Background: Acute heart failure and chronic obstructive pulmonary disease (COPD) exacerbation are common, and are sometimes difficult to differentiate in the emergency department (ED). Objectives: To determine the clinical impact of Point-of-Care Ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD. Methods: We conducted a prospective health records review with 1:3 matching, and analyzed time to events using time-dependent Cox regression analyses, classification performance, and adverse events. Results: There were 81 patients with lung POCUS and 243 matched patients. No differences were found in ED length of stay or length of care, nor adverse events. Significance was found for time to treatment (P=0.03). Lung POCUS had high sensitivity (92.5%) and specificity (85.7%) for identifying acute heart failure. Conclusions: Lung POCUS could result in faster treatments for patients with suspected acute heart failure and COPD, and has high accuracy in identifying acute heart failure.

Doctor of Philosophy / Department of Kinesiology / David C. Poole / The onset of skeletal muscle contractions induces rapid and robust increases in metabolic rate (V̇O₂) and blood flow (Q̇) in order to supply the energetic demands of the muscle. In young healthy populations, these variables increase proportionally to maintain oxygen flux into the myocyte for both sexes. However, while the resultant changes in V̇O₂ and Q̇ conflate to establish adequate driving pressures of oxygen (PO₂), it appears that the underlying control processes express distinct sexual dimorphism. Estrogen is crucial for cardiovascular control for young women through its relationship with nitric oxide (NO) and results in lower blood pressure and risk of cardiovascular disease for women. However, in post-menopausal women and some disease states, such as heart failure (HF), these protections are lost due to reductions in estrogen and NO bioavailability which causes women to catch and surpass men in rates of hypertension and cardiovascular disease. The purpose of this dissertation is to explore the mechanisms responsible for establishing the oxygen delivery-to-utilization matching (Q̇O₂/V̇O₂) necessary for skeletal muscle contractions in health and disease. In the first investigation (Chapter 1), we explored the effect of altered NO bioavailability on spinotrapezius muscle interstitial space PO₂ (PO₂is; determined by Q̇O₂/V̇O₂) of healthy male and female rats. We show that both sexes regulate PO₂is to similar levels at rest and during skeletal muscle contractions. However, modulating NO bioavailability exposes sex differences in this regulation with females having greater reliance on basal NO bioavailability and males having greater responsiveness to exogenous NO. In the second investigation (Chapter 2), we sought to determine whether measures of central and peripheral function in HF rats predicted exercise tolerance (as critical speed (CS)). We showed for the first time, that CS can be resolved in HF animals and that decrements in central cardiac (echocardiography) and peripheral skeletal muscle function (PO₂is) predicted CS. Building upon these findings, the third investigation (Chapter 3) aimed to determine if the sex differences in the control of PO₂is seen in healthy rats translated to greater deficits in HF for females. Furthermore, this investigation sought to determine if five days of dietary nitrate supplementation (an exogenous NO source) would raise PO₂is in HF rats, with a greater effect seen in females. We revealed that HF reduces PO₂is at rest and during skeletal muscle contractions and this negative effect is exacerbated for females. However, elevating NO bioavailability with dietary nitrate increases resting PO₂is and alters the dynamic response during contractions with females potentially being more responsive than males. The results herein reveal the importance of NO in the control of Q̇O₂/V̇O₂ in health. The onset of HF results in deleterious declines in exercise tolerance, which are mediated through reductions in central and peripheral function, due, in part, to attenuated NO bioavailability. This creates intensified Q̇O₂/V̇O₂ dysfunction in females with HF; however, this can potentially be countered with dietary supplementation of inorganic nitrate. Altogether, the present dissertation suggests that targeting NO bioavailability, particularly in female HF patients, could be a beneficial non-pharmaceutical therapeutic strategy.

A congestão sistêmica é o principal fator relacionado à descompensação de pacientes com insuficiência cardíaca (IC), conferindo manifestações clínicas como dispneia, ortopneia, cansaço, distensão da veia jugular e edema. Estes sinais e sintomas, assim denominados características definidoras (CD) na classificação de Diagnósticos de Enfermagem (DE) da NANDA-International, fazem parte do diagnóstico de Volume de líquidos excessivo (VLE) frequentemente estabelecido em pacientes congestos. Estes sinais e sintomas também são frequentemente associados a diagnósticos do sistema respiratório e, por conseguinte, podem comprometer a acurácia diagnóstica. É nessa perspectiva, que se apresenta um marcador bastante estudado nas duas últimas décadas, Peptídeo Natriurético tipo B (BNP), que consegue diferenciar a dispneia de origem cardíaca da dispneia de causa pulmonar. Visando agregar este biomarcador ao conjunto de CD do diagnóstico VLE que este estudo foi desenvolvido. O objetivo do estudo é analisar o comportamento do Peptídeo Natriurético tipo B com a presença das CD do diagnóstico VLE em pacientes com IC descompensada durante a internação. Trata-se de um estudo de coorte conduzido em hospital público universitário, Porto Alegre, RS. Foram incluídos pacientes com diagnóstico de IC, função sistólica reduzida ou preservada, que internaram por descompensação aguda. A coleta foi sistematizada por meio de uma avaliação clínica na admissão e após compensação da IC (até sete dias após a admissão, denominado avaliação final), contendo as CD já validadas clinicamente para este diagnóstico em pacientes com IC como principais e secundárias. Também foram coletadas amostras de sangue para dosagem do BNP nestes dois períodos. Foram incluídos 64 pacientes, com média de idade de 69±13 anos, fração de ejeção do ventrículo esquerdo 50±16%. Da avaliação inicial à final, houve redução significativa das seguintes CD principais: dispneia (97% x 62%), ortopneia (91% x 67%), edema (89% x 62%), refluxo hepatojugular positivo (60% x 32%), dispneia paroxística noturna (95% x 26%), congestão pulmonar (66% x 49%), pressão venosa central elevada (53% x 27%); e secundárias, como ganho de peso (59%x9%), hepatomegalia (14%x11%), crepitação (86%x 50%) e oligúria (3%x1,5%). Em uma análise quantitativa das CD, observa-se uma redução da admissão à avaliação final no estudo, 11,3 ±3 versus 7,5±3, p<0,001; os valores de BNP da admissão no estudo à avaliação final reduziram significativamente 381(202-707) pg/ml versus 309(180- 640) pg/ml, p=0,012. Houve correlação positiva de moderada magnitude e significativa entre o delta do BNP com o número das CD presentes na avaliação clínica inicial do estudo r=0,304 e p=0,018. A área da curva ROC verificada resultou em 0,552, mostrando o nível de sensibilidade de 66,7%, quando o ponto de corte do valor do BNP for 447pg/ml e no teste de especificidade 54%. Os achados deste estudo indicam que o BNP apresentou um comportamento semelhante às CD, diminuindo seus valores de acordo com as manifestações do estado congestivo em pacientes internados por IC descompensada. A inclusão desse marcador como CD pode melhorar a acurácia diagnóstica. / Systemic congestion is the main factor related to decompensation of patients with heart failure (HF). The main clinical manifestations resulting from congestion are dyspnea, orthopnea, tiredness, distension of jugular vein, and edema. These signs and symptoms called Defining Characteristics (DC) in the classification of NANDA-International Nursing Diagnoses (ND) are part of the diagnosis of Excess Fluid Volume (EFV) often established in congested patients. These signs and symptoms are also often associated with respiratory system diagnoses and therefore may compromise diagnostic accuracy. In that sense, a wellstudied marker has been presented in the last two decades, B-type Natriuretic Peptide (BNP), which can distinguish cardiac dyspnea from pulmonary dyspnea. Aiming to add this biomarker to the DC set of the EFV diagnosis, this study was developed. This study aimed to analyze the behavior of BNP with the presence of defining characteristics of nursing diagnosis excessive fluid volume in hospitalized patients with decompensated HF during hospitalization. This is a Cohort study conducted in the emergence of a public university hospital, of a Southern Brazilian University Hospital. We included patients with HF diagnosis, reduced or preserved systolic function who were hospitalized by acute decompensation. The collection was systematized through a clinical evaluation at admission and discharge, containing the signs and symptoms already clinically validated as major and secondary for this diagnosis in patients with HF. Blood samples were also collected for BNP measurements. In the study, 64 patients were included, with mean age of 69±13 years, and fraction ejection of the left ventricular of 50±16%. From the initial to the final evaluation, there was a significant reduction of the following major dyspnea (97% x 62%), orthopnea (91% x 67%), edema (89% x 62%), hepatojugular reflux positive (60% x 32%), paroxysmal nocturnal dyspnea (95%x26%), pulmonary congestion (66% x49%), elevated central venous pressure (53% x27%) and secondary DC such as: weight gain (59% x9%), hepatomegaly (14% x11%), crepitations (86% x 50%) and oliguria (3% x 1,5%). The frequency of those signs and symptoms of the EFV DC on admission (11,3 ±3) and discharge (7,5±3) were statistically significant p<0,001. The median of the BNP values were reduced significantly: 381(202-707) pg/ml in admission and 309(180-640) pg/ml in discharge, p=0,012. There was a moderate and significant positive correlation between the BNP delta and the number of DC present in the initial clinical evaluation of the study r = 0.304 and p = 0.018. There was also a moderate and significant positive correlation between BNP´s delta and number of DC presented in the clinical initial evaluation of this study r=0,304 e p=0,018. The area of the ROC curve was found to be 0.552, showing the sensitivity level of 66.7% when the BNP value cutoff point was 447pg / ml and the specificity test was 54%. The findings of this study indicate that BNP presented a similar behavior to DC, reducing its values according to the reduction of clinical of congestive status in patients admitted for decompensated HF. Inclusion of this marker as a DC can improve diagnostic accuracy.

Metabolomic Insights into the Pharmacological and Genetic Inhibition of Cyclooxygenase-2 William T. E. Briggs The cyclooxygenase (COX)-2 inhibitors, or “coxibs,” are excellent anti-inflammatory agents, but their reputation has been tarnished by the adverse cardiovascular (CV) events, including heart failure (HF), with which they are associated. Whilst the risk of HF represents the greatest adverse CV event signal seen with these compounds, it is also perhaps the least well understood and has often been explained away as a consequence of the thrombotic risk with which the coxibs are also associated. One recent hypothesis, put forward by Ahmetaj-Shala et al., suggests that asymmetric dimethylarginine (ADMA) may serve as a mechanistic bridge between COX-2 inhibition and HF. However, the ADMA-COX-2 hypothesis was developed based on findings in a constitutive mouse model of COX-2 knock-out (KO), which is compromised by severe developmental cardio-renal pathology, and pharmacological studies which may not accurately reflect coxib use in clinical practice. Various studies have explored the metabolic changes induced by coxib treatment. However, these studies have been limited in scope and have tended to focus on specific pathways or certain tissues/bio-fluids. This has left large regions of the metabolome, in the context of coxib-treatment, unexplored. Given that metabolic remodelling is a key feature of HF, changes in these metabolites may hold the key to understanding the pathogenesis of coxib-induced HF. L-Carnitine shuttles activated long-chain fatty acids (FAs) across the inner mitochondrial membrane to the mitochondrial matrix, where they are oxidised by β-oxidation. This is especially important in the heart, which derives the majority of its energy from the metabolism of FAs. Changes in carnitine metabolism are also seen in HF. It is therefore biologically plausible that derangements in carnitine metabolism may contribute to the pathogenesis of coxib-induced HF. This thesis employs a combination of targeted and untargeted metabolomic techniques, stable isotope labelling and quantitative reverse transcription polymerase chain reaction (RT-qPCR) to i) profile the metabolic changes induced by celecoxib and rofecoxib, in the mouse; ii) specifically interrogate the effect of celecoxib, rofecoxib and global COX-2 gene deletion on carnitine synthesis, metabolism and shuttling, and iii) explore the advantages and disadvantages of the inducible post-natal global (IPNG) COX-2 KO (COX-2-/-) mouse, an alternative to the constitutive COX-2-/- mouse used by Ahmetaj-Shala et al. The results of this thesis demonstrate that i) celecoxib and rofecoxib have similar metabolomic consequences in the mouse; ii) carnitine metabolism may be affected by celecoxib, rofecoxib and dietary composition, via a peroxisome proliferator-activated receptor-alpha (PPAR-α) mediated effect on hepatic carnitine synthesis and iii) the IPNG COX-2-/- mouse neither exhibits the severe developmental cardio-renal pathology nor the altered ADMA metabolism observed in the constitutive COX-2-/- mouse. These findings contradict those of Ahmetaj-Shala et al., oppose the ADMA-COX-2 hypothesis and highlight a potential role for carnitine metabolism and diet in coxib induced HF.

Made available in DSpace on 2014-06-11T19:25:36Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-02-17Bitstream added on 2014-06-13T20:14:17Z : No. of bitstreams: 1 bussoni_mf_me_botfm.pdf: 519756 bytes, checksum: c724f1d40d7988265c8b8b601c44ca60 (MD5) / A insuficiência cardíaca (IC) é uma síndrome grave associada a alta mortalidade em 5 anos, após o início dos sintomas. Portanto, é de interesse o estudo de tratamentos farmacológicos e não-farmacológicos que visem impedir a progressão da lesão miocárdica, reduzir os sintomas e melhorar a qualidade de vida. Uma das formas de tratamento não farmacológico é o uso de Pressão Positiva Contínua em Vias Aéreas (CPAP). Estudos mostraram que a CPAP está associada com melhora da função sistólica ventricular esquerda. Entretanto, há poucos dados na literatura referentes aos seus efeitos na função diastólica. Objetivos: o objetivo primário desse estudo foi avaliar os efeitos de sessão única de CPAP na função diastólica ventricular e na capacidade funcional de pacientes com IC compensada. Adicionalmente, foram analisadas, nesses pacientes, as associações entre capacidade funcional e função ventricular; capacidade funcional e qualidade de vida; e função ventricular e qualidade de vida. Estudo prospectivo, randomizado e duplo-cego, utilizando programa informatizado de números aleatórios, na proporção 1:1. Vinte e um pacientes foram alocados no grupo sham (ou CPAP simulado) e 23 no grupo CPAP, que recebeu a intervenção. Os pacientes, inicialmente, permaneciam 10 minutos em repouso e passavam por avaliação clínica. Em seguida, eram submetidos a ecocardiograma basal. Então, realizavam Teste de caminhada de 6 minutos (TC6) para aprendizagem, sendo que os dados obtidos nesse teste foram descartados. Enquanto descansavam por, no mínimo, 15 minutos, os pacientes respondiam ao Questionário de Qualidade de Vida de Minnesota (QQVM). Após, realizavam um segundo TC6, no qual os dados foram utilizados para análise. Ao seu término, os pacientes do Grupo CPAP recebiam a intervenção por 30 minutos a uma pressão de 10 cmH20. O pacientes do Grupo Sham permaneciam... / Heart failure (HF) is a syndrome associated with high mortality within 5 years after the onset of symptoms. Therefore) the study on pharmacological and non-pharmacological therapies for preventing myocardial damage progression) reducing symptoms and improving quality of life is desirable. One of the forms of non-drug treatment is the use of Continuous Positive Airway Pressure (CPAP). Studies have shown that CPAP is associated with left ventricular systolic function improvement. However) few data are available referring to its effects on diastolic function. The primary aim of this study was to evaluate the effects of a single CPAP session on ventricular diastolic function and on the functional capacity of patients with compensated HF. Additionally) the associations between functional capacity and ventricular function) functional capacity and quality of life and ventricular function and quality of Iife were analyzed in these patients. This was a prospective) randomized) double-blind study using a random-figure computerized program in the proportion of 1:1. Twenty-one patients were included in the Sham group (or simulated CPAP) and 23 in the CPAP group) which received the intervention. Initially) the patients rested for 10 minutes and then underwent c1inical evaluation. Next) they were submitted to a basal echocardiogram. Then) the six-minute walk test (6MWT) was performed for learning) and the data obtained in that test were discarded. While they rested for at least 15 minutes) the patients answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ). They then performed the second 6MWT) in which the data were used for analysis. Upon completion) the patients in the CPAP group received the intervention for 30 minutes at apressure of 10 cmH20. The patients in the Sham group kept the CPAP mask on for that period of time) but without producing positive pressure. Next)... (Complete abstract click electronic access below)

abstract: Background: Heart failure is the leading cause of hospitalization in older adults and has the highest 30-day readmission rate of all diagnoses. An estimated 30 to 60 percent of older adults lose some degree of physical function in the course of an acute hospital stay. Few studies have addressed the role of posture and mobility in contributing to, or improving, physical function in older hospitalized adults. No study to date that we are aware of has addressed this in the older heart failure population. Purpose: To investigate the predictive value of mobility during a hospital stay and patterns of mobility during the month following discharge on hospital readmission and 30-day changes in functional status in older heart failure patients. Methods: This was a prospective observational study of 21 older (ages 60+) patients admitted with a primary diagnosis of heart failure. Patients wore two inclinometric accelerometers (rib area and thigh) to record posture and an accelerometer placed at the ankle to record ambulatory activity. Patients wore all sensors continuously during hospitalization and the ankle accelerometer for 30 days after hospital discharge. Function was assessed in all patients the day after hospital discharge and again at 30 days post-discharge. Results: Five patients (23.8%) were readmitted within the 30 day post-discharge period. None of the hospital or post-discharge mobility measures were associated with readmission after adjustment for covariates. Higher percent lying time in the hospital was associated with slower Timed Up and Go (TUG) time (b = .08, p = .01) and poorer hand grip strength (b = -13.94, p = .02) at 30 days post-discharge. Higher daily stepping activity during the 30 day post-discharge period was marginally associated with improvements in SPPB scores at 30 days (b = <.001, p = .06). Conclusion: For older heart failure patients, increased time lying while hospitalized is associated with slower walking time and poor hand grip strength 30 days after discharge. Higher daily stepping after discharge may be associated with improvements in physical function at 30 days. / Dissertation/Thesis / Doctoral Dissertation Exercise and Wellness 2015

Made available in DSpace on 2014-06-11T19:22:58Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-02-25Bitstream added on 2014-06-13T20:29:31Z : No. of bitstreams: 1 bertaglia_rs_me_botib.pdf: 404383 bytes, checksum: 685b1ff908a8d635b02a9b8e84ddbf1e (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A insuficiência cardíaca (IC) está associada à miopatia dos músculos esqueléticos dos membros, com perda da massa muscular, diminuição na proporção da cadeia pesada das miosinas do tipo I (MHCI), aumento na proporção da cadeia pesada das miosinas do tipo II (MHCII), decréscimo do metabolismo oxidativo e alterações nos fatores de regulação miogênica (MRFs). Na IC também ocorre aumento do estresse oxidativo na musculatura esquelética, o qual está relacionado às mudanças estruturais, morfológicas e funcionais. Nesse estudo, nós investigamos e comparamos as características morfofuncionais dos músculos Sóleo (SOL), lento e com predomínio de fibras oxidativas e Extensor Digitorum Longus (EDL), rápido e com predomínio de fibras glicolíticas em ratos com IC induzida pela monocrotalina. Foram utilizados ratos Wistar, machos (90 a 100 g), divididos em 2 grupos: controle (CT) e insuficiência cardíaca (IC), induzida pela injeção de dose única de monocrotalina (MCT, 30mg/Kg i.p.). Após 22 dias da injeção da MCT, quando os animais apresentaram sinais de IC, todos os animais foram sacrificados e pesados. Os músculos SOL e EDL foram retirados, pesados e processados para as análises morfológicas, moleculares, bioquímicas e funcionais. A expressão gênica da MyoD e miogenina foram determinadas usando qRT-PCR, as isoformas de MHC foram determinadas por eletroforese em gel de poliacrilamida, a freqüência e área de secção transversal dos tipos de fibra foram analisadas pela reação histoquímica de ATPase miofibrilar (mATPase). Foram realizados estudos bioquímicos para a determinação do hydroperóxido de lipídeo (HL), da glutationa peroxidase (GSH-Px) e da superóxido dismutase (SOD) e catalase (CAT); o estudo miográfico foi realizado para determinar a força máxima de contração, o tempo de contração e de relaxamento e a resistência à fadiga... / Heart failure (HF) is characterized by a limited exercise tolerance, skeletal muscle myopathy with atrophy, shift toward fast muscle fiber and myogenic regulatory factors (MRFs) changes. Reactive oxygen species (ROS) also contribute to target organ damage in the heart failure syndrome. In this study, we investigated and compared the morphofunctional characteristics in SOL, a slow oxidative muscle and EDL, a fast glycolytic muscle in a monocrotaline-induced heart failure. Two groups of rats were studied: control (CT) and Heart Failure (HF), induced by a single intraperitoneal injection of monocrotaline (MCT, 30mg/Kg). MyoD and myogenin expression were determined by using qRT-PCR, MHC isoforms were studied by using polyacrylamide gel electrophoresis, muscle fiber-type frequency and cross sectional area (CSA) were analyzed by myofibrillar adenosine triphosphatase (mATPase). Biochemical study were performed to determine: lipid hydroperoxide (LH), glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD); myographic study was performed to analyze: amplitude, rise time, fall time and fatigue resistance in SOL and EDL muscles. All monocrotaline treated rats showed signs of HF (atrium and right ventricular hypertrophies, pleural and pericardial effusions, and congested liver). HF group showed SOL and EDL muscles atrophy, confirmed by CSA decreased in muscle fiber types (types I, IC, IIC and IIA in SOL and I, IIC, IIA, IIA/D and IIDB in EDL muscles); the frequency of IIC fiber type and the fall time of muscle contraction increased only in SOL muscle; he myogenin mRNA expression was lower only in the SOL muscle and the MyoD mRNA expression decreased only in EDL muscle. HF group also presented the concentration of lipid hydroperoxide increased, superoxide-dismutase and glutathione peroxidase activity reduced only in SOL muscle; EDL muscle showed the contractile properties, concentration... (Complete abstract click electronic access below)

A congestão sistêmica é o principal fator relacionado à descompensação de pacientes com insuficiência cardíaca (IC), conferindo manifestações clínicas como dispneia, ortopneia, cansaço, distensão da veia jugular e edema. Estes sinais e sintomas, assim denominados características definidoras (CD) na classificação de Diagnósticos de Enfermagem (DE) da NANDA-International, fazem parte do diagnóstico de Volume de líquidos excessivo (VLE) frequentemente estabelecido em pacientes congestos. Estes sinais e sintomas também são frequentemente associados a diagnósticos do sistema respiratório e, por conseguinte, podem comprometer a acurácia diagnóstica. É nessa perspectiva, que se apresenta um marcador bastante estudado nas duas últimas décadas, Peptídeo Natriurético tipo B (BNP), que consegue diferenciar a dispneia de origem cardíaca da dispneia de causa pulmonar. Visando agregar este biomarcador ao conjunto de CD do diagnóstico VLE que este estudo foi desenvolvido. O objetivo do estudo é analisar o comportamento do Peptídeo Natriurético tipo B com a presença das CD do diagnóstico VLE em pacientes com IC descompensada durante a internação. Trata-se de um estudo de coorte conduzido em hospital público universitário, Porto Alegre, RS. Foram incluídos pacientes com diagnóstico de IC, função sistólica reduzida ou preservada, que internaram por descompensação aguda. A coleta foi sistematizada por meio de uma avaliação clínica na admissão e após compensação da IC (até sete dias após a admissão, denominado avaliação final), contendo as CD já validadas clinicamente para este diagnóstico em pacientes com IC como principais e secundárias. Também foram coletadas amostras de sangue para dosagem do BNP nestes dois períodos. Foram incluídos 64 pacientes, com média de idade de 69±13 anos, fração de ejeção do ventrículo esquerdo 50±16%. Da avaliação inicial à final, houve redução significativa das seguintes CD principais: dispneia (97% x 62%), ortopneia (91% x 67%), edema (89% x 62%), refluxo hepatojugular positivo (60% x 32%), dispneia paroxística noturna (95% x 26%), congestão pulmonar (66% x 49%), pressão venosa central elevada (53% x 27%); e secundárias, como ganho de peso (59%x9%), hepatomegalia (14%x11%), crepitação (86%x 50%) e oligúria (3%x1,5%). Em uma análise quantitativa das CD, observa-se uma redução da admissão à avaliação final no estudo, 11,3 ±3 versus 7,5±3, p<0,001; os valores de BNP da admissão no estudo à avaliação final reduziram significativamente 381(202-707) pg/ml versus 309(180- 640) pg/ml, p=0,012. Houve correlação positiva de moderada magnitude e significativa entre o delta do BNP com o número das CD presentes na avaliação clínica inicial do estudo r=0,304 e p=0,018. A área da curva ROC verificada resultou em 0,552, mostrando o nível de sensibilidade de 66,7%, quando o ponto de corte do valor do BNP for 447pg/ml e no teste de especificidade 54%. Os achados deste estudo indicam que o BNP apresentou um comportamento semelhante às CD, diminuindo seus valores de acordo com as manifestações do estado congestivo em pacientes internados por IC descompensada. A inclusão desse marcador como CD pode melhorar a acurácia diagnóstica. / Systemic congestion is the main factor related to decompensation of patients with heart failure (HF). The main clinical manifestations resulting from congestion are dyspnea, orthopnea, tiredness, distension of jugular vein, and edema. These signs and symptoms called Defining Characteristics (DC) in the classification of NANDA-International Nursing Diagnoses (ND) are part of the diagnosis of Excess Fluid Volume (EFV) often established in congested patients. These signs and symptoms are also often associated with respiratory system diagnoses and therefore may compromise diagnostic accuracy. In that sense, a wellstudied marker has been presented in the last two decades, B-type Natriuretic Peptide (BNP), which can distinguish cardiac dyspnea from pulmonary dyspnea. Aiming to add this biomarker to the DC set of the EFV diagnosis, this study was developed. This study aimed to analyze the behavior of BNP with the presence of defining characteristics of nursing diagnosis excessive fluid volume in hospitalized patients with decompensated HF during hospitalization. This is a Cohort study conducted in the emergence of a public university hospital, of a Southern Brazilian University Hospital. We included patients with HF diagnosis, reduced or preserved systolic function who were hospitalized by acute decompensation. The collection was systematized through a clinical evaluation at admission and discharge, containing the signs and symptoms already clinically validated as major and secondary for this diagnosis in patients with HF. Blood samples were also collected for BNP measurements. In the study, 64 patients were included, with mean age of 69±13 years, and fraction ejection of the left ventricular of 50±16%. From the initial to the final evaluation, there was a significant reduction of the following major dyspnea (97% x 62%), orthopnea (91% x 67%), edema (89% x 62%), hepatojugular reflux positive (60% x 32%), paroxysmal nocturnal dyspnea (95%x26%), pulmonary congestion (66% x49%), elevated central venous pressure (53% x27%) and secondary DC such as: weight gain (59% x9%), hepatomegaly (14% x11%), crepitations (86% x 50%) and oliguria (3% x 1,5%). The frequency of those signs and symptoms of the EFV DC on admission (11,3 ±3) and discharge (7,5±3) were statistically significant p<0,001. The median of the BNP values were reduced significantly: 381(202-707) pg/ml in admission and 309(180-640) pg/ml in discharge, p=0,012. There was a moderate and significant positive correlation between the BNP delta and the number of DC present in the initial clinical evaluation of the study r = 0.304 and p = 0.018. There was also a moderate and significant positive correlation between BNP´s delta and number of DC presented in the clinical initial evaluation of this study r=0,304 e p=0,018. The area of the ROC curve was found to be 0.552, showing the sensitivity level of 66.7% when the BNP value cutoff point was 447pg / ml and the specificity test was 54%. The findings of this study indicate that BNP presented a similar behavior to DC, reducing its values according to the reduction of clinical of congestive status in patients admitted for decompensated HF. Inclusion of this marker as a DC can improve diagnostic accuracy.

Orientador: Fernanda Aparecida Cintra, Maria Cecilia Jayme Bueno Gallani / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T18:54:11Z (GMT). No. of bitstreams: 1 Saccomann_IzabelCristinaRibeirodaSilva_M.pdf: 1268829 bytes, checksum: f4a044fe5f528f3bc98a4da6155b095b (MD5) Previous issue date: 2005 / Resumo: A Insuficiência Cardíaca (IC) traz implicações na qualidade de vida (QV); nos idosos, a sua incidência e prevalência mostram-se elevadas. Recentes estudos têm sido desenvolvidos para identificar os determinantes de QV, buscando avaliar as mudanças no estilo de vida imposto pela própria doença. Dentre os instrumentos genéricos, o mais utilizado em nosso país é o The Medical Study 36-item Short-Form Health Survey (SF-36). Com respeito aos específicos, o Minnesota Living with Heart Failure (LHFQ) corresponde ao instrumento mais reconhecido para a IC, entretanto ele não contempla as especificidades dos idosos. Este estudo teve como objetivo verificar se o instrumento LHFQ apresenta propriedades psicométricas satisfatórias, na sua aplicação em idosos com IC. Trata-se de uma investigação de natureza metodológica. Os dados foram coletados junto a 170 idosos portadores de IC, em seguimento ambulatorial, por meio da aplicação de três instrumentos: 1. questionário para a caracterização dos sujeitos; 2. LHFQ; e, 3. SF-36. Os dados foram submetidos à análise estatística descritiva, de confiabilidade por meio do alfa de Cronbach, de Análise de Variância (ANOVA nos Ranks) e de correlação por meio do coeficiente de correlação de Spearman. A consistência interna do LHFQ foi elevada, indicando confiabilidade satisfatória (a >0,80). O LHFQ discriminou entre os três grupos de classificação funcional da New York Heart Association (NYHA), Classe Funcional I, II e III/IV (p < 0,0001), exceto a dimensão emocional que discriminou entre as Classes Funcionais I e III/IV (p < 0,0034). A validade convergente demonstrou correlação de moderada a forte magnitude com o SF-36, especialmente nas dimensões relacionadas às limitações físicas (r > 0,50; p< 0,001), entretanto, demonstrou ausência de validade divergente. O LHFQ apresentou itens não respondidos nas questões referentes ao trabalho e à atividade sexual, e mostrou efeito teto em suas dimensões. Esse instrumento revelou ser uma medida confiável e válida para avaliar as dimensões que afetam a QV dos idosos, embora contemple alguns itens não respondidos pela amostra estudada. Recomenda-se considerar com cautela a aplicabilidade desse instrumento, com respeito às questões que não se aplicam à idade avançada, pelas características inerentes à essa faixa etária / Abstract: The Heart Failure (HF) brings consequences to the quality of life (QOL); in the elderly its incidence and prevalence are very high. Recent studies have been developed to identify the quality of life determinants, trying to evaluate the changes in the life style imposed by the disease itself. The instruments that evaluate the quality of life focus on subjective aspects in different domains, like the physical, the emotional and the cognitive functioning. Among the generic instruments, the most used in our country is The Medical Study 36-item Short Form Health Survey (SF-36). Among the specific ones, The Minnesota Living With Heart Failure (LHFQ) corresponds to the most recognized instrument for HF despite not analyzing the elderly specificities. This study¿s objective was to check if the LHFQ instrument presents satisfactory psychometric properties in the elderly with HF. It is a methodological investigation, with a sample of 170 elderly people bearing HF, clinic outpatients. Data were collected through three instruments: 1. a questionnaire to characterize the subjects; 2. LHFQ and 3. SF-36. In the analysis, central trends (mean, standard deviation and median), frequency distribution, Cronbach's alpha, ANOVA in the ranks and Spearman correlation coefficients calculus were carried out. The LHFQ internal consistency was high, indicating satisfactory reliability (a >0,80). The LHFQ discriminated among the New York Heart Association (NYHA) class I, II and III/IV (p < 0,0001), except the emotional dimension that discriminated among NYHA class I and III/IV (p < 0,0034). The convergent validity has demonstrated moderate to strong magnitude correlation with the SF-36, specially in the dimensions related to the physical limitations (r> 0,50; p < 0,001), however it has showed absence of discriminative validity. The LHFQ presented items which were not answered in questions referring to work and sexual activity as well as ceiling effect in its dimensions. The LHFQ has proved to be a valid and reliable measure to evaluate the dimensions that affect the elderly quality of life although it analyses some items that were not answered by the population in this study. It is recommended that this instrument applicability be carefully considered in relation to the questions that do not apply to advanced age due to specific characteristics, inherent to this age range / Mestrado / Enfermagem e Trabalho / Mestre em Enfermagem

Orientador: Kleber Gomes Franchini / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-07T01:54:36Z (GMT). No. of bitstreams: 1 Ribeiro_GustavoCaladodeAguiar_D.pdf: 2448805 bytes, checksum: 884ae49c4ce46337410548bb393439fa (MD5) Previous issue date: 2006 / Resumo: A insuficiência cardíaca é um dos maiores problemas de saúde publica da atualidade. Esforços têm sido feitos para a obtenção do entendimento dos mecanismos que resultam no comprometimento funcional e estrutural do miocárdio, responsáveis, em última instância, pela síndrome clínica. A doença isquêmica resulta em infarto do miocárdio e hipertrofia excêntrica das câmaras ventriculares que têm papel central no estabelecimento e evolução das alterações estruturais que acompanham a deterioração funcional do miocárdio e, por conseguinte, a da função global das câmaras cardíacas. No presente estudo foram avaliados pacientes portadores de insuficiência cardíaca decorrente de infarto do miocárdio e apresentando acinesia na parede anterior com indicação clínica de tratamento cirúrgico, com o objetivo de avaliar alterações estruturais e funcionais do miocárdio. Os pacientes foram avaliados clinicamente, por ecocardiografia e ressonância magnética no período pré-operatório e clínica e ecocardiograficamente em seguimento de 2 anos após a cirurgia. Foram realizadas biópsias intra-operatórias do endocárdio ventricular para avaliação de área de fibrose. A percentagem da área de fibrose encontrada na biópsia foi comparada com a percentagem de fibrose encontrada na ressonância magnética e comparada com a evolução. Os pacientes foram divididos de acordo com os territórios vasculares do miocárdio infartados e comparados na evolução. Os pacientes apresentavam sintomas importantes de insuficiência cardíaca (CF III-IV) no pré-operatório de cirurgia para correção da geometria do ventrículo esquerdo. A média da fração de ejeção era de 35,6% e o volume sistólico final do ventrículo esquerdo era de 150,6 ml. Foram verificadas reduções dos sintomas de insuficiência cardíaca (NYHA) no período de seguimento pós-operatório ( de 3,7± 0,4 para 1,53± 0,6, p<0,001) e melhora da fração de ejeção (de 35,5± 5,4 para 47,3± 7,3, p<0,001). Houve também redução do remodelamento no período de seguimento pós-operatório (de 150,6 ± 52,8 ml para 91,92± 32,7 ml, p<0,001). Houve correlação inversa entre o volume sistólico final do ventrículo esquerdo e as frações de ejeções do pré (r= -0,6) e pós-operatório (r=-0,88). Houve uma correlação positiva entre o percentual da área de fibrose tanto com o volume sistólico final (r=0,67) e correlação inversa com a fração de ejeção do ventrículo esquerdo (r=-0,78). Pacientes com menor percentual da área de fibrose do ventrículo esquerdo evoluíram com menor número de eventos cardiovasculares (p<0,001), assim como pacientes com menor volumes sistólico (p=0,004). Houve correlação com área de fibrose analisada pela ressonância magnética e mensurada pela biópsia (r=0,89) Os achados deste estudo são que pacientes com múltiplas áreas acinéticas também apresentam benefício com este procedimento e o percentual de área de fibrose mensurada por ressonância magnética correlaciona-se com a biópsia, e com a evolução pós-operatória analisada pelo volume sistólico final do ventrículo esquerdo, com a fração de ejeção do pós-operatório e com menor número de eventos. Esses achados permitem concluir que a cirurgia de reconstrução geométrica do ventrículo esquerdo alivia sintomas, melhora a remodelamento do ventrículo esquerdo em pacientes com insuficiência cardíaca com sintomas avançados. Finalmente, que a análise do percentual de área de fibrose avaliada por ressonância nuclear magnética sugere ser um importante método não-invasivo para análise da evolução / Abstract: Heart failure is one of the biggest problems faced by public health. Efforts have been made in order to achieve full understanding of the mechanisms that result in the myocardium structural and functional deterioration, which is responsible for advanced symptoms. Coronary disease results in myocardium infarction and eccentric hypertrophy of the ventricular chambers, which play a central role in the setting up and evolution of the structural alterations that follow myocardium functional deterioration and, consequently, the global ventricular dysfunction. In the present study patients presenting heart failure due to myocardium infarction and akinesia in the anterior wall that underwent surgery were evaluated, aiming at analyzing structural and functional alterations of the myocardium. These patients were evaluated by clinical exams, echocardiography, and magnetic resonance in the pre-operative period and underwent clinical and echocardiograph exams for a period of two years after surgery. Endomyocardial biopsy were done intra-operatively in all patients for fibrosis analysis. The fibrosis area in endomyocardium tissue was correlated with percentage of fibrosis found in magnetic resonance. The patients were separated in two groups, according of the number of myocardium infarctions. The patients presented advanced symptoms of heart failure (CF III-IV) in the pre-operative for the reconstruction of the left ventricle. The average ejection fraction was 35,6% and the left ventricle end systolic volume was 150,6ml. Patients with multiterritory myocardial infarction were evaluated and correlated with the percentage of scar tissue was measured by magnetic resonance imaging and was correlated to the patient¿s evolution and biopsy. Significant reductions in number and intensity of symptoms in the post-operative outcome were verified (from 3.7± 0.4 to 1.53± 0.6, p<0.001). There was correlation between the left ventricle final systolic volume (from 150.6 ± 52.8 ml to 91.92± 32.7 ml, p<0.001). and the ejection fractions in the pre and port-operative (from 35.5± 5.4 to 47.3± 7.3, p<0.001). There was also a correlation between the percentage of the scar tissue both in the final systolic volume (r=0.67) and in the ejection fraction (r=-0,88) of the left ventricle. Patients having a smaller percentage of the scar tissue area evolved with a smaller number of cardiovascular events (p<0.001) Patients with multiple ventricle territories presenting myocardium infarction evolved with larger left ventricle final systolic volume (p=0.004) The findings of this study are patients presenting akinetic multiple areas are benefited by this type of procedure and the percentage of scar tissue area measured by resonance magnetic correlates to the left ventricle final systolic volume in post-operative, with an ejection fraction of the post-operative and with a smaller number of events. These findings lead to the conclusion that geometric reconstruction surgery of the left ventricle relieves symptoms, improve left ventricle remodeling in patients with advanced symptoms of heart failure. Finally, the analysis of the percentage of scar tissue evaluated magnetic resonance is an important non-invasive method to analyze evolution / Doutorado / Biologia Estrutural, Celular, Molecular e do Desenvolvimento / Doutor em Fisiopatologia Medica