas hos personer som har insjuknat i hjärtinfarkt. Med ett personcentrerat förhållningssätt kan sjuksköterskan inom hjärtsjukvård utgå från patientberättelsen och tillsammans med patienten identifiera omvårdnadsbehov samt vidta omvårdnadsåtgärder. / Person-centered care is one of the nurse’s core competencies. Alleviate suffering and promote health, which is a changeable multidimensional phenomenon, are included in the nurse’s responsibilities. Myocardial infarction requires acute treatment and it can affect daily life, as well as the sexual life. Secondary prevention includes supporting the patient and relatives. Nurses have difficulties discussing sexual health and their knowledge about the impact of myocardial infarction on sexual health is insufficient. The aim was to describe experiences of sexual health in people who have had myocardial infarction. The applied method was a literature review which was carried out with a systematic search strategy. An integrated analysis of 16 research articles was conducted in order to identify similarities and differences in the results of the articles, further to find subcategories and categories to finally compile into a synthesized result. Four categories were identified in the result; Experiences of sexual function, Experiences of discussing sexual health, Experiences of information from health care professionals and Experiences of close relationships. It emerged a decreased desire and lubrication, difficulties to have an orgasm and erectile dysfunction. There were also an anxiety and fear of resuming sexual activities, which could lead to altered sexual activities. Difficulties in discussing sexual health with a partner, relatives and health care professionals were also described. Lack of sexual counselling was found with an increased need of information of sexual health following myocardial infarction. It also emerged that sexual relationships were altered and an increased need for intimacy with non-sexual relationships was described. Also the body image altered and myocardial infarction affected the existence. The conclusion is that sexual health can be affected in people who have had myocardial infarction. With a person-centered approach and the patient narrative, the nurse in cardiac care can together with the patient identify nursing needs and take nursing interventions.

Chest pain is one of the most common complaints amongst patients seeking urgent medical care at hospitals. Chest pain can be a symptom of serious cardiovascular disease such as acute coronary syndrome (ACS), however, most underlying causes are benign. Risk stratification in early stages of medical evaluation is difficult. As a consequence, many patients with chest pains are unnecessarily admitted to hospitals. There is precedent for using machine learning (ML) to aid in predicting cardiovascular disease. In this thesis, our goal is to investigate the feasibility of using ML as a complement to safely discharge patients. We use data collected by the ‘Clinical Expert Operating System - Chest Pain Danderyd Study’ (CLEOS-CPDS). Several models are developed to predict the risk of ACS following chest pains and for identifying important factors. Our best performing model on the highest risk class uses the random forest algorithm. The model has a recall score of 0.58 on the highest risk class using a subset of the medical history background. It admits 10 out of 12 patients who ultimately suffers from ACS, however, only 7 out of 12 are classified as high risk. Identified important features are mostly known risk factors, some of which are used in current risk calculations. However, less known factors such as chest pain radiation and associated symptoms, are also identified as important. The conclusion is that it is feasible to use a machine learning model to aid in risk stratification of ACS in early stages of evaluation, but that the current model needs improvement. In future work, a larger and more complete dataset with a longer follow-up period of patients may be highly beneficial to improve the model performance and verify the conclusions of this thesis. / En av de vanligaste orsakerna till att patienter söker akut sjukvård är bröstsmärta. Bröstsmärta kan vara ett symptom på livshotande sjukdom såsom akuta koronara syndrom (AKS), vilket innefattar hjärtinfarkt. Men i de allra flesta fall brukar orsakerna vara ofarliga. Det är svårt att bedöma bröstsmärtor i ett tidig skede och som en konsekvens utreds många patienter kanske i onödan, för att inte missa AKS. Vårt mål med den här rapporten är att utreda möjligheten att använda maskininlärning som stöd i riskbedömningen. Vi försöker identifiera viktiga faktorer i ett tidigt skede som kan hjälpa läkare att på ett säkert sätt utesluta allvarlig sjukdom. Detta görs genom att vi utvecklar flera maskininlärningsmodeller och jämför dessa mot varandra. Vi använder oss av data insamlad genom den pågående studien ‘Clinical Expert Operating System - Chest Pain Danderyd Study‘ (CLEOS-CPDS). Modellen bäst på att förutspå hög risk väljs sedan ut och analyseras närmare. Resultatet är en ‘Random Forest‘ modell. Modellen klassificerar åtminstone inläggning i 10 av 12 allvarliga fall, varav 7 av 12 fall klassificeras helt korrekt. Flera välkända riskfaktorer identifieras som viktiga, varav en del, men inte alla, redan ingår i nuvarande riskkalkyler. Vår slutsats är att det finns goda chanser att använda maskininlärning som ett komplement i sjukvården för att kunna utesluta allvarlig sjukdom, men att den nuvarande modellen behöver förbättras. För att säkerställa resultaten från denna rapport och förbättra modellen kan framtida undersökningar med fördel genomföras på mer data i fullständigare skick, samt med längre uppföljningstid på patienterna.

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Il y a plus de 40 ans, la cardiologie interventionnelle a vu le jour et n’a cessé de révolutionner la prise en charge de l’athérosclérose coronarienne. Les endoprothèses vasculaires biorésorbables (BVS) avaient été conçues pour pallier les risques liés à la présence permanente de tuteurs métalliques dans les artères. En principe, ils fournissent de manière transitoire un soutien mécanique pour le scellement des dissections et la prévention du vasospasme et du remodelage constrictif en plus d’une élution médicamenteuse avant de se résorber et restaurer la vasomotricité coronarienne. L’enthousiasme autour des endoprothèses biorésorbables ABSORB™ était mitigé par un risque soutenu de thrombose du tuteur. Ce mémoire traitera en premier lieu des bases moléculaires de l’athérosclérose. Il abordera ensuite la prise en charge de la coronaropathie athérosclérotique ainsi que l’histoire de la cardiologie interventionnelle et ses différentes révolutions. Ensuite, deux études cliniques ont été conduites dans le cadre de ce travail et seront présentées. La première étude évalue le rôle du BVS dans la revascularisation de la coronaropathie extensive (multivaisseaux ou diffuse) et a montré que, dans un contexte aussi peu favorable au déploiement d’un tuteur coronarien, ABSORB™ a présenté des résultats cliniques acceptables à très long terme comparativement aux tuteurs métalliques de deuxième génération. La deuxième étude s’intéresse quant à elle aux caractéristiques angiographiques de resténose des BVS. Elle a démontré qu’à long terme, la resténose des BVS devient de plus en plus diffuse, et était associée à des issues cliniques moins favorables. Le dernier chapitre de ce mémoire se constitue d’une ouverture conclusive présentant les différentes endoprothèses biorésorbables actuellement à l’étude ou en cours de développement en soulignant leurs principales différences avec ABSORB™. / More than 40 years ago, interventional cardiology was born and has continued to revolutionize the management of coronary atherosclerosis. Bioresorbable Vascular Scaffolds (BVS) were designed to alleviate the risks associated with the permanent presence of metal stents in the arteries. In theory, they provide a transient mechanical support for sealing dissections and preventing vasospasm and constrictive remodeling in addition to a drug-eluting function before complete bioresorption and restoration of coronary vasomotion. Enthusiasm around the ABSORB™ bioresorbable scaffold was mitigated by a sustained risk of scaffold thrombosis. This thesis will first review the molecular basis of atherosclerosis. It will then discuss the management of atherosclerotic coronary artery disease, the history of interventional cardiology and its multiple revolutions. Then, two clinical studies that were conducted as part of this work will be presented. The first study that evaluates the role of BVS in the revascularization of extensive coronary artery disease (multivessel or diffuse) showed that, in such an unfavorable context for the deployment of a coronary stent, ABSORB™ has shown acceptable clinical results in the very long term compared to second generation drug-eluting stents. The second study focuses on the angiographic patterns of BVS restenosis. It showed that in the long term, the pattern of restenosis tended to be more diffuse than focal and that restenosis was associated with less favorable clinical outcomes. The final chapter of this thesis presents the different bioresorbable scaffolds currently under study or under development while highlighting their main differences with ABSORB™.

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.

Les plaquettes sanguines sont les principaux acteurs de l’hémostase primaire et de la thrombose, deux éléments majeurs de la physiopathologie vasculaire. Plusieurs médicaments régulent les fonctions plaquettaires mais peu de tests sont validés pour suivre leur efficacité en fonction de l’évolution clinique des patients. Mon doctorat a eu pour but de développer de nouvelles approches d’évaluation de la fonction plaquettaire. Deux essais cliniques réalisés sur des patients atteints de syndrome coronarien stable ont constitué la première partie de mon doctorat. La première étude met en évidence la nécessité d'une standardisation des tests biologiques pour la détection de patients répondant moins au clopidogrel, un inhibiteur du récepteur plaquettaire de l'ADP P2Y12. L’étude suivante montre le potentiel thérapeutique, chez ces patients, de l’inhibition conjointe de P2Y12 et du second récepteur plaquettaire de l'ADP P2Y1, sur la fonction plaquettaire. De plus, le suivi en temps réel par vidéomiscroscopie a permis de distinguer des effets précoces et tardifs des antiplaquettaires sur la formation du thrombus en chambre de perfusion. La seconde partie de mon doctorat concerne les microdomaines membranaires de type « lipid rafts » qui tiennent une place fondamentale dans les fonctions cellulaires et plaquettaires. Ainsi plusieurs récepteurs dépendent de ces microdomaines, régulant la fonction plaquettaire et les effets des médicaments antiplaquettaires. Cependant, les techniques d’étude de ces microdomaines sont complexes et peu adaptées aux études cliniques. Profitant de nouvelles sondes fluorescentes sensibles au niveau d’ordre liquide membranaire (OLM), nous avons développé une méthode de mesure de l’OLM par cytométrie de flux spectrale. Grâce à cette approche, nous avons montré que l’activation plaquettaire diminue l’OLM alors qu’il est augmenté chez des patients traités par un inhibiteur de la synthèse du cholestérol ou par le clopidogrel. Nous avons également mis en évidence, en condition de forces de cisaillement élevées correspondant à celles retrouvées au niveau de sténoses artérielles, une sous-population plaquettaire présentant un OLM plus bas. Le passage dans le domaine clinique de ces approches fondamentales qui privilégient l’étude dynamique des plaquettes pourrait permettre d’améliorer le diagnostique et le suivi de traitement de pathologies cardiovasculaires. / Blood platelets play a central role in primary hemostasis and thrombosis, two major elements of vascular physiopathology. Although a number of drugs regulate platelet functions, there are no validated tests that monitor their efficacy on the basis of the patients' clinical course. This doctorate, therefore, aims to develop novel approaches to evaluate platelet function. The first part of my work consisted of two clinical trials involving patients with stable coronary syndrome. The first study demonstrated the need for standardized biological tests to screen for patients who respond less well to clopidogrel, an ADP P2Y12 receptor antagonist. The second study showed the therapeutic potential of the joint inhibition of P2Y12 and P2Y1 receptors on platelet adhesion, activation, and aggregation for these patients. Furthermore, a video microscopy model using perfusion chambers made it possible to monitor the course of thrombosis in real time, and enabled us to dissociate the early and late effects of the antiplatelet drugs. Lipid raft membrane microdomains play a pivotal role in many cell functions. At the platelet level, many receptors depend on these microdomains and thus modulate the function as well as the drug sensitivity of platelets. However, current techniques for the study of these microdomains are complex and limit their clinical applications. By taking advantage of new fluorescent probes that are sensitive to the level of the membrane order, we developed a method of measuring the membrane order using spectral flow cytometry. Through this approach we showed that platelet activation reduced the lipid order of the membranes, whereas it was increased in patients treated with a cholesterol synthesis inhibitor or clopidogrel. It was also possible for us to demonstrate the appearance, under shear stress similar to that of stenotic arteries, of a platelet sub-population with a very low membrane order. These approaches which privilege the dynamic study of thrombi and platelets could be applied to the clinical practice and thus widen the fields of clinical studies.

<p>Uvod: U savremenom svetu koronarna arterijska bolest srca (KABS) je vodeći uzrok obolevanja i umiranja, a akutni koronarni sindrom (AKS) je jedna od njenih najče&scaron;ćih i najopasnijih kliničkih manifestacija. Dijastolna disfunckija leve komore često prati KABS i mogući je doprinosni faktor za lo&scaron; klinički tok i ishod. Postavlja se pitanje u kom obimu je dijastolna disfunkcija leve komore udružena sa koronarnom arterijskom bole&scaron;ću i da li savremeni programi ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR) imaju uticaja na bolju prognozu ove grupe kardiolo&scaron;kih bolesnika. Uprkos &scaron;irokoj primeni revaskularizacionih procedura u svakodnevnoj kardiolo&scaron;koj praksi i brojnih studija koje su ukazale na pozitivne efekte programa SKR na funkcionalni status pacijenata nakon AKS, jo&scaron; uvek postoji mnogo kontroverzi o efektima fizičkog treninga, na srčanu funkciju i pobolj&scaron;anje funkcionalnog kapaciteta kod pacijenata sa KABS i pridruženom dijastolnom disfunkcijom. Cilj istraživanja: bio je da ispita uticaj superviziranih vežbi fizičkim opterećenjem (VFO) u okviru programa ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR), na dijastolnu disfunkciju leve komore (DDLK) i funkcionalni status pacijenata (FS), nakon AKS, re&scaron;enog perkutanom koronarnom intervencijom (PCI), kao i da li, s druge strane, prisustvo i stepen dijastolne disfunkcije na početku istraživanja, utiče na funkcionalni status i pojavu neželjenih kardijalnih događaja, kod ove grupe pacijenata u okviru programa ASKR i van njega&nbsp; Materijal i metode: Istraživanjem je bilo obuhvaćeno ukupno 85 ispitanika, oba pola, starosti od 18-65 godina, koji su tokom indeksne hospitalizacije lečeni kao klinički dokazani AKS (APNS; NSTEMI; STEMI) i kod kojih je urađena neka od interventnih koronarnih procedura (pPCI; PCI; PTCA). Nakon 4 nedelje od otpusta sa hospitalizacije, zbog NSTEMI ili APNS, odnosno nakon 6 nedelja od otpusta sa hospitalizacije zbog STEMI, pacijenti sa EFLK &ge; 45%, bez značajnih valvularnih i drugih mana i sa nekim od poremećaja dijastolne funkcije, bili su kandidati za uče&scaron;će u istraživanju. Svi ispitanici su podvrgavani &bdquo;ulaznom&ldquo;ehokardiografskom pregledu (EHO) u cilju procene sistolne funkcije i stepena dijastolne disfunkcije leve komore, kao i &bdquo;ulaznom&ldquo; spiroergometrijskom testu (CPET) u cilju procene funkcionalnog statusa, na osnovu kojeg je vr&scaron;ena preskripcija vežbi fizičkim opterećenjem (VFO) u okviru programa ASKR. Program ASKR odvijao se u ukupnom trajanju od 12 nedelja, odnosno 36 pojedinačnih sesija VFO, 3 puta nedeljno u trajanju od po 30 minuta. Kontrolna grupa obuhvatila je grupu pacijenata koja nije živela u blizini IKVBV i koja nije bila u mogućnosti da dolazi redovno na VFO u sklopu ASKR. Njima je bilo pu&scaron;teno na volju da na osnovu urađenog EHO pregleda i CPET, određuju stepen VFO po sopstvenom nahođenju, uz primenu optimalnog medikamentnog lečenja i ostalih mera sekundarne prevencije. Nakon 3 meseca obe grupe pacijenata bile su podrvrgnute novom &ndash;&ldquo;izlaznom&rdquo; ehokardiografskom i CPET pregledu u cilju komparacije sa rezultatima na početku istraživanja. Rezultati:Istraživanje je pokazalo da nakon 3 meseca superviziranog treninga VFO, u okviru programa ASKR, kod bolesnika nakon AKS, lečenih perkutanom koronarnom intervencijom, dolazi do pobolj&scaron;anja stepena dijastolne disfunkcije leve komore, naročito kroz promene vrednosti ehokardiografskih parametara e&rsquo;l i E/e&rsquo; l. U kontrolnoj grupi e&rsquo;l se smanjio za (0,003 &plusmn; 0,025), a u osnovnoj se povećao za (0,011 &plusmn; 0,021). U kontrolnoj grupi e&rsquo;l se nije značajno promenio (p = 0,515), a u osnovnoj grupi se značajno povećao (p &lt; 0,0005). Na početku istraživanja u osnovnoj grupi e&rsquo;l je bio (0,097 &plusmn; 0,027 m/sec), a na kraju (0,108 &plusmn; 0,031 m/sec). E/e&rsquo;l se nije značajno promenio u kontrolnoj grupi (p = 0,226), a u osnovnoj grupi se značajno smanjio (p = 0,002). Na početku istraživanja u osnovnoj grupi E/e&rsquo;l je bio (8,02 &plusmn; 2,98), a na kraju (6,97 &plusmn; 2,17). Takođe je utvrđeno da nakon 3 meseca superviziranog treninga u okviru programa ASKR, dolazi do pobolj&scaron;anja funkcionalnog kapaciteta pacijenata sa KABS i dijastolnom disfunkcijom leve komore, kroz povećanje CPET parametara: peak VO2, VO2 predict i METs. U kontrolnoj grupi peak VO2 se smanjio za (1,79 &plusmn; 3,84), a u osnovnoj se povećao za (1,67 &plusmn; 4,29). U kontrolnoj grupi peak VO2 se značajno smanjio (p = 0,018), a u osnovnoj grupi se značajno povećao (p = 0,005).Na početku istraživanja u kontrolnoj grupi srednja vrednost peak VO2 iznosila je (23,01 &plusmn; 3,99 ml/kgTT/min), a u osnovnoj grupi je iznosila (23,15 &plusmn; 4,99 ml/kgTT/min). Na kraju istraživanja u osnovnoj grupi srednja vrednost peak VO2 iznosila (24,82 &plusmn; 5,77 ml/kgTT/min), dok je kod kontrolne grupe iznosila (21,21 &plusmn; 4,05 ml/kgTT/min). U kontrolnoj grupi ppVO2(%) se smanjio za (5,28 &plusmn; 14,39), a u ispitivanoj se povećao za (7,16 &plusmn; 18,51). U kontrolnoj grupi ppVO2(%) se nije značajno promenio (p = 0,058), dok se u osnovnoj grupi statistički značajno povećao (p = 0,005). Razlika srednjih vrednosti promena METs između osnovne i kontrolne grupe je bila statistički značajna (p &lt; 0,0005). U kontrolnoj grupi METs se smanjio za (0,55 &plusmn; 1,12), a u osnovnoj se povećao za (0,58 &plusmn; 1,12). U kontrolnoj grupi METs se značajno smanjio (p = 0,013), a u osnovnoj grupi se značajno povećao (p &lt; 0,0005). Zaključak: Program ambulantne sveobuhvatne kardijalne rehabilitacije, kod bolesnika nakon akutnog koronarnog sindroma, lečenih perkutanom koronarnom intervencijom, utiče na pobolj&scaron;anje faktora rizika kardiovaskularnih bolesti, značajno utiče na pobolj&scaron;anje stepena dijastolne disfunkcije leve komore i na pobolj&scaron;anje funkcionalnog statusa pacijenata, u odnosu na početak istraživanja.</p> / <p><!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>mladen</o:Author> <o:Version>16.00</o:Version> </o:DocumentProperties> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings></xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> 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Introdução: O manejo inadequado dos pacientes com dor torácica sugestiva de síndrome coronariana aguda (SCA) é fator de risco para morte ou outros eventos cardíacos adversos maiores (ECAM), o que contribui para o aumento da morbidade e mortalidade, do estresse da equipe e do paciente e maiores custos com o uso de serviços de saúde. Os protocolos de dor torácica para alta precoce (protocolos de diagnósticos acelerados ADP) surgem como instrumentos de melhoria da qualidade da assistência em departamentos de emergência (DE), possibilitando alta precoce (em até 6 horas) e segura a esses pacientes. Objetivo: Sintetizar as evidências científicas sobre a efetividade de protocolos de dor torácica na alta precoce e segura de adultos com sintomas sugestivos de SCA em DE, quando comparados ao tratamento usual ou outros protocolos de dor torácica (usual ou de alta precoce). Métodos: Revisão Sistemática (RS) da literatura que seguiu as recomendações do Joanna Briggs Institute. Para a busca dos estudos foi utilizada a estratégia PICOS (P= adultos (> 18 anos) com dor torácica sugestiva de SCA; I e C= protocolos de dor torácica utilizados para alta precoce; O= alta precoce e ECAM em 30 dias; e, S= ensaios clínicos randomizados, nas bases de dados: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, além de banco de teses e dissertações de universidades dos quatro continentes. Não foi determinado limite temporal para a busca e esta foi finalizada em 31 de janeiro de 2018. A seleção inicial, avaliação inicial e qualidade metodológica dos estudos foi realizada por dois revisores independentes e as discordâncias foram resolvidas por consenso. A extração dos dados dos estudos foi feita pelo revisor primário, analisada, discutida e apresentada de forma descritiva e com metanálise. Resultados: Incluídos quatro estudos do tipo ensaio clínico randomizado controlado, sendo que os protocolos para alta precoce utilizadas e testadas nesses estudos foram: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol e 4-Hour Protocol. Porém, devido a alta hetergneidade (I=91%) apenas dois estudos foram agrupados em metanálise e os resultados foram apresentados com gráficos de floresta. Para a alta precoce a estimativa de efeito sugeriu que os benefícios da alta precoce superam os malefícios, recomendando o uso de protocolos acelerados de dor torácica na prática assistencial de departamentos de emergência. Para ECAM, a metanálise foi inconclusiva. Conclusão: Os protocolos estudados são efetivos na alta precoce, porém ainda não há evidência suficiente para afirmar que essa alta precoce seja segura. Contudo, essa RS é um primeiro passo importante para provar que sua utilização é viável e facilitará a alta precoce e segura de DE. / Introduction: Inadequate management of patients with chest pain suggestive of acute coronary syndrome (ACS) is a risk factor for death or other major adverse cardiac events (MACE), which contribute to increased morbidity and mortality, team and patient stress, and a higher expenses with health services. Early-onset chest pain protocols (accelerated diagnostic protocols - ADPs) appear as tools for improving the quality of care in emergency departments (ED), enabling early and safe discharge (up to 6 hours) for these patients. Objective: To synthesize the scientific evidences about the effectiveness of chest pain protocols in the early and safe discharge of adults with symptoms suggestive of ACS in ED, when compared to the usual treatment or other protocols of chest pain (usual or early discharge). Methods: Systematic Review (SR) of the literature that followed the recommendations of the Joanna Briggs Institute. In order to search for the studies, the PICOS strategy was used (P = adults (> 18 years) with chest pain suggestive of ACS, I and C = thoracic pain protocols used for early discharge; O = early discharge and MACE in 30 days and S = randomized clinical trials found in the following databases: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, as well as a thesis and dissertations bank from universities of the four continents. A time limit was not determined to end this research; however this was finalized on January 31, 2018. The initial selection, initial evaluation and methodological quality of the studies were performed by two independent reviewers and the disagreements were resolved by consensus. Data extraction from the studies was done by the primary reviewer, analyzed, discussed and presented in a descriptive form with meta-analysis. Results: Four randomized controlled trials were included, the earlydischarge protocols used and tested in these studies were: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol and 4-Hour Protocol. However, there is high heterogeneity between the studies (I = 91%), only two studies were grouped in meta-analysis and the results present by the funnel plot. For early discharge, the effect estimate suggested that the benefits of early discharge exceed the harm, recommending the use of accelerated chest pain protocols in emergency department assistance practice. For ECAM, the meta-analysis was inconclusive. Is not enough to affirm that early discharge is higher in the experimental groups who were discharged by the new protocol. Conclusion: The protocols studied are effective at early, however there is still insufficient evidence to affirm that this early discharge is safe. But this SR is an important first step to prove that its use is feasible and will facilitate the early and safe discharge of ED.

Introdução: Alguns autores estudaram o valor prognóstico do eletrocardiograma inicial na sobrevida em longo prazo dos pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. O valor prognóstico de outros traçados eletrocardiográficos na fase intra-hospitalar do tratamento foi menos estudado. Objetivos: Avaliar o papel no prognóstico clínico dos registros eletrocardiográficos obtidos durante o evento índice dos participantes do estudo Estratégia de Registro de Insuficiência Coronariana (ERICO) com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Métodos: Foram analisados e classificados, de acordo com o Código de Minnesota, os traçados eletrocardiográficos intra-hospitalares de 634 participantes do estudo ERICO com síndrome coronariana aguda sem supradesnivelamento do segmento ST, no período de fevereiro de 2009 a dezembro de 2013. Foram classificados como alterados os traçados eletrocardiográficos com infradesnivelamento do segmento ST > 1mm e/ou com onda T negativa > 1mm. Foram construídos modelos de regressão de Cox brutos e ajustados, para estudar se o padrão eletrocardiográfico foi um preditor independente de desfechos clínicos (morte por qualquer causa, morte por causa cardiovascular, morte por infarto agudo do miocárdio, e desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal). Resultados: A mediana de seguimento foi de 3 anos. Encontramos uma tendência não significativa para a associação entre a presença de alteração de segmento ST no eletrocardiograma inicial com o desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal [Hazard Ratio (HR) ajustado: 1,64, intervalo de confiança de 95% (IC 95%): 1,00-2,70, p = 0,052]. Encontramos um risco significativamente maior de morte por infarto do miocárdio em indivíduos com alterações do segmento ST no eletrocardiograma final (HR ajustado: 2,04; IC 95%: 1,06-3,92). Os indivíduos com alterações do segmento ST em qualquer traçado durante o evento índice apresentaram risco significativamente maior para desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal (HR ajustado: 1,71; IC 95%: 1,04-2,79). Quando as alterações de onda T foram incluídas na classificação dos traçados, não houve associação significativa com o prognóstico a longo prazo. Conclusões: Encontramos associações significativas entre as alterações de segmento ST e pior prognóstico em longo prazo. A avaliação sequencial dos traçados eletrocardiográficos durante o evento índice parece adicionar informação prognóstica ao ECG inicial / Introduction: Some authors have studied the prognostic value of initial electrocardiogram in long-term survival of patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The prognostic value of other in-hospital electrocardiographic tracings has been less studied. Objectives: To describe the association between electrocardiogram abnormalities (in ST-segment and T wave) during the index event and outcomes in patients with NSTE ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort. Methods: We analyzed and classified, according to the Minnesota Code, in-hospital ECG tracings of 634 ERICO participants with NSTE-ACS, from February 2009 to December 2013. We considered as altered electrocardiographic tracings with ST-segment depression > 1 mm and / or negative T wave > 1 mm. We built crude and adjusted Cox regression models to study if ECG pattern was an independent predictor for clinical outcomes (death from any cause, death from cardiovascular causes, death from acute myocardial infarction, and combined outcome of fatal or new nonfatal myocardial infarction). Results: Median follow-up was 3 years. We found a trend for the association between initial ECG tracing and the combined outcome of fatal or new nonfatal myocardial infarction [Hazard Ratio (HR) adjusted: 1,64, confidence interval 95% (95% CI): 1,00-2,70, p = 0,052]. We found a significantly higher risk of death due myocardial infarction in patients with ST-segment abnormalities in the final ECG tracing (adjusted HR: 2,04; 95% CI: 1,06 to 3,92). Individuals with ST-segment abnormalities in any tracing had significant higher risk for fatal or new nonfatal myocardial infarction (adjusted HR: 1,71; 95% CI: 1,04 2,79). When the T wave changes were included in the classification, there was no significant association with long-term prognosis. Conclusions: We found significant associations between ECG patterns and worse long-term prognosis. Sequential evaluation of electrocardiographic tracings during the index event seems to add prognostic information to the initial ECG