Ce travail de thèse avait pour objectif d'évaluer l'intérêt des peptides collagéniques sanguins dans différentes populations à haut risque de développer une insuffisance cardiaque (patients présentant une obésité abdominale ou en post-infarctus du myocarde) ou déjà symptomatiques (post-infarctus du myocarde). En effet la fibrose myocardique est un élément essentiel de l'évolution péjorative de l'insuffisance cardiaque.Ces travaux ont permis de montrer la pertinence clinique des dosages sanguins des peptides collagéniques tout au long du processus de l'insuffisance cardiaque : du stade asymptomatique aux stades symptomatiques. Nous avons mis en évidence, à travers l'expression des peptides collagéniques que : 1/ des patients asymptomatiques ayant une obésité abdominale présentent un remodelage cardiaque précoce tant structurel que fonctionnel (augmentation de la masse ventriculaire gauche, dysfonction diastolique associée au PIIINP) : R2C2 Study. 2/ le ratio PIIINP/ICTP ≤ 1, mesuré 1 mois après un infarctus, est indépendamment associé à la survenue d'un remodelage ventriculaire gauche à un an et améliore la prédiction de survenue d'évènements cardiovasculaires (décès cardiovasculaires et hospitalisation pour décompensation cardiaque) à 3 ans : REVE-2 study. 3/ les antagonistes des récepteurs aux minéralocorticoïdes (éplérénone), traitement anti-fibrotique par excellence, sont efficaces et sûrs (hyperkaliémie et insuffisance rénale) chez des patients à haut risque de remodelage et de complications: EMPHASIS-HF study. Ce travail doit conduire à la validation dans d'autres populations du rôle prépondérant de la fibrose mais surtout au bénéfice thérapeutique des classes anti-fibrotiques dans l'insuffisance cardiaque. / No abstract available

There is a growing epidemic of chronic heart failure (CHF) in the developed world. The costs associated with providing care is profound and despite our best efforts, new, more effective treatments for CHF are needed; 50% of patients diagnosed with CHF are dead within 5 years. Current paradigms rely heavily on pharmacologic interventions, which merely help manage the disease. Surgical interventions may also be considered for late stage CHF patients such as heart transplant or left ventricular assist device (LVAD) but require burdensome and invasive surgical procedures. In addition they are costly, and require the need for life long immunosuppressive and anticoagulant therapies respectively. Despite our best intentions, the long-term prognosis for CHF patients remains poor. With over a decade of clinical investigation taken place, data from cell-based therapy trials remains inconsistent. While demonstrating safety, limited efficacy has been reported and to date, no stem cell therapy has been approved by the FDA. Despite these shortcomings important lessons have been learned that can be applied to future developments. Retrospective analysis of early cell-based clinical trial data has suggested that variations in isolated cell number, viability, and potency from donor to donor in autologous preparations yielded wide discrepancies in functional outcomes. In addition, sub culturing adult stem cells, even for short periods of time in 2D polystyrene environments void of complementary cell populations and extra cellular matrix protein interactions, may alter the therapeutic potential of a given cell. As a solution, allogeneic approaches where donor cell quality and potency can be assessed and optimized may help achieve functional benefits. Furthermore, co-dosing with multiple cell populations or developing 3D sub-culture environments that more closely mimic the in vivo milieu may ultimately yield more potent therapeutic cell populations. While these alterations may improve cell-based therapy outcomes, other solutions have been proposed such as tissue engineering. While the concept of tissue engineering is not new, advancements in biomaterials, bioreactor design and cell sources have greatly enhanced the reality of these preparations. Previously, one of the greatest limitations to tissue engineering is overcoming the cell requirements for developing and testing where millions if not billions of cells are required. Cell sourcing limitations appear to have been solved with the discovery and development of induced pluripotent stem cell (iPSC) derived cell populations. First reported in 2007, they have the ability to generate embryonic like pluripotent stem cells without the ethical concerns of embryonic stem cells. These iPSCs hold tremendous potential for drug toxicology / screening, personalized medicine and cell therapies. The body of work described in this dissertation looks at developing and testing a tissue engineered cardiac patch to treat heart failure. For which, an emphasis has been to provide 1) structural support for engrafted cells and 2) a rapidly inducible vascular supply once implanted in vivo. Biomaterials were sourced that facilitate infill by multiple cell populations in 3D culture and the establishment of extra cellular matrix deposits. Together, these patches enhanced cellular development in vitro and result in long term functional improvements in small animal models for CHF. Additional feasibility work was performed in large animal models to permit upscaling and development of surgical implantation techniques to demonstrate clinical applicability

Personal Health Records (PHRs) allow patients to access and in some cases manage their own health records. Their potential benefits include access to health information, enhanced asynchronous communication between patients and clinicians, and convenience of online appointment scheduling and prescription refills. Potential barriers to PHR use include lack of computer and internet access, poor computer or health literacy, security concerns, and provider disengagement. PHRs may help those living in rural areas and those with chronic conditions such as heart failure, monitor and manage their disease, communicate with their health care team and adhere to clinical recommendations. To provide some much needed actual research, a descriptive mixed methods study of the usability, usefulness, and disease management potential of PHRs for rural heart failure patients was conducted. Fifteen participants were enrolled. Usability issues fell into three categories: screen layout; applying consistent, standard formatting; and providing concise, clear instructions. Participants used PHR features that were more convenient than other methods or that had some additional benefit to them. There was no difference between rural and urban participants. A heart failure nurse promoted recording daily heart failure symptoms in the PHR. Most participants did so at least once, but many found it cumbersome. Reasons for recording included the comfort of having clinical staff monitor the data. Participants who were stable did not find recording as useful as did those who were newly diagnosed or unstable. Participants used asynchronous communication to send messages to the heart failure nurse that they would not otherwise have communicated. The study expands the knowledge of PHR use by addressing useful functionality and disease management tools among rural patients with heart failure. The patients were able to complete tasks they found useful. The increased communication and disease management tools were useful to some.

Durant le développement myocardique, les cardiomyocytes s'allongent et se connectent entre eux grâce à une structure spécialisée, le disque intercalaire. Cette organisation des cardiomyocytes est essentielle pour le couplage mécanique et la conduction électrique. Un des éléments responsables de l'insuffisance cardiaque est la perturbation de ces sites de contact intercellulaire. Actuellement, aucun facteur n'est connu pour coordonner l'organisation polarisée des cardiomyocytes. Ici, nous présentons une augmentation importante de Pdzrn3 dans des cardiomyopathies hypertrophiques humaines et dans des myocardes murins, corrélée à une perte de l'élongation polarisée des cardiomyocytes. De plus la délétion spécifique intramyocardique de l'expression de Pdzrn3, dans un modèle murin, protège de la survenue d'une insuffisance cardiaque secondaire à une cardiomyopathie hypertrophique. Nos résultats révèlent une nouvelle voie de signalisation qui contrôle un programme génétique essentiel pour le développement myocardique, le maintien de la géométrie et de la fonction contractile des cardiomyocytes. Cette voie de signalisation implique PDZRN3 et cette molécule constitue une cible thérapeutique potentielle pour la protection de l’insuffisance cardiaque chez l’homme. / During heart maturation, individual cardiomyocytes stretch out and connect some with the others via their extremities by intercalated disk protein complexes. This planar and directionnel organization of the myocyte sis crucial for the machanical coupling and the anisotropic conduction of the electric signal in the heart. One of the hallmarks of heart failure concerns alterations in the contact sites between cardiomyocytes. Yet no factors on its own is known to coordinate cardiomyocyte polarized organization. Here we reported enhanced levels of Pdzrn3 in the diseased hypertrophic human and mouse myocardium, correlated with the loss of cardiomyocyte polarized elongation. Furthermore, mouse cardiac Pdzrn3 deficiency protected against heart failure in a mouse model of hypertrophic cardiomyopathy. Our results reveal a novel signaling that controls a genetic program essential for heart maturation and for maintain of cardiomyocyte overall geometry and contractile function and implicates PDZRN3 as a potential therapeutic target for human heart failure protection.

Orientador: Carlos Roberto Padovani / Resumo: Nas áreas de Ciências da Saúde e Biológicas, encontram-se vários estudos, considerando as mais variadas patologias. Contudo, os procedimentos de análise estatística utilizados nos dados não têm relevado a estrutura de variação envolvida no conjunto das variáveis biológicas, quando se procede o fracionamento para discutir cada variável isoladamente. No presente texto, será abordada a Remodelação Cardíaca em ratos com Estenose Aórtica induzida e submetidos a um determinado protocolo de Treinamento Físico, sob o aspecto de não fracionamento do conjunto de variáveis, a fim de considerar toda a estrutura de variação envolvida nas respostas biológicas. A Insuficiência Cardíaca (IC) é uma das principais causas de morte na atualidade. Em estudos experimentais, uma maneira de induzir a IC em um rato, para posteriormente estudar medidas que atenuem tal quadro clínico, é simulando uma Estenose Aórtica (EAo), por meio da implantação de um clipe milímetros acima de sua válvula aórtica. Estudos sugerem que treinamento físico suaviza os sintomas antecedentes à insuficiência cardíaca. A fim de comprovar tal hipótese, um grupo de pesquisadores da Cardiologia Experimental da Faculdade de Medicina de Botucatu - UNESP realizou alguns experimentos, em que ratos da variedade Wistar foram induzidos à Estenose Aórtica e, posteriormente, submetidos a um específico protocolo de treinamento físico. Para a avaliação da contribuição do treinamento na resposta cardíaca desses animais, outros ratos, aqui d... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Heart failure (HF) is a leading cause of death nowadays. In experimental studies a way to induce the HF in a rats for subsequently studying measures that mitigate such clinical picture is simulating an aortic stenosis (EAo) through the implantation of a clip above the aortic valve. Studies suggest that physical training improves symptoms prior to heart failure. In order to prove this hypothesis, a group of researchers from the Experimental Cardiology of the Medical School of Unesp, Botucatu Campus, has made some experiments in which Wistar rats were induced to aortic stenosis and subsequently submitted to a specific protocol of physical training. For the assessment of the training contribution in cardiac response of these animals, other rats, here called Sham (without implantation of clip), also underwent the training protocol. Therefore, four groups were formed: EAo (rats induced to xv aortic stenosis); EAoTF (rats induced to aortic stenosis and submitted to physical training); Sham (without physical training); ShamTF (submitted to physical training). For this study were considered only two experiments in which at first were measured some variables from the echocardiogram and cardiomyocyte isolated and, in the second, the echocardiogram and papillary muscle. The goal of this research was to use multivariate techniques that consider the simultaneous study of the variables in each experiment aiming to conclude about the insertion of physical training as a mitigation of clinica... (Complete abstract click electronic access below) / Mestre

Bakgrund: Hjärtsvikt är en folksjukdom som förekommer i slutet av livet vid de allra flesta hjärtsjukdomarna. Symtom som andnöd skapar ångest och lidande för patienten vilket ställer krav på sjuksköterskan att hitta lindrande omvårdnadsåtgärder. Som teoretisk referensram valdes Kari Martinsens omvårdnadsteori som inriktar sig på de svagaste med stort behov av omsorg och hjälp med omvårdnad. Syfte: Att beskriva sjuksköterskors uppfattningar av god omvårdnad till patienter med hjärtsvikt i sent palliativt skede.   Metod: Studien genomfördes som en kvalitativ intervjustudie med fenomenografisk forskningsmetod.  Resultat: Sjuksköterskors uppfattningar om god omvårdnad är att lindra symtom med hjälp av läkemedel, genom att utföra omvårdnadshandlingar samt att ge omsorg genom mänsklig närvaro. Information till och från patienten och anhöriga var viktigt för en god vård. Sjuksköterskor visade en vilja att ge den bästa vården och arbeta tillsammans i team med en helhetssyn för patienten. Hinder för den goda omvårdnaden var brist på mänsklig närvaro, tid och kunskap hos omvårdnadspersonal om sjukdomens symtom. Slutsats: En organisation som gör det möjligt för sjuksköterskan att vara mer närvarande hos patienten lindrar symtom och ger ett mindre lidande. Utbildning av dem som utför omvårdnad ger kunskap och en större förståelse för patienten. / Background: Heart failure is a common disease that occurs at the end of life in most heart diseases. Symptoms such as shortness of breath create anxiety and suffering for the patient, which requires the nurse to find relieving nursing actions. The theoretical framework was the nursing theory of Kari Martinsen that focus on the weakest with a great need of care and help with nursing. Purpose: To describe nurses' perceptions of good care to patients with heart failure in late palliative stages. Method: The study was conducted as a qualitative interview study with phenomenographic research method. Result: Nurses' beliefs about good nursing are to alleviate symptoms with the help of drugs, to perform nursing actions and to provide care through human presence. Information to and from the patient and relatives was important for good care. Nurses showed a willingness to provide the best care and work together in teams with a holistic view of the patient. Obstacles to the good nursing care were lack of human presence, time and knowledge of nursing staff about the symptoms of the disease. Conclusion: An organization that allows the nurse to be more present at the patient relieves symptoms and gives less suffering. Education of those who perform nursing provides knowledge and a greater understanding of the patient.

SAMMANFATTNING Bakgrund: I en åldrande befolkning ökar prevalensen av hjärtsvikt. När det kommer till behandling av sjukdomen läggs mycket ansvar på patienten när det gäller symtomlindring. Strategier för att kunna kontrollera symtomen kan innebära en omfattande livsstilsförändring, vilket i sin tur kan skapa en mängd olika känslor för patienten.  Syfte: Syftet med denna studie var att beskriva patienters upplevelser av att leva med hjärtsvikt. Metod: En deskriptiv, systematisk litteraturstudie genomfördes. Tolv kvalitativa artiklar användes, och materialet analyserades genom kodning och teman. Databasen som användes var PubMed. Den teoretiska referensramen som tillämpades var livsvärldsperspektivet.    Resultat: Tre kategorier med tolv underkategorier identifierades. Patienter upplevde olika typer av begränsningar i det dagliga livet, både fysiska och emotionella. Andnöd och trötthet var en central fysisk upplevelse. Ensamhet, isolering och förändrade roller inom familjen rapporterades. Upplevelser av skuld, skam och känslan av att utgöra en börda gentemot familjen framkom. Vidare rapporterades olika former av anpassning till ett nytt liv, som till exempel förändringar i kost, alkoholkonsumtion och fysisk aktivitet. Positiv attityd och spiritualitet visades vara strategier för att hantera sitt tillstånd. Sjukhuset upplevdes vara den säkraste platsen för rehabilitering och hantering av symtom. Vidare framkom dock upplevelser av brister inom sjukvården gällande empati, kontinuitet och förmedlande av information. Familj och vänner upplevdes vara en viktig resurs gällande fysiskt och emotionellt stöd samt motivation.  Slutsats: Patienter med hjärtsvikt upplevde olika typer av begränsningar i det dagliga livet relaterat till sjukdomen, brister inom sjukvården samt behov av stöd. Sjukvården behöver ta dessa upplevelser i beaktande i mötet med patienten för att kunna individanpassa omvårdnad och egenvårdsrekommendationer. Vidare kan detta ge ett ökat oberoende och därmed en ökad livskvalitet för patienten. / ABSTRACT Background: In an ageing population the prevalence of heart failure is rising. When it comes to treating the disease, a lot of responsibility lies with the patient in terms of symptom management. Strategies to control symptoms may mean a significant change of life style which in turn can cause a range of emotions.  Objective: The objective for this study was to describe the experience of patients living with heart failure.  Methods: A descriptive systematic literature review was conducted. Twelve qualitative studies were used, and the material was analyzed by making codes and themes. The database that was used was PubMed. The theoretical framework that guided this study was theperspective of life world. Results: Three categories with twelve subcategories were identified. Patients experienced different types of limitations in their daily life, both physical and emotional. Central physical experiences were breathlessness and fatigue. Loneliness, isolation and changing roles within the family was also reported. Experiences of guilt, shame and a sense of being a burden towards the family emerged. Furthermore, various forms of adaptation were reported, such as changes in diet, alcohol consumption and physical activity. Positive attitude and spirituality proved to be strategies used to cope with the condition. The hospital was considered the safest place for rehabilitation and management of symptoms. Moreover, the hospital environment proved to lack in empathy, continuity and in conveying information. Family and friends were important resources regarding both physical and emotional support and motivation. Conclusions: Heart failure patients experience different types of limitations related to the disease in their daily life, shortcomings in health care, and need of support. The health care system needs to take these experiences into consideration when meeting the patient in order to personalize the care and self-care recommendations to increase independency and with that increase overall life quality for the patient.

Introdução: a insuficiência cardíaca (IC) caracteriza-se por uma síndrome complexa, que apresenta, como principais sintomas, falta de ar, fadiga e função cardíaca anormal, o que exige, dos pacientes, mudanças no estilo de vida. Observa-se que as orientações de cuidado, muitas vezes, não são incorporados pelo portador de IC, sendo este um importante aspecto para a piora clínica deste paciente. Na perspectiva do enfrentamento, o Senso de Coerência proposto por Aaron Antonovsky, referencial adotado nesta pesquisa, é um construto que, se bem aplicado aos portadores de IC, pode revelar aos profissionais de saúde a percepção que os pacientes apresentam acerca de sua condição de doença. Objetivo: analisar a existência de correlação entre a adesão ao tratamento e o senso de coerência em pacientes ambulatoriais com diagnóstico de IC. Material e Método: estudo exploratório, descritivo, prospectivo e de abordagem quantitativa, realizado no ambulatório especializado em Insuficiência Cardíaca e Transplante do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com amostra de 100 pacientes. Os instrumentos utilizados na análise foram o Questionário de Senso de Coerência e o Questionário de Adesão em Pacientes com Insuficiência Cardíaca, além de um roteiro de entrevista semiestruturada para a caracterização da amostra da população de estudo. Os dados clínicos foram coletados do prontuário eletrônico dos pacientes. A regressão linear múltipla foi a estratégia utilizada para identificação dos fatores associados à adesão e ao senso de coerência, enquanto o nível de significância utilizado foi 5%. Resultados: o perfil biossocial da amostra foi predominantemente de homens (70%), com idade superior a 40 anos (89%), casados ou com companheiros (66%), baixa escolaridade (65% ensino fundamental), vinculados à religião católica (66%), aposentados (44%), com antecedentes clínicos de hipertensão (54%), dislipidemias (31%) e diabetes (25%). O principal diagnóstico responsável pelo quadro de IC foram as miocardiopatias (91%). Com relação ao senso de coerência, a distribuição da pontuação na amostra da população estudada variou entre 79 e 196, com média de 147,99 e desvio padrão de 23,101. A pontuação do questionário podia variar entre 29 e 203 pontos. A pontuação no questionário de adesão variou entre 26 e 58 pontos, média de 43,13, desvio padrão em 8,099. Neste questionário, a pontuação poderia variar entre 0 e 60 pontos. A idade foi o único fator preditor de adesão ao tratamento. Gênero e renda familiar apareceram como fatores preditores do domínio compreensão do senso de coerência. O gênero, isoladamente, foi determinado como fator preditor dos domínios Manuseio, Significado e para o senso de coerência. A correlação entre senso de coerência e adesão ao tratamento não foi significativa. Houve correlação significativa e negativa entre idade e adesão ao tratamento. A miocardiopatia mostrou-se como significativa, quando se refere à adesão ao tratamento. Neste caso, dentre os indivíduos que apresentaram valores menores ou iguais à média para o escore adesão (51%), 43% eram miocardiopatas. A hipertensão arterial sistêmica apresentou-se como variável significativa para o domínio compreensão do construto senso de coerência. Dentre os indivíduos que apresentaram valores menores ou iguais à média, para o escore em questão (51%), 22% eram hipertensos. Conclusões: a análise do Senso de Coerência e sua relação com a adesão ao tratamento em doenças crônicas é, em geral, pouco estudada. Não houve correlação entre Senso de Coerência e adesão ao tratamento, porém o instrumento de adesão não apresentou consistência interna relevante para a análise. Os resultados desta pesquisa poderão ser utilizados para a melhoria da prática assistencial de enfermeiros no cuidado a pacientes com IC. / Introduction: heart failure (HF) is characterized by a complex syndrome that has as its main symptoms shortness of breath, fatigue, and abnormal cardiac function. It demands a change of lifestyle in patients, that most of the time, are not adequately adopted, causing problems in treatment Compliance. In the confrontation perspective, the Sense of Coherence proposed by Aaron Antonovsky, used in this research as reference, is a construct that, if well applied to the sufferers of heart failure, it could reveal to the health professional, the perception patients have around their illness. Objective: Analyze the existence of a correlation between compliance to treatment and Sense of Coherence in clinical patients with a diagnosis of heart failure. Materials and Method: This is a exploratory study, descriptive, prospective, of a quantitative approach, which took place in the Heart Failure and Transplant Specialty Clinic at the Instituto do Coração (Heart Institute) of Hospital das Clínicas of the Medical College of the University of São Paulo (InCor-HC FMUSP), with a sample of 100 patients. The means used for analysis were Sense of Coherence and Treatment Compliance Questionnaire, as well as a directed semi-structured interview for the characterization of the sample of the population in the study. The clinical data was collected from the patients electronic medical records. Multiple Linear Regression was the strategy used to identify the factors associated to Treatment Compliance and Sense of Coherence, and the significance level used was 5%. Results: The Biosocial profile of the sample was predominantly of males (70%), over 40 years old (89%), married or with partners (66%), retired (44%), with a history of clinical hypertension (54%), dyslipidemia (31%) and diabetes (25%). The primary diagnosis responsible for the Heart Failure Clinical profile was Cardiomyopathy (91%). As for the Sense of Coherence, the distribution of scoring points in the sample of the population studied varied between 79 and 196, with an average of 147, 99 and standard deviation of 23.101. The scoring in the Questionnaire can vary between 29 and 203 points. The scoring in the Treatment Compliance Questionnaire varied between 26 and 58 points, average of 43,13 and Standard Deviation in 8.099. In this questionnaire the scoring can vary between 0 and 60 points. Age was the only predictor in Treatment Compliance. Gender and family income appear as predicting factors in the domain of Sense of Coherence comprehension. Isolated, gender was a determinant as a predicting factor in the domains of handling, Significance and Sense of Coherence. The correlation between Sense of Coherence and Compliance of Treatment wasnt significant. There was a significant and negative correlation between age and Treatment Compliance. Cardiomyopathy appeared as significant when dealing with Treatment Compliance. In this case, among the individuals that showed lower or equal values to the average score of Treatment Compliance (51%), 43% had Cardiomyopathy. Systemic Arterial Hypertension, appeared as a significant variable for the domain of Comprehension of the Sense of Coherence Construct. Among the individuals that showed lower or equal to the average score in question values (51%), 22% were hypertensive. Conclusion: The Analysis of the Sense of Coherence in relation to Treatment Compliance in chronic diseases is in general, not very well researched. There was no correlation between Sense of Coherence and Treatment Compliance, although the Treatment Compliance instrument did not present internal consistence relevant to the analysis. The conclusions of this research can be employed in the improvement of clinical practice of nurses in the caring of patients with Heart Failure.

O objetivo deste estudo foi avaliar o uso da cintilografia de perfusão miocárdica planar de repouso para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e eletrocardiograma sem alterações sugestivas de isquemia. Foram estudados 71 pacientes com idades entre 34 e 87 (média 58, desvio-padrão 12) anos; 44 (62%) eram do sexo masculino e 27 (38%) do feminino. Os pacientes com dor torácica foram avaliados na unidade de emergência com anamnese, exame físico e eletrocardroqrarna de 12 derivações. Pacientes com dor torácica de duração superior a 20 minutos, em vigência da dor ou sem dor, mas que sofreram dor torácica até seis horas anies do atendimento e com eletrocardioqrarna sem alterações sugestivas de isquemia miocárdica, foram submetidos à cintilografia planar de perfusão miocárdica de repouso quando solicitada pelo médico assistente. O tempo médio entre o início da dor toràcica e a Injeção do radiotraçador foi de três horas e seis minutos. Treze pacientes apresentavam dor torácica no momento da injeção. Foram colhidas amostras sanguineas para dosagens de atividade da creatinoquinase-MB (CK-MB), CK-MB massa, troponina I e mioglobina, seis horas após o início da dor torácica. O diagnóstico de insuficiência coronariana aguda foi feito em pacientes com angina de repouso, infarto agudo do miocárdio, pacientes submetidos à revascularização miocárdica, presença de lesões coronarianas significativas na angiografia (>- 70% estenose em artérias coronárias ou seus ramos ou .- 50% em tronco de artéria coronária esquerda) realizada durante a inernação e morte cardíaca foram considerados eventos cardíacos maiores. As cintilografias com defeito de captação foram consideradas sugestivas de isquemia miocárdica e foram comparadas com o diagnóstico clínico e com a ocorrência de eventos cardíacos maiores até três meses após a alta.Pacientes sem insuficiência coronariana aguda, dispensados da unidade de emergência, foram encaminhados para realização ambulatorial de cintilografia de perfusão miocárdica tomográfica de esforço ou com dipiridamol. Vinte e um pacientes (29,6%) tiveram o diagnóstico de insuficiência coronariana aguda e em 15 (21,1%) ocorreram eventos cardíacos maiores (oito com infarto agudo do miocárdio e sete foram submetidos à revascularização miocárdica). A cintilografia planar de perfusão miocárdica demonstrou defeitos de captação em 21 (29,6%) pacientes, dos quais 16 (76,2%) tiveram o diagnóstico de insuficiência coronariana aguda, 12 (80%) apresentaram eventos cardíacos maiores e 7 (87,5%) infarto agudo do miocárdio. O valor preditivo negativo da cintilografia planar de perfusão miocárdica foi de 90% para o diagnóstico de insuficiência coronariana aguda e de 94% para detecção de eventos cardíacos maiores. Portanto a cintilografia planar de perfusão miocárdica foi eficaz para o diagnóstico de insuficiência coronariana aguda em pacientes com dor torácica e electrocardiograma sem alterações sugestivas de isquemia / The objective of the study was to evaluate the usefulness of rest scintigraphic planar myocardial perfusion imaging in patients with acute chest pain suspected of myocardial ischemia and nondiagnostic ECG in the diagnosis of acute coronary syndromes and to predict adverse cardiac outcomes. Patients within 6 hours of chest pain onset and nondiagnostic ECGs underwent planar myocardial perfusion imaging with Technetium-99m sestamibi and measurements of serum creatine kinase-MB, creatine kinase-MB mass. troponin and myoglobin 6 hours after the onset of symptoms. Studies showing perfusion defects were considered suggestive of acute coronary syndromes and were compared to the diagnosis made by the attending cardiologist. Clinical diagnosis of acute coronary syndromes was made In patients with rest angina admitted to the hospital, acute myocardial Infarction, myocardial revascularization, demonstration of significant coronary artery disease on angiography or cardiac death. Acute myocardial revascularization and cardiac death were considered major cardiac events. Patients discharged without acute coronary syndromes were scheduled for outpatient stress myocardial perfusion imaging. A total of 71 patients underwent planar myocardial perfusion imaging. The mean age was 58 +- 12 years, 44 (62%) were male and 27 (38%) female. The mean time between chest pain onset and radiotracer injection was 3 hours and 6 minutes, thirteen patients had chest pain at the moment of iniection. Twenty-one (29,6%) patients had acute coronary syndromes, 15 (21,1 %) had major cardiac events (8 myocardial infarction and 7 underwent myocardial revascularization). Planar perfusion imaging demonstrated perfusion defects in 21 patients, 16 (76,2%) patients with acute coronary syndromes, 12 (80%) patients who had major cardiac events and in 7 (87,5%) patients with myocardial infarction. The negative predictive value of planar perfusion image was 90% for diagnosis of acute coronary syndromes and 94% for detecting major cardiac events. In conclusion, early planar perfusion imaging allowed for a rapid and accurate risk stratification of emergency departments patients with possible myocardial ischemia and nondiagnostic ECGs

A desnutrição freqüentemente está presente em pacientes com insuficiência cardíaca (IC), podendo trazer aumento de complicações e mortalidade. O objetivo do estudo foi o de avaliar o estado nutricional de pacientes portadores de IC refratária, aguardando a realização de transplante cardíaco. Avaliação nutricional foi realizada utilizando-se da avaliação subjetiva global, avaliação antropométrica completa [índice de massa corpórea (IMC), circunferência do braço (CB), prega cutânea tricipital (PCT), circunferência muscular do braço (CMB) e área gordurosa do braço (AGB)], avaliação laboratorial e realização de anamnese alimentar em dois momentos: no momento de admissão na fila de transplante (1a avaliação) e 4 meses após (2a avaliação). Na 1ª avaliação foram estudados 56 pacientes, idade média de 46±12 anos, 67,8% homens, 33,9% com miocardiopatia chagásica. Análise de dados antropométricos revelou com base no IMC: 73,2% eutróficos e 5,3% com baixo peso; CMB: 66% apresentavam depleção. Houve correlação negativa e significativa entre IMC e fator de necrose tumoral (r= - 0,305; p= 0,022). Análise laboratorial demonstrou: baseado na albumina, 50% dos pacientes apresentavam-se com algum grau de depleção, na transferrina 40% e na contagem de linfócitos 80%. Houve correlação negativa e significativa entre albumina e interleucina-6 (r = - 0,464; p< 0,001), transferrina e interleucina-6 (r= -0,269; p= 0,047) e contagem de linfócitos e interleucina-6 (r= - 0,394; p=0,003). Na 2ª avaliação 18 pacientes foram estudados. Não foram observadas diferenças significativas entre as duas avaliações quanto aos parâmetros estudados. Com base na realização da anamnese alimentar os pacientes atingiram aproximadamente 85% e 84% de suas necessidades calóricas na 1ª e 2ª avaliações, e com relação à ingestão protéica, tanto na 1ª como na 2ª avaliação mais de 70% dos pacientes apresentaram consumo adequado de proteínas. Foi observado consumo abaixo das necessidades nutricionais de cálcio, potássio, magnésio, zinco, folato e vitamina E. Quanto ao sódio verificamos um consumo acima do recomendado. Foram transplantados 14 pacientes com idade de 44 ± 21 anos, 57,1% do sexo masculino, quatro pacientes morreram no pós operatório. Não houve diferenças significativas quanto aos dados antropométricos, laboratoriais, de adequação alimentar e idade entre o grupo de transplantados que sobreviveram (n=9) comparados com os que faleceram (n=4). Concluímos que a desnutrição é comum em pacientes com IC grave aguardando transplante cardíaco. A avaliação nutricional baseada no IMC não mostrou ser um bom método, necessitando ser complementada com as medidas de CB, CMB, PCT e AGB. A avaliação laboratorial permitiu a detecção de comprometimento nutricional. A participação das citocinas inflamatórias no processo de desnutrição foi evidenciada em nossa população. Portanto, a avaliação nutricional completa deve fazer parte do atendimento em pacientes com IC crônica, particularmente aqueles com IC refratária à espera por um transplante cardíaco / Malnutrition is frequently present in patients with heart failure (HF) and is associated with an increase in morbidity and mortality. The objective of this study was to evaluate nutritional status of patients with refractory HF waiting for cardiac transplantation. Nutritional evaluation was done with the use of subjective global assessment, complete anthropometric measurements (body mass index (BMI), mid-arm circumference (MAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC) and arm fat area), laboratory evaluation and food intake assessment in two moments: at the admission to the cardiac transplantation waiting list (1st evaluation) and after 4 months (2nd evaluation). On the 1st evaluation, we studied 56 patients, mean age 46±12 years, 67.8% were men, and 33.9% had Chagas disease. Analyzing anthropometric measurements, we found that, based on BMI 73.2% of patients were normal and 5.3% had underweight; MAMC revealed 66% with depletion. There was a negative and significant correlation between BMI and tumor necrosis factor-a (r= - 0.305; p<0.022). Laboratory evaluation showed that based on albumin levels, 50% of patients had some degree of depletion, based on transferrin 40% and on lymphocyte count 80%. There were negative and significant correlations between albumin and interleukin-6 (r= - 0.464; p<0.001), transferrin and interleukin-6 (r= -0.269; p<0.047) and lymphocyte count and interleukin-6 (r= -0.394; p<0.003). On the 2nd evaluation 18 patients were studied. There were no significant differences in the studied parameters between the 1st and 2nd evaluations. Based on the food intake assessment, percentage of adequacy of calories intake was 85% and 84% on 1st and 2nd evaluations, and more than 70% of patients had adequate protein intake on both evaluations. Low intake of calcium, potassium, magnesium, zinc, folate and vitamin E was detected. Daily sodium intake was found to be above the recommended levels. Fourteen patients were submitted to cardiac transplantation, mean age 44±21 years, 57.1% were men. Four patients died in post operative period. No relation was observed between anthropometric, laboratory, alimentary adequacy and age variables between patients transplanted that survive (n=9) and that died (n=4). We concluded that malnutrition is common in patients with refractory HF listed for cardiac transplantation. Nutritional assessment based on BMI did not show to be a good index to detect nutritional disorders and need to be used together with MAC, TSF, MAMC and arm fat area. Laboratory evaluation permitted the detection of compromised nutritional status. The participation of inflammatory cytokines in the process of malnutrition was evidenced in our population. Therefore, a complete nutritional evaluation should be part of routine care of patients with chronic HF, particularly in those with refractory HF waiting for cardiac transplantation