Predikce rizika rozvoje akutního koronárního syndromu na základě neinvazivních vyšetření ABSTRACT The aim of presented diploma thesis coming out of the project held by II. interní klinika Všeobecná fakutní nemocnice v Praze is to determinate the risk assessment for development of acute coronary syndrome based on non-invasive examinations - intracoronary ultrasound, retinal arteries examination, biochemical markers of atherosclerosis and selected genes polymorphism. The thesis is divided into two main parts. The first part is theoretical and it consists of three chapters, the second part is analytical and it contains the research. The theoretical part gives concise information about the acute coronary syndrome, essential part focuses on atherosclerosis as a pathophysiologic base of this syndrome, risk factors, and stratification of cardiovascular risk which proved to be insufficient are as well mentioned. Next part describes a non-invasive coronary arteries examinations focusing on presented research. The last chapter of the theoretical part focuses on invasive coronary arteries examinations. The research part describes design and purpose of the project - the identification the high risk for development of acute coronary syndrome patients irrespective of the risk coming out standard evaluation models, and...

Majority of medical decisions are based on results of diagnostic tests that help to differentiate normal from abnormal. The choice of appropriate test and its intepretation are neccessary steps for correct diagnosis and treatment strategy determination. Rapid prove of acute coronary syndrome (ACS) plays a key role in choice of optimal treatment strategy, because timing of intervention directly influences prognosis of the patient. Pregnancy-associated plasma protein-A (PAPP- A) has been studied as a promising marker of ACS. For PAPP-A evaluation in patients with coronary atherosclerosis, we have chosen commercially available system Kryptor that had been verified in prenatal screening of pregnancies in risk. PAPP-A belongs among metalloproteinases. It is important marker of physiological development of placenta and fetus. The only proven physiological role of PAPP- A is the enabling of bioavailability of insulin-like growth factor (IGF). IGF as a growth factor, plays significant role in atherosclerosis development, but also it might contribute to healing processes connected with tissue injury. Nevertheless, PAPP-A role in plaque destabilization has not been proven yet, although it was found in other metaloproteinases. In our pilot study, we confirmed the use of Kryptor system also for patients with coronary...

The association between acute coronary events and acute allergic reactions has been recognized for several years. The first reported case occurred in 1950, during an allergic reaction to penicillin. In 1991, Kounis and Zavras described the syndrome of allergic angina and allergic myocardial infarction, currently known as Kounis syndrome. Two subtypes have been described: type I, which occurs in patients without predisposing factors for coronary artery disease and is caused by coronary artery spasm, and type II, which occurs in patients with angiographic evidence of coronary disease when the allergic events induce plaque erosion or rupture. This syndrome has been reported in association with a variety of medical conditions, environmental exposures, and medication exposures. Entities such as Takotsubo cardiomyopathy, drug-eluted stent thrombosis, and coronary allograft vasculopathy appear to be associated with this syndrome. In this review, we discuss the pathobiology, clinical features, associated entities, and management of Kounis syndrome.

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13121号 / 論社医博第10号 / 社新制||医||9(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川村 孝, 教授 妹尾 浩, 教授 福原 俊一 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

SAMMANFATTNING Akut koronart syndrom (AKS) är benämningen på den process som innebär en plackruptur med efterföljande trombotisering i ett kranskärl. Insjuknandet kan debutera med allt ifrån en vag obehagskänsla till en dramatisk situation och är potentiellt livshotande. Kranskärlssjukdom är ett kroniskt tillstånd som den drabbade tvingas hantera resten av livet. Närstående, vilka utgör en viktig resurs i sammanhanget, drabbas även de av sjukdomens följder. Hänsyn och anpassning till den nya situationen kan leda till förändring i livet. Syftet med föreliggande studie var att belysa närståendes upplevelse av förändring i livet efter att partnern insjuknat i akut koronart syndrom. En kvalitativ metod valdes. Sex närstående till personer som för första gången insjuknat i akut koronart syndrom intervjuades. Insamlad data bearbetades genom kvalitativ innehållsanalys enligt Lundman och Hällgren Graneheim. Det resultat som framkom har indelats i tre kategorier: närståendes upplevelse av förändring av partnerns fysiska, psykiska och kognitiva tillstånd, närståendes upplevelse av förändring i livsstil samt närståendes upplevelse av nytillkommen oro och ökat ansvar. Exempel på vanliga förändringar var partnerns trötthet, vilken kunde leda till ökat sömnbehov och mindre ork för aktiviteter och socialt umgänge. Glömska och förändringar i humör och sinnesstämning hos partnern kunde leda till ökad kontroll och större hänsynstagande för den närståendes del. En tydlig förändring var den ökade mängden läkemedel där närstående ofta hjälpte till att kontrollera medicineringen. Flertalet hade gjort någon form av förändring gällande levnadsvanor som att öka andelen grönsaker i kosten eller att öka den fysiska aktiviteten. En nytillkommen oro för hälsa och framtid fanns. De närstående använde olika strategier som kontroll och försök till påverkan för att tillsammans med sina partners återfå en balans i livet. Den slutsats som kan dras är att närstående erfar förändringar i livet då partnern insjuknar i akut koronart syndrom. De närstående känner ofta stort ansvar för sin partner och kan genom sin närvaro bidra till att jämvikten återfås.

SAMMANFATTNING För att kunna möjliggöra att patienter med akut koronart syndrom erhåller god vård utifrån riktlinjer och vårdprogram ställs stora krav på sjuksköterskans agerande vid omhändertagandet av patienten. Akut koronart syndrom är ett potentiellt livshotande tillstånd som kräver omedelbar sjukvård. Patientens behov av omedelbart omhändertagande ställer stora krav på sjuksköterskans förmåga att identifiera, prioritera och agera vid omhändertagandet av patient med akut koronart syndrom. För att underlätta och påskynda vård och behandling kan sjuksköterskans agerande betraktas som en avgörande aspekt för hur händelseförloppet utfaller. Syftet med studien är att identifiera faktorer som påverkar sjuksköterskans agerande vid omhändertagande av patienter som drabbats av akut koronart syndrom För att besvara studiens syfte användes en litteraturöversikt om metod. Litteraturöversikten inkluderade 15 vetenskapliga artiklar från databaserna CINAHL och PubMed. Samtliga vetenskapliga artiklar kvalitetsgranskades, klassificerades och analyserades i en integrerad analys. Resultatet som framkom kunde delas in i fyra huvudkategorier med tillhörande underkategorier. Dessa fyra huvudkategorier var sjuksköterskans kompetens, relation mellan sjuksköterska och patient, teamarbete och arbetsmiljö. Resultatet visade att sjuksköterskans förmåga att identifiera och lindra smärta samt bedöma EKG och hjärtövervakning var faktorer som kunde påverka sjuksköterskans agerande vid omhändertagandet av patient med AKS. Likaså betraktades sjuksköterskans kommunikation och bemötande till patienterna som faktorer som inverkade på hur sjuksköterskan agerade. Det framgick också i resultatet att kommunikation och samarbete i teamet, men också att aspekter inom sjuksköterskans arbetsbelastning, var faktorer som kunde påverka sjuksköterskans agerande vid omhändertagandet av patient som drabbats av AKS. I denna litteraturöversikt kunde flera faktorer som påverkade sjuksköterskans agerande vid omhändertagande av patient med akut koronart syndrom fastställas. Sjuksköterskans kompetens, kunskapsnivå och färdigheter framträdde som avgörande aspekter för hur omhändertagandet utföll. Likaså betraktades relationen mellan sjuksköterska och patient, förmågan att samverka i team samt arbetsmiljö och utrustning som väsentliga faktorer för sjuksköterskans agerande vid omhändertagande av patient med akut koronart syndrom. / ABSTRACT The demands of the nurses in acting of the care of the patients is increasing, thus, to enable that patients with acute coronary syndrome receives good care based on guidelines and care programs. Acute coronary syndrome is a potentially life-threatening condition that requires immediate care. Patients’ need of immediate care makes great demands of nurses’ ability to identify, prioritize and act in care of patients with acute coronary syndrome. The nurses acting portrayed as a significant aspect on outcomes of the turn of event, thus, to ease and to precipitate the care process and treatment with acute coronary syndrome. The aim of this study was to identify the factors that influence nurses actions in care of patients sustaining acute coronary syndrome. A literature review was used as method to answer the aim of the study. The literature review included 15 articles from the databases CINAHL and PubMed. Every article was quality reviewed, classified and analyzed in an integrated analysis. The result that appeared was categorized in to four different main categories. These were the nurses’ competence, the relationship between nurse and patient, teamwork and work environment. The result viewed that nurses’ ability to identify and ease pain and the ability to assess ECG-monitoring were factors that could influence nurses actions in care of patients sustaining acute coronary syndrome. Also nurses’ communication skills could affect nurses’ acting in caring for patients with AKS. It also appeared that teamwork, communication between colleagues and different aspects on nurses’ work environment played an essential aspect on factors that could influence nurses’ actions in care of patients sustaining acute coronary syndrome. This literature review determined several factors that affected the nurses’ actions in caring of patients with acute coronary syndrome. Nurses’ competence, knowledge and skill appeared as crucial aspects for the outcome of the care. Also the relationship between nurse and patient, the ability to collaborate in teams, work environment and equipment was established as essential factors for the nurses’ actions in caring of patients sustaining acute coronary syndrome.

Begreppet akut coronart syndrom (ACS) används för tillstånd som orsakar syrebrist i hjärtmuskeln genom förträngning av kranskärlen. I Sverige sker ca 42 % av alla dödsfall hos både kvinnor och män till följd av hjärtkärlsjukdom. Riskfaktorer utgörs av kön, ålder och ärftlighet samt relateras till livsstils faktorer såsom rökning, förhöjda blodfetter, hypertoni, diabetes, stress och låg fysisk aktivitet. För personen som insjuknar i en hjärtinfarkt kan upplevelsen innebära en kris och sjuksköterskan har en central roll som rådgivare och vägledare för patienter under deras sjukhusvistelse och i eftervården.Syfte med denna litteratursammanställning var att beskriva sjuksköterskans omvårdnadsåtgärder som kan stödja patienter med ACS.Studien utgörs av en systematisk litteraturssammanställning och resulterade i sex kvalitativa och fem kvantitativa vetenskapliga artiklar.Resultatet belyser två teman som betydelsefulla omvårdnadsåtgärder sjuksköterskan kan stödja patienter med vid ACS. Dessa teman presenteras som information/utbildning och skapande av relationen mellan sjuksköterska och patient. Sjuksköterskans kompetens och professionalitet samt förmågan att möta patienten på ett bekräftande sätt leder till trygg relation mellan sjuksköterska och patient. En god relationen och information förefaller påverka patienten till att förstå och förbättra sin hälsa. Det är viktigt att få tid till att etablera en relation med patienten. Inom området bemötande och kommunikation ses flera framtida forskningsfrågor. / Acute coronary syndrome (ACS) is used to describe conditions that causes lack of oxygen to the heartmuscle due to a stenosis in the coronary arteries. The death rate in coronary heart disease is 42% in Sweden in both females and males and is the most common course of death. Risk factors are gender, age and heredity as well as lifestyle factors as smoking, hyperlipidemia, hypertonia, diabetes, stress and low fysical activity. The person that experience a heart failure might get into a crisis and nurses has an important role as a guide and councillor during the stay in hospital and in the aftercare.The aim of this systematic litterature review was to describe nursing interventions to support the patients with ACS. The study includes six qualitative and five quantitative articles. The result highlights two themes as important nursing interventions to support patients with ACS. These themes are presented as information/education and the establishment of a nurse-patient relation. The nurse’s competence and professionality and her capacity to confirm the patient leads to a confident relation between the nurse and the patient. A good relation and information seems to affect the patients understanding of, and improving of his/hers health. It seems to be of importance to obtain time to enable the possibility to establish the relation with the patient. In the domain of how the patient is approached and communicated with, future research is recommended.

The P2Y inhibitor, ticagrelor, has been shown to prevent thrombotic events and hence, improve morbidity and mortality in patients with acute coronary syndrome following coronary artery stent placement. Despite many clinical benefits, ticagrelor has been associated with several adverse effects, including dyspnea, easy bruising, and gastrointestinal bleeding. We report the case of a 67-year-old patient with an acute coronary artery syndrome requiring percutaneous coronary artery intervention with stenting who developed ticagrelor-induced diarrhea. The patient's ticagrelor medication was replaced with clopidogrel, and his diarrhea completely resolved within one week with no complications observed at his one-month follow-up visit. Clinicians should be aware of this adverse effect of ticagrelor so as to guide them toward possible underlying etiologies and appropriate workup of chronic diarrhea.

O tecido adiposo é considerado não somente uma fonte de energia estocável, mas principalmente um órgão endócrino que secreta várias citoquinas, as quais podem contribuir para o desenvolvimento de doenças relacionadas à obesidade, incluindo o diabetes mellitus e a doença vascular aterosclerótica. Dentre esse pool de moléculas, a adiponectina (Arcp30, AdipoQ, apM1, ou GBP28), uma nova proteína semelhante ao colágeno, foi descoberta como uma citoquina específica do adipócito. Neste estudo, realizamos a determinação dos níveis séricos da adiponectina em uma amostra de pacientes hospitalizados com SCA e, posteriormente, avaliamos a associação com os eventos cardiovasculares no seguimento clínico. Método: avaliamos 114 pacientes com SCA de ambos os sexos neste estudo de corte transversa com seguimento clínico mediano de 18 meses. Realizamos análise de regressão multivariada de Cox para identificar associação independente entre adiponectina e o risco subsequente de óbito CV, IAM não-fatal, AVE não-fatal, e rehospitalização com revascularização. Também comparamos os diversos biomarcadores metabólicos, inflamatórios, de coagulação e de necrose miocárdica por quartis de adiponectina. Resultados: Adiponectina não correlacionou-se de modo independente com o risco CV, tanto na análise univariada quanto nos modelos de Cox. Das variáveis metabólicas, a única com valor preditivo para os desfechos primário e co-primário foi a glicemia de jejum, com OR ajustado=1,06 (IC95% 1,01-1,11), p=0,016, e OR ajustado=1,10 (IC95% 1,03-1,17), p=0,003, ambos para incrementos de 10 na glicemia de jejum. Conclusões: Adiponectina não se mostrou variável independente de risco cardiovascular nesta amostra de pacientes com SCA. A glicemia de jejum foi a única variável metabólica com valor preditivo independente para os desfechos cardiovasculares. / Background: The adipose tissue is considered not only an energy resource stock, but mainly an endocrine organ that secretes several cytokines, which may contribute to the development of diseases related to obesity, including diabetes mellitus and the atherosclerotic vascular diseases. Within this pool of molecules, adiponectin (Arcp30, AdipoQ, apM1, or GBP28), a novel protein similar to collagen, was discovered as an adipocyte-specific cytokine. In this study, we determined the serum levels of adiponectin in a sample of patients hospitalized with acute coronary syndromes (ACS), and subsequently we evaluated the association with the cardiovascular events during the follow-up phase. Methods: we evaluated 114 patients with ACS of both genders in this cross-sectional study with a median follow-up of 18 months. We performed a proportional multiple regression analysis of Cox to identify independent association between adiponectina and risk of cardiovascular death, non-fatal acute MI, non-fatal CVA, and rehospitalization requiring revascularization. We also compared the various biomarkers of metabolism, inflammation, coagulation, and of myocardial necrosis divided by quartiles of adiponectin. Results: Adiponectin did not correlate independently with CV risk, either on univariate analysis or on the multiple regression models of Cox. Among the metabolic biomarkers, the only variable with predictive value for the primary and co-primary endpoints was fasting glucose, with an adjusted OR=1,06 (95%CI 1,01-1,11), p=0,016, and adjusted OR=1,10 (95%CI 1,03-1,17), p=0,003, both for increments of 10. Conclusions: Adiponectin was not an independent risk factor for cardiovascular risk in this sample of ACS patients. Fasting glucose was the only metabolic biomarker with a significant and independent predictive value for cardiovascular outcomes.

Os avanços na área da saúde têm resultado na redução da morbidade e permitido maior sobrevida aos pacientes coronariopatas. Entr etanto, a Síndrome Coronariana Aguda (SCA) ainda representa uma das questões de saúde públ ica mais relevante da atualidade. O objetivo geral do estudo foi avaliar a evolução clínica dos pacientes dur ante a primeira internação decorrente da SCA e nos primeiros dois anos a pós a hospitalização. As principais variáveis de interesse investigadas foram: mortalidade, rein ternações e tratamentos de revascularização do miocárdio (Intervenção Coronária Percutânea - ICP e Cirurgia de Revascularização do Miocárdio - CRVM). O delineamento utilizado foi observacional, tipo coorte. A amostra foi composta por pacientes que foram internados em decorrência do prim eiro episódio de uma SCA, entre maio de 2006 e julho de 2009, em um hospital geral público de ensino. Os dados foram coletados em 2011 mediante consultas ao s prontuários dos participantes e ao sistema eletrônico de agendamento do hospital, utilizando-se de um instrumento elaborado pela pesquisadora. Os dados foram analisados utiliz ando testes de associação Qui-quadrado, Exato de Fisher e t de Student para amostras independentes. O nível de significância adotado foi de 0,05. A taxa de mortalidade foi calculada divi dindo o número de óbitos ocorridos em até dois anos de seguimento pela somatória do tempo total de observação do estudo. Participaram da investigação 234 pacientes, sendo 140 (59,8%) diagnosticados com Infarto Agudo do Miocárdio (IAM) e 94 (40,2%) com Angina Instável (AI). A idade média foi de 58 anos (D.P.=12,2 anos), com predomínio de indiví duos do sexo masculino (69,2%). Durante a internação inicial não houve associação entre a presença de complicações e a manifestação clínica da SCA; os pacientes com AI tiveram média de tempo de permanência hospitalar maior que IAM (12,5 e 10 dias, respectivamente), mas essa diferença não foi estatisticamente significante. As ICPs foram mais realizadas nos pacien tes com IAM, enquanto as CRVMs foram mais realizadas nos pacientes com AI , sendo a associação entre essas variáveis estatisticamente significantes. Ao longo do se guimento de até dois anos após a alta da internação inicial, 71,4% dos pacientes foram subm etidos a, pelo menos, um procedimento de revascularização do miocárdio; 27,4% necessita ram de outras hospitalizações, e desses, 71% tiveram uma nova internação e 6,5% reinternaram cinco vezes. Na primeira reinternação, a causa mais prevalente foi a ICP programada e na s internações posteriores foi a angina. A taxa de mortalidade hospitalar foi de 3%, tendo ocorrido 13 óbitos durante todo o seguimento do estudo, sem diferença estatística entre as manifestações da SCA. A taxa de mortalidade geral do estudo foi de 35,75/1000 pessoas por ano. Os resultados do estudo ampliaram nossos conhecimentos sobre como é o perfil deste grupo de pacientes atendidos em decorrência do primeiro episódio de SCA em um hospital geral, de nível terciário, e como se dá a evolução clínica durante a internação e a longo prazo. / The advances in health have led to reduced mo rbidity and improved survival of patients living with coronary diseases. However, Acute Cor onary Syndrome (ACS) represents one of the most relevant public health issues nowadays. The aim of this study was to assess the clinical evolution of patients who suffered from ACS, fr om their first admission to the hospital until two years after that episode. The main interest variables investigated were: mortality, hospital readmissions and myocardial reva scularization therapies (percuta neous coronary intervention - PCI and Coronary Artery Bypass Grafting surg ery - CABG). This research was designed as an observational cohort study. The study sample was patients admitted into a general school hospital due to the first episode of ACS, from May 2006 through July 2009. Data were collected in 2011 from patients\' medical records and the hospital\'s appointment schedule database, using a form designed by the researcher. Data were analyzed by chi-square, Fisher\'s exact test and t-Student association tests for independent samples. The significance level was 0.05. Mortality rate was calculated by dividing the number of deaths occurred up to two years after the first ACS episode by the total period of observation taken within the study. As such, 234 patients took part in the study, 140 (59.8%) were diagnosed with Acute Myocardial Infarction (AMI) and 94 with Unstable Angi na (UA). The mean age was 58 years old (s.d.=12.2), most were male (69.2%). During hosp ital stay there was no association between medical complications and clinical manifest ation of ACS. Patients with UA had mean hospital stay higher than AMI patients (12.5 and 10 days, respectively), alt hough this was not statistically relevant. PCI were more prevalen t in AMI patients, whereas CABG were to UA patients, displaying statistically relevant association between these variables. During the two-year follow up period after hospital discharge, 71.4% of patients were submitted to, at least, a myocardial revascularization pr ocedure. 27.4% of patients were hospitalized again, 71% of this group had to be readmitted and 6.5% had been readmitted five times. At their first readmission, the most prevalent cause was a sc heduled PCI and the following hospitalizations were due to angina. The hospital mortality rate was 3%, as 13 deaths occurred during the period of study, with no statistically significance between the ACS manifestations. The general mortality rate of this study was 35.75/1000 people per year. The results of this study improved our knowledge over the profile of this population admitted into a general tertiary hospital due to their first ACS episode. It also shone some light over the clinical evolution of this disease during hospitalizat ion and at long term period.