Background: Renal failure (RI) is a common and treatable disease. Its presentation is frequent in patients with coronary artery disease (CAD). Numerous studies have demonstrated significant increases in morbidity and mortality in patients with Acute Coronary Syndrome (ACS) and RI. However, the current prognostic models available for SCA use little of the study of renal function as a predictive and predictive factor. Objectives: To analyze renal function in patients with Acute Coronary Syndrome through creatinine clearance and to evaluate whether there is interference of renal dysfunction in the in-hospital evolution of patients with ACS. Methods: This is a longitudinal and prospective hospital cohort study performed at the Thoracic Pain Unit (UDT) of a private hospital considered a cardiological reference in Sergipe, Brazil. Subjects of both sexes with SCA and hospitalized for investigation and treatment were used during the period from May 2012 to December 2016. A total of 401 patients were included, analyzed for the presence or absence of renal damage, followed up until hospital discharge (or death). Results: The mean age of patients was 65.4 (± 13.0) years with male predominance (58.6%). Of the 324 (80.8%) patients with acute coronary syndrome without ST-segment elevation, 165 (41.1%) were suffering from unstable angina and 159 (39.6%), myocardial infarction without ST. Among the risk factors, hypertension was more prevalent (72.5%) followed by dyslipidemia (53.6%). Regarding the distribution of hospital days, there was a median of 6 days and a mean of 9 (± 12.8) days.The mean creatinine clearance was 80.8 (± 33.6) mL/min/1.73m², in which 241 patients presented with estimated glomerular filtration rate below 90 mL/min/1.73m² (OR= 1.74; CI 95% 1.11-2.71; p= 0.015) was a predictor for events. Conclusion: Patients with acute coronary syndrome and renal failure had a greater number of days of hospitalization when compared to patients without renal injury (IRR 0.9; CI 0.9-0.9; p=0.02). Therefore, assessment of renal function is an important tool for prognostic stratification in patients with ACS. / Fundamentos: A insuficiência renal (IR) é uma enfermidade comum e tratável. Sua apresentação é frequente em pacientes portadores de doença arterial coronariana (DAC). Inúmeros estudos têm demonstrado aumentos expressivos de morbidade e mortalidade em pacientes com Síndrome Coronariana Aguda (SCA) e IR. Contudo, os atuais modelos prognósticos disponíveis para SCA pouco se utilizam do estudo da função renal como fator preditivo e de prognósticos. Objetivos: Analisar a função renal em pacientes com Síndrome Coronariana Aguda através do clearance de creatinina e avaliar se há interferência da disfunção renal na evolução intra-hospitalar dos pacientes com SCA. Métodos: Trata-se de um estudo de coorte hospitalar, longitudinal e prospectivo, realizado na Unidade de Dor Torácica (UDT) de um hospital privado considerado referência cardiológica em Sergipe, Brasil. Foram utilizados sujeitos de ambos os sexos, com quadro de SCA e internados para investigação e tratamento durante o período de maio de 2012 a dezembro de 2016. Foram incluídos 401 pacientes, analisados pela presença ou ausência de lesão renal, acompanhados até a alta hospitalar (ou óbito). Resultados: A média de idade dos pacientes foi de 65,4 (± 13,0) anos com predominância do sexo masculino (58,6%). Dos 324 (80,8%) pacientes que apresentaram síndrome coronariana aguda sem supradesnivelamento do segmento ST, 165 (41,1%) foram acometidos por angina instável e 159 (39,6%), infarto sem supra. Dentre os fatores de risco, a hipertensão arterial sistêmica mostrou-se mais prevalente (72,5%) seguida da dislipidemia (53,6%). Quanto à distribuição dos dias de internamento, observou-se uma média de 9 (± 12,8) dias. A média do clearance de creatinina foi de 80,8 (± 33,6) mL/min/1,73m², em que 241 pacientes apresentaram taxa de filtração glomerular estimada inferior a 90 mL/min/1,73m² (OR= 1,74; IC95% 1,11-2,71; p= 0,015) foi fator preditor para eventos. Conclusão: Pacientes com síndrome coronariana aguda e insuficiência renal apresentaram maior número de dias de internação quando comparados aos pacientes sem lesão renal (IRR 0,9; IC 0,9-0,9; p=0,02). Portanto, a avaliação da função renal é uma importante ferramenta para a estratificação prognóstica em pacientes com SCA. / Aracaju, SE

Introduction: Acute Coronary Syndrome (ACS) is responsible for raising admissions numbers and hospital readings. Patients are associated with increased costs to the patient and the health system, as well as access to hospital mortality rates. Objective: To investigate rehospitalization factors in patients with ACS. Methodology: This is a retrospective study of patients of both sexes, adults and elderly, diagnosed with ACS. The records of health and health cases were evaluated in relation to cardiology, the occurrence of rehospitalization, the time between admissions and the use of medications at the time of rehospitalization, up to one year after admission for ACS. Logistic regression was used to evaluate the predictive variables of rehospitalization. Results: The occurrence of readmissions was 21.46% (n = 115) and the mean period between hospitalizations was 122.74 (SD 112.14) days. Most patients were male (64.0%), mean age was 63.15 years (SD 12.26) years, 7% had readmission and 68.7% had more than one readmission in 01 year. The cardiovascular causes, among them, the recurrence of ACS, were the most prevalent among hospital readmissions. Public utility (OR 0.46) and the diagnosis of CHF (OR 1.81) were associated with reintroduction following multiple logistic regression. Conclusion: As the rehospitalizations are therapeutic and they return to help health professionals and are associated with the recurrence of the ACS event and the type of care. / Introdução: A Síndrome Coronariana Aguda (SCA) é responsável por elevados números de admissões e readmissões hospitalares. Esses números estão associados ao aumento dos custos para o paciente e para o sistema de saúde, bem como à elevação nas taxas de mortalidade hospitalar. Objetivo: Investigar os determinantes de reinternação entre pacientes com SCA. Metodologia: Trata-se de uma coorte retrospectiva de pacientes de ambos os sexos, adultos e idosos, diagnosticados com SCA. Foram avaliados, a partir dos registros dos hospitais locais públicos e privados de referência em cardiologia, a ocorrência de reinternação, em até 01 ano após a internação por SCA, o tempo entre as admissões e uso de medicamentos no momento da reinternação. Regressão logística múltipla foi utilizada para avaliar as variáveis preditoras da reinternação. Resultados: A ocorrência de reinternações foi de 21,46% (n=115) e o período médio entre as internações foi de 122,74 (DP 112,14) dias. Os pacientes avaliados eram, em sua maioria, do sexo masculino (64,0%), com média de idade de 63,15 (DP 12,26) anos, 7% apresentaram óbito na reinternação e 68,7% apresentaram mais de uma reinternação em 01 ano. As causas cardiovasculares, entre elas a recorrência da SCA, foram as mais prevalente entre as reinternações hospitalares. A assistência pública (OR 0,46) e o diagnóstico de ICC (OR 1,81) tiveram associados às reintrenação após a regressão logística múltipla. Conclusão: As reinternações são reflexo das condições clínicas do paciente e ao acesso do paciente aos serviços de saúde e estão associadas a recorrência do evento de SCA e o tipo de assistência. / Aracaju

Contexto: a eficácia dos inibidores da 3-hidróxi-3-metilglutaril-coenzima (HMG-CoA) redutase (estatinas) na prevenção primária e secundária na doença cardiovascular é bem estabelecida na literatura. Contudo os benefícios destes fármacos na prevenção secundária de mortalidade e eventos cardiovasculares no paciente com Síndrome Coronariana Aguda (SCA), ainda não foram completamente esclarecidos. Objetivo: analisar os benefícios do uso das estatinas comparadas a placebo ou cuidados usuais nos pacientes com SCA quanto a redução de mortalidade (por todas as causas), infarto agudo do miocárdio (fatal e não-fatal), intervenção coronária percutânea, revascularização cirúrgica do miocárdio e hospitalização. Base de Dados: trata-se de uma revisão sistemática finalizada em 29 de Janeiro de 2012, cuja seleção dos ensaios clínicos controlados e randomizados (ECCR) foi realizada nas bases de dados eletrônicas PubMed/MEDLINE, EMBASE, Cochrane Central, LILACS e Banco de Teses - CAPES. Coleta de Dados: a extração das informações sobre características basais dos estudos incluídos, avaliação da qualidade metodológica e desfechos não combinados foi realizada por dois investigadores de forma independente. Resultados: foram incluídos na metanálise 18 ECCR, que envolveram 15.370 pacientes com SCA. O uso das estatinas mostrou benefício na redução da mortalidade por todas as causas, diferença de risco (rd) = -0,0066 (IC 95% -0,0121 a -0,001; P=0,8459; I2=0%) e hospitalização rd = -0,0101 (IC 95% -0,0188 a -0,0014; P=2,1496; I2=76%). Quanto aos desfechos mortalidade cardiovascular, infarto agudo do miocárdio fatal e não fatal, intervenção coronária percutânea e revascularização cirúrgica do miocárdio não houve diferença estatisticamente significante entre os grupos estatinas versus placebo ou cuidados usuais. Conclusões: as evidências disponíveis apontam que as estatinas causam redução na mortalidade por todas as causas e na hospitalização, porém não demonstram diferença quando comparadas ao placebo ou cuidados usuais em outros eventos de importante magnitude clínica e econômica no âmbito dos serviços de saúde e da sociedade. / Context: the effectiveness of inhibitors of 3-Hydroxy-3-methylglutaryl-Coenzyme (HMG-CoA) reductase (statins) in primary and secondary prevention of cardiovascular disease is well established in the literature. However, the benefits of these drugs in secondary prevention of mortality and cardiovascular events in patients with Acute Coronary Syndrome (ACS) have still not been fully clarified. Objective: to analyze the benefits of using statins compared to placebo or usual care in patients with SCA on the reduction of mortality (from all causes), myocardial infarction (fatal and non-fatal), percutaneous coronary intervention, revascularization and hospitalization. Database: this is a systematic review completed on January 29, 2012, whose selection of randomized and controlled clinical trials (ECCR) was held in electronic databases MEDLINE, EMBASE, PubMed/Cochrane Central, LILACS and Theses database-CAPES. Data collection: two researchers performed the extraction of information about Basal characteristics of included studies, evaluation of methodological quality and outcomes not independently combined. Results: were included in the meta-analysis, involving 18 ECCR 15,370 patients with SCA. The use of statins has shown benefit in reducing mortality from all causes, risk difference (rd) = -0.0066 (CI 95% -0.0121 to -0.001; P = 0.8459; I2 = 0%) and hospitalization rd = -0.0101 (CI 95% -0.0188 to -0.0014; P = 2.1496; I2 = 76%). As to cardiovascular, myocardial infarction fatal and non-fatal coronary intervention, and percutaneous revascularization mortality outcomes, there was no statistically significant difference between the groups statins versus placebo or usual care. Conclusions: the available evidence suggests that statins cause a reduction in mortality from all causes and hospitalization, but do not demonstrate difference when compared to placebo or usual care in other important events within cost-effective clinic and economic magnitude of health services and society.

Introdução: As diretrizes atuais recomendam classificar o risco de doentes com síndrome coronária aguda (SCA), visando a embasar decisões terapêuticas e para informar pacientes e equipe de saúde. Há diversos modelos prognósticos para pacientes com SCA, que, no entanto, podem ter limitações de calibração ou discriminação em função de terem sido elaborados há vários anos e em outras populações. Objetivo: Elaborar escores prognósticos para predição de eventos desfavoráveis em 30 dias e 6 meses, em população não selecionada portadora de SCA, com ou sem supradesnivelamento do segmento ST (SST), atendida em hospital privado terciário. Métodos: Trata-se de uma coorte prospectiva de pacientes recrutados consecutivamente de 1º de agosto de 2009 até 20 de junho de 2012. Definimos como desfecho primário composto a ocorrência de óbito por qualquer causa, infarto ou reinfarto não fatais, acidente vascular cerebral (AVC) não-fatal, parada cardiorrespiratória revertida e sangramento maior. As variáveis preditoras foram selecionadas a partir de dados clínicos, laboratoriais, eletrocardiográficos e da terapêutica. O modelo final foi obtido por meio de regressão logística e submetido à validação interna, utilizando-se técnica de bootstrap. A performance, calibração e discriminação do modelo final foram avaliadas com a estatística Brier escore, o teste de Hosmer-Lemeshow e a área sob a curva ROC (AROC), respectivamente. Resultados: A amostra de desenvolvimento dos escores foi de 760 pacientes, dos quais 132 com diagnóstico de SCA com SST e 628 com SCA sem SST. A média de idade foi de 63,2 anos (± 11,7), sendo 583 homens (76,7%). O modelo final para predição de eventos em 30 dias contém cinco variáveis preditoras: idade >=70 anos, antecedente de neoplasia, fração de ejeção do ventrículo esquerdo (FEVE) ?40%, valor de troponina I > 12,4ng/ml e trombólise química. O valor de P do teste de Hosmer-Lemeshow foi 0,72. Na validação interna, a estatística C foi de 0,71, e Brier escore, 0,06. O modelo final para predição de eventos em 6 meses é composto das seguintes variáveis: antecedente de neoplasia, FEVE <40%, trombólise química, troponina I >14,3ng/ml, creatinina >1,2mg/dl, antecedente de doença pulmonar obstrutiva crônica (DPOC) e hemoglobina <13,5g/dl. O valor de P do teste de Hosmer-Lemeshow foi 0,38. Na validação interna, a estatística C foi de 0,69, e Brier escore, 0,08. Conclusão: Desenvolvemos escores (Escores HCor) de fácil utilização e boa performance para predição de eventos adversos em 30 dias e 6 meses em pacientes com síndrome coronária aguda, com ou sem SST, atendidos em hospital terciário privado. / Introduction: Current guidelines recommend classifying the risk of acute coronary syndrome (ACS) with the aim of improving therapeutic decisions and better communicate prognosis to patients and healthcare personnel. There are several prognostic models for ACS patients. However, these may have limited calibration and discrimination as they were elaborated several years ago and using different populations. Objective: To develop prognostic scores for prediction of unfavorable events on 30 days and 6 months in an unselected population of ST-segment elevation ACS or non-ST-segment elevation ACS, admitted to a private tertiary hospital. Methods: We conducted a prospective cohort enrolling all eligible patients from August 1, 2009 to June 20, 2012. Our primary composite endpoint for both the 30-day and 6-month models was death from any cause, non-fatal myocardial infarction or re-infarction, non-fatal cerebrovascular accident (CVA), non-fatal cardiac arrest and major bleeding. Predicting variables were selected for clinical, laboratory, electrocardiographic and therapeutic data. We elaborated the final models using logistic regression, and used boostrap analysis for internal validation. We used Brier score, Hosmer-Lemeshow goodness-of-fit test and area under the ROC curve to assess global performance, calibration and discrimination, respectively. Results: We considered 760 patients for the development sample, of which 132 had ST-segment elevation ACS and 628 non-ST-segment elevation ACS. The mean age was 63.2 years (± 11.7), and 583 were men (76.7%). The final model to predict 30-day events is comprised by five independent variables: age >= 70 years, history of cancer, ejection fraction (LVEF) ? 40%, troponin I value of ?12.4 ng /ml and chemical thrombolysis. Hosmer-Lemeshow p-value was 0.72. In the internal validation analysis, C statistics was 0.71 and Brier score 0.06. The final model to predict 6-month events also includes history of of neoplasia, LVEF ? 40%, chemical thrombolysis, troponin >14.3 ng/ml, and three additional variables: creatinine ? 1.2 mg/dl, history of chronic obstructive pulmonary disease (COPD) and hemoglobin ? 13.5 g/dl. Hosmer-Lemeshow p-value was 0.38. In the internal validation analysis, C statistics was 0.69 and Brier score 0.08. Conclusion: We elaborated prognostic scores (HCor Score) of easy application and good performance for predicting adverse events in 30 days and 6 months for patients with ST-elevation and non-ST elevation ACS admitted to a tertiary private hospital.

No Brasil são realizadas aproximadamente três milhões de cirurgias por ano. Apesar dos avanços nas técnicas cirúrgicas e anestésicas, a mortalidade e o custo relacionados a estes procedimentos estão aumentando, sendo fundamental o desenvolvimento de estratégias para redução da mortalidade. A ocorrência de um infarto agudo do miocárdio (IAM) perioperatório prolonga a estadia hospitalar e aumenta a mortalidade. A fisiopatologia do IAM perioperatório pode envolver a instabilização de placas de ateroscleose com trombose ou o desbalanço entre oferta e consumo de oxigênio secundário à anemia ou hipotensão. Dependendo do mecanismo predominante, o prognóstico e tratamento podem ser diferentes. Apesar disto, faltam estudos clínicos desenhados para estabelecer a fisiopatologia do IAM perioperatório em pacientes que sobreviveram a estes eventos. O achado de lesões complexas na cineangiocoronariografia, embora possa ocorrer em pacientes com doença arterial coronária (DAC) estável, é mais freqüente em pacientes com angina instável e IAM, estando claramente relacionado com ruptura e instabilização da placa. O objetivo deste estudo foi comparar os achados angiográficos, incluindo as características das lesões coronarianas, em pacientes divididos em três grupos diagnósticos distintos: Síndromes Coronarianas Agudas (SCA) após operações não cardíacas, SCA espontâneas e doença arterial coronária estável. Entre fevereiro de 2006 e junho de 2010, foram avaliadas e comparadas as características clínicas e angiográficas de 120 pacientes com SCA após operações não cardíacas (grupo SCAPO), 120 pacientes que procuraram o serviço de emergência com SCA espontâneas (grupo SCAES) e 240 pacientes do ambulatório de DAC crônica (grupo DAC crônica). Os filmes das cineangiocoronariografias foram avaliados por um hemodinamicista experiente sem conhecimento do diagnóstico clínico. As cineangiocoronariografias foram avaliadas quanto ao número, localização e presença de lesões do tipo II da Classificação de Ambrose e de lesões complexas. Quatrocentos e oitenta pacientes e 1470 lesões foram avaliadas. Não houve diferença entre os grupos com relação ao sexo (p=0,51), à prevalência de diabetes (p=0,23) ou hipertensão arterial sistêmica (p=0,837). Os pacientes do grupo SCAPO eram mais idosos do que os dos grupos SCAES e DAC crônica (média de idade 67,8 anos x 64,5 anos x 61,9 anos, respectivamente; p<0,001). No grupo SCAPO, 45% dos pacientes apresentavam lesões do tipo II da Classificação de Ambrose x 56,7% dos pacientes do grupo SCAES e 16,4% dos pacientes do grupo DAC crônica (p<0,001). Os pacientes do grupo SCAES apresentaram maior número de lesões complexas do que aqueles do grupo SCAPO, que, por sua vez, apresentaram maior número de lesões complexas do que os pacientes do grupo DAC crônica (79,2% x 56,7% x 31,8%; p< 0,001). Concluímos que, em pacientes com SCA perioperatórias e SCA espontâneas, as lesões complexas e lesões do tipo II da classificação de Ambrose são mais freqüentes do que em pacientes com DAC estável e em aproximadamente metade dos casos SCA perioperatória ocorre a instabilização e ruptura de placa desencadeando um IAM tipo 1 / Annually, nearly three million noncardiac surgeries are performed in Brazil. Despite improvements in surgical and anesthetic techniques, mortality and cost related to these procedures are raising. Strategies for reducing mortality are needed. Patients experiencing a myocardial infarction (MI) after noncardiac surgeries have a high mortality and prolonged hospital stay. The pathophysiology of acute coronary syndrome (ACS) in the perioperative setting may involve thrombosis over a vulnerable plaque or decreased oxygen supply secondary to anemia or hypotension. Depending on the predominant mechanism, prognosis and treatment may be different. There are no studies designed to establish this pathophysiology in patients that survived a perioperative MI. Although the presence of complex lesions in coronary angiography may occur in stable coronary artery disease (CAD) patients, it is far more common in unstable angina and MI and, strongly associated to plaque disruption. The purpose of this study was to compare the angiographic characteristics between ACS in the perioperative setting (PACS), in the emergency room - spontaneous ACS (SACS), and stable CAD patients. Between February 2006 and June 2010 clinical and angiographic data were prospectively recorded into a database for consecutive patients that had ACS after noncardiac surgery (n=120), and for 120 patients with SACS. We also collected data for a control group of 240 patients with stable CAD. All angiographies were analyzed by a single expert observer who was unaware of the patients clinical diagnosis. The number and location of coronary lesions with obstructions greater than 50% were recorded. Each lesion was classified based on Ambroses classification and if they had a complex morphology. The presence of Ambroses type II and complex lesions was compared between the three groups. Four hundred and eighty patients and 1470 lesions were analyzed. There were no differences between the three groups in the prevalence of male sex (p=0.521), hypertension (p=0.837) or diabetes (p=0.230). Patients in PACS were older than patients of SACS or CAD groups (mean age 67.8±10.2 years x 64.5±12.4years x 61.9±9.7years, respectively; p<0.001). In PACS, 45% of patients had Ambroses type II lesions x 56.7% in SACS group and 16.4% in CAD group (p<0.001). Patients in PACS had less complex lesions than patients in SACS, but more lesions than patients in CAD group (56.7% x 79.2% x 31.8%, respectively; p< 0.001). In conclusion, patients with perioperative ACS and spontaneous SCA have more Ambroses type II and complex lesions than patients with stable CAD. Nearly 50% of patients with perioperative myocardial infarction have evidence of coronary plaque rupture, characterizing a type 1 MI

Much previous work on air pollution epidemiology has studied end-stage outcomes such as mortality or severe ill health warranting emergency admission, often based on clinical criteria prone to misclassification, and usually without accompanying study of the mediating mechanisms. Therefore this work has three specific objectives: firstly, to assess the effects of short-term exposure to particles and gases on acute coronary syndrome (ACS), by measuring the levels of cardiac troponin T (cTnT), a highly sensitive and specific marker of myocardial damage in patients admitted to hospital for chest pain of myocardial origin; secondly, to investigate the effects of short-term changes in ambient air pollution on the occurrence of transient ischaemic attacks (TIA); finally, to investigate the effects of ambient and personal exposure to air pollutants on a range of mediators or markers in a putative susceptible population. Two case-crossover studies were conducted to study the association between short-term changes in air pollutants and ischaemic cardiac events and TIA. Hospital data on admissions were analysed for actual or suspected ischaemic events and the associated cTnT levels were obtained. For the TIA project, data on 709 subjects were obtained from five TIA centres clustered around Manchester and Liverpool. In the third project a panel of 35 type 2 diabetes mellitus patients were prospectively followed fortnightly for a total of four visits. At each visit blood was collected to measure markers of inflammation, coagulation and endothelial function. In all three projects ambient air pollution data were obtained from background monitoring networks and in the third project personal exposure to PM2.5 was measured. Project 1: Of 28,622 admissions, 17.5% were ACS with myocyte necrosis (cTnT 0.03-1ng/ml) and 1004 (3.5%) were cases of myocardial infarction (cTnT ≥ 1 ng/ml). Both particulate and gaseous pollutants were associated with admission for ACS. The two largest effects per interquartile increase of exposure were observed with PM10 with ORof 1.14 (95% CI: 1.05-1.24) and with SO2, OR 1.11 (95% CI: 1.00-1.23). Associations between pollution and ACS admissions were the strongest for women, those above the age of 65 years and in the cooler season. Project 2: In the Manchester dataset, exposure to nitric oxide (NO) was associated with occurrence of TIA, while no effect was observed for Liverpool data. Subgroup analysis reveals that CO, NO and NO2 were more strongly related to the occurrence of TIA in participants above the age of 65 years and male patients. Project 3: No consistent association was observed between measured biomarkers and air pollutants using exposure data from ambient monitoring stations. In contrast, significant association between personal PM2.5 and interleukin-6 (IL-6) was observed. Similarly, personal PM2.5 had large but non-significant positive associations with high sensitivity C-reactive protein and fibrinogen. The results of this study reveal that short-term changes in particulate and gaseous pollution are related to the risk of admission for ACS as demonstrated by a specific marker hitherto not used for this purpose. It provides limited evidence for an association between changes in ambient NO concentration (which may have been a surrogate for another pollutant), and the occurrence of TIA, which had not previously been studied as an air pollution outcome, and increase in IL-6, a major pro-inflammatory marker. The IL-6 response to personal PM2.5 provides evidence in support of the link between ambient levels of particles/gases and cardiopulmonary morbidity and mortality.

L'apport des biomarqueurs aux urgences est bien documenté. Depuis l'apparition de la myoglobine et de la troponine pour le diagnostic de syndrome coronaire aigu (SCA), de multiples marqueurs ont été développés pour l'aide au diagnostic de multiples pathologies aux urgences. Certains biomarqueurs sont même intégrés à la définition de syndromes ou pathologies comme le SCA avec la troponine, ou le sepsis sévère avec le lactate. Nous abordons dans ce travail l'approche multimarqueurs, qui consiste à combiner le dosage de plusieurs biomarqueurs pour améliorer les performances diagnostiques ou pronostiques. L'hypothèse de base de ce travail est que l'association d'un marqueur sensible, généraliste, avec un marqueur spécifique de pathologie ou de dysfonction d'organe, permettrait d'améliorer la prise en charge diagnostique ou la stratification du risque aux urgences. On illustre cette approche dans trois cas particuliers : la prédiction du sepsis sévère, le diagnostic du syndrome coronaire aigu, et l'évaluation du risque après une crise convulsive. Plusieurs méthodes sont envisagées pour combiner plusieurs biomarqueurs, et on développera ici la détermination de la meilleure combinaison linéaire pour obtenir une discrimination optimale. / The added value of biomarkers in the emergency settings is well reported, in various pathologies. Since the burst of myoglobin and troponine for the diagnosis of myocardial infarction (MI), various biomarkers have been developed and adopted for diagnostic purposes in different pathologies. Some of them are part of the very definition of specific syndrom or disease (MI with troponin, or severe sepsis with lactate). We present here the multimarker approach in the emergency department – a strategy that combines the results of several different biomarkers to enhance diagnostic or prognostic performances. We made the hypothesis that the association of a sensitive and generalist biomarker, with an organ or syndrome specific one, would result in better performances.We illustrate here this strategy in three particular cases: the prediction of severe sepsis, the diagnosis of acute coronary syndrome, and the risk stratification after a convulsive seizure. Several methods are considered for the combination of biomarkers, and we will focus on the determination of the best linear combination.

Recent published studies have provided new information about the significant influence of environmental factors, especially air pollution in the development of acute coronary syndrome. Besides the well-known controllable and uncontrollable risk factors it is necessary to focus on non-conventional risk factors. The thesis aims to determine whether there is a statistically significant relationship between the days in which patients with acute coronary syndrome type STEMI were rescued by the EMS Most and the average daily concentrations of pollutants in air (PM2,5 and PM10, ozone, carbon monoxide and nitrogen dioxide) in seven previous days. The research methodology is based on a retrospective observational analysis of 116 patients with acute myocardial infarction in prehospital emergency care and the impact of the above pollutants in air with the use of statistical methods. The results in sets of ozone and nitric oxide effect presents a significant impact of day (p=0.0283/0.0424), sex (p=0.0216/0.0232) and age (p=0.0008/0 .0187). Although we have found a statistically significant effect of a day, gender and age in our analysis, it is necessary to continue research in a larger statistical sample to minimize the statistical errors. Key words: acute coronay syndrome, air pollution, emergency medical service

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

2030 förväntas hjärtkärlsjukdomar vara den ledande dödsorsaken i världen bland både kvinnor och män. Kvinnor tenderar att visa upp en större variation av symptom vid händelse av akuta koronara syndrom vilket riskerar att skapa förvirring och feltolkning. Genom en ökad kunskap kring kvinnor och deras upplevelse av akuta koronara syndrom ges möjlighet till bättre omhändertagande, omvårdnad och medicinska resultat för kvinnor. Syftet med studien var att belysa kvinnors upplevelser av akuta koronara syndrom. Litteraturstudien gjordes utifrån 11 vetenskapliga originalartiklar som var relevanta för det valda syftet. Utifrån analys av de utvalda artiklarna sammanställdes studiens resultat i två huvudkategorier Upplevelser av akuta koronara syndrom vid insjuknande och Upplevelser av akuta koronara syndrom efter insjuknande. Resultatet visar att kvinnors upplevelser av akuta koronara syndrom skiljer sig från den traditionella synen på hur akuta koronara syndrom presenteras, vilket leder till att kvinnor upplever svårigheter att tolka och agera på sina symptom. Resultatet visar också att många kvinnor som upplevt akuta koronara syndrom beskriver ett ökat behov av stöd under arbetet med återanpassning till vardagen, samt hur diagnosen bidrar till ett nytt perspektiv på livet, hälsa och välmående. / In 2030 cardiovascular diseases is expected to be the leading cause of death in the world amongst both men and women. Women tend to show a greater variation of symtoms in the event of acute coronary syndromes which risk creating confusion and misinterpretation. Through increased knowledge amongst women and acute coronary syndromes is given the opportunity for better care, nursing and medical results for women and their experience of acute coronary syndromes. The aim of the study was to highlight women ́s experiences of acute coronary syndrome. The literature study was made from 11 scientific original articles about women ́s experiences with acute coronary syndromes. These were examined and compiled and gave the studies result that generated two main categories: Experiences of acute coronary syndromes during illness and Experiences of acute coronary syndromes after illness. The results shows that women’s experiences of acute coronary syndrome differ from the traditional view of how acute coronary syndrome presents, which leads to women experiencing difficulties in interpreting and acting on their symptoms. The results also show that many women who have experienced acute coronary syndrome describe an increased need for support during the work on re- adjusting to everyday life, as well as how the diagnosis helps for a new perspective on life, health and wellbeing.