Orientador: Orlando Petrucci Junior / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T16:20:22Z (GMT). No. of bitstreams: 1 Lima_FanySilva_M.pdf: 1729080 bytes, checksum: a3d4e3c77bc179cf859c845d5e3bac06 (MD5) Previous issue date: 2015 / Resumo: O infarto agudo do miocárdio (IAM) ainda permanece como umas das principais causas de morbimortalidade em indivíduos adultos, ocasionando lesões miocárdicas pela isquemia seguida da reperfusão. No presente trabalho estudamos a cardioproteção por meio de três diferentes estratégias: a utilização de um fármaco denominado - Piracar (Piracetam, L-carnitiva, glutamato e aspartato), a utilização de uma solução contendo eritropoietina, glicose, insulina e potássio (EG); e por meio da modulação humoral/neurológica denominada isquemia de pré-condicionamento remoto (IPCR). Para esta análise utilizou-se de modelo agudo de isquemia e reperfusão miocárdica em suínos onde foram avaliadas variáveis hemodinâmicas, quantificação da área de infarto, quantidade de troponina I liberada (TnI-C) e de adenosina trifosfato no músculo cardíaco (ATP). Também foram estudadas proteínas relacionadas a isquemia e reperfusão miocárdicas de duas vias conhecidas como a Survivor Activating Factor Enhancement (SAFE) e a Reperfusion Injury Salvage Kinase Pathway (RISK) utilizando Western Blotting. Foi observado maior ativação das proteínas ERK (p?0,05) e STAT (p?0,05) no grupo EG e IPCR comparados ao controle, quando comparados entre si o grupo que se apresentou melhor foi o EG, também com a quantidade de ATP significativamente maior. No grupo Piracar e IPCR a AKT (p?0,05) apresentou-se ativada comparada aos demais grupos. Não encontramos diferença nas análises hemodinâmicas e na porcentagem de área de infarto. Entretanto, a TnI-C apresentou-se elevada na fase de reperfusão nos grupo IPCR e EG; e reduzida no grupo Piracar. Dos tratamentos estudados, o grupo EG foi o que mais se destacou pelo aumento significativo das proteínas ERK e STAT, e aparente melhora na reserva metabólica pela quantidade elevada de ATP disponível, enquanto os demais grupos e nas demais formas de análises foram semelhantes ou com resultados inferiores / Abstract: Acute myocardial infarction (AMI) still the major cause of morbidity and mortality in adults, causing myocardial ischemia followed by lesions of reperfusion. In the present study, we studied cardioprotection by 3 different strategies: the use of a so-called drug - Piracar ( Piracetam, L- carnitiva, glutamate and aspartate) using a solution containing erythropoietin, glucose, insulin and potassium (EG); by humoral and/modulation neurological called remote ischemic preconditioning (IPCR) . For this analysis we used the model of acute myocardial ischemia and reperfusion in pigs where hemodynamic variables were evaluated, quantification of infarct area, amount of troponin I released (cTnI) and adenosine triphosphate in the heart muscle (ATP). Were also studied proteins related to myocardial ischemia and reperfusion two-way known as the Survivor Activating Factor Enhancement (SAFE) Reperfusion Injury and Salvage Kinase Pathway (RISK) using Western blotting. We found greater activation of ERK proteins (p= 0,05) and STAT (p= 0,05) in the EG group and IPCR compared to the control, when comparing between the group that performed best was the EG, also with the amount significantly higher ATP. In group Piracar AKT (p= 0,05) was significantly activated compared to the other groups. No differences in hemodynamic analysis and the percentage of infarcted area. However, cTnI showed up high in the reperfusion phase in IPCR and EG group; and reduced in Piracar group. Of the treatments, the EG group was the one that stood out the significant increase in ERK and STAT proteins, and apparent improvement in metabolic reserve by the high amount of ATP available, while the other groups and other forms of analysis were similar or results below / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Background: Myocardial infarction (MI), also known as heart attack, is the leading cause of morbidity and mortality among the heart diseases spectrum. It results from an insufficient supply of blood to the heart muscles. According to the United States (U.S.) Centers for Disease Control and Prevention (CDC), about 610 000 people die of heart disease in the U.S. every year. Myocardial infarction contributes 370 000 of these deaths annually. Every 40 seconds, someone in the U.S. experience heart attack. This burden is disproportionately distributed within the U.S. population. The rate of heart disease in Central Appalachia is 249 per 100 000, 42% higher than the national rate. Exploring further within the region, rural areas experience higher heart disease mortality rates; 27% higher than the region’s metro counties. According to 2018 America Health Ranking, the prevalence of heart attack in Tennessee is 5.9%, compared to the 4.9% nationwide, with the majority of the burden seen among adults aged ≥65 years and with a 1:1.8 female to male ratio. Patients with heart disease often have other comorbid conditions such as peripheral arterial disease (PAD), hypertension, diabetes, dyslipidemias, which contribute immensely to this chronic condition. Therefore, the aim of this study is to explore the association between cardiovascular comorbidities such as diabetes mellitus, hypertension and dyslipidemia, and the prevalence of heart attack among patients with PAD in rural Central Appalachia. Methods: We used a cross-sectional data of patients diagnosed with PAD in the Central Appalachian region. A total of 13455 patients with PAD were recruited using ICD 9 and 10 search terms for PAD from the electronic medical records (EMR) system between January 1, 2008, and April 30, 2018. Descriptive statistics of the variables were extracted. The association between the comorbidities, including hypertension, diabetes, dyslipidemia, body mass index(BMI) and the prevalence of MI was determined using a binomial logistic regression model. All analysis was done using IBM SPSS statistics 25. Results: Of the total 13455 patients with PAD, 3045 had MI (37.7% female and 62.3% male) with a mean age of 69±10.5years. While 93% had hypertension, 56% had diabetes. For the lipids, the mean of HDL, Cholesterol, and LDL among participants with a history of MI is 40.99mg/dl±13, 156.32mg/dl±45, 82.08mg/dl±36.35 respectively. The results of binomial logistic regression with stratification based on gender shows that female patients with diabetes had 86% increased odds of MI [OR: 1.858, C.I: 1.308-2.638, p-value=0.001), and for female hypertensives, 4.51 times increased odds of MI was found (C.I: 1.576-12.895, p-value=0.005). The male diabetics and hypertensives showed a similarly increased odds of MI with (OR 1.138, C.I: 0.870-1.489 p-value=0.345) and (OR 3.697C.I: 1.559-8.736, p-value=0.003) respectively. No significant association was found among the various lipid profiles examined. Conclusion: The results showed that female PAD patients with hypertension and diabetes have a significantly increased likelihood of having MI. In contrast, male with PAD also showed increased likelihood (although to a lesser degree) of MI in those with hypertension, but not those with diabetes. These findings underscore the importance of a proactive approach to preventive care and adequate control among PAD patients with diabetes and hypertension in a bid to curbing the morbidity and mortality associated with myocardial infarction among residents in Central Appalachia.

Bakgrund: I sjuksköterskans profession ingår att främja hälsa, förebygga sjukdom, återställa hälsa och lindra lidande. En hjärtinfarkt är en omtumlande händelse och flera tusen drabbas varje år, för en sådan kris saknar ofta människor beredskap. En hjärtinfarkt kan ge plötslig, svår smärta samt ångest och orsakas av stopp i ett kranskärl, vilket leder till syrebrist i hjärtat. Anhöriga kände ett stort ansvar och saknade information från sjukvården. De kände även en oro att deras närstående skulle drabbas av ännu en hjärtinfarkt. Syfte: Att beskriva kvinnor och mäns erfarenheter efter en hjärtinfarkt.  Metod: Resultatet av denna litteraturstudie utgjordes av tio kvalitativa artiklar identifierade i databasen PubMed.     Huvudresultat: Det framkom att flera konsekvenser upplevdes efter hjärtinfarkten, såsom utmattning, ångest, oro och rädsla för att drabbas igen, vilket gav begränsningar i livet. Efter hjärtinfarkten kunde livet präglas av en rädsla att anstränga det sjuka hjärtat och minskad tro på hjärtats förmåga. Vidare framkom behovet av mer information från sjukvården. Närstående visade sig ha stor betydelse för tillfrisknandet samt möjligheten att få träffa andra i samma situation. Hjärtinfarkten var för många en väckarklocka som gav insikt om det viktiga i livet och kunde motivera till livsstilsförändringar. Slutsats: Hjärtinfarkten medförde många konsekvenser. Trots en rädsla att anstränga det sjuka hjärtat kunde händelsen motivera till livsstilsförändring. Anhöriga var ett stort stöd i tillfrisknandet, dock fanns en önskan om mer stöd och information från sjukvården. Denna litteraturstudie kan ge vårdpersonalen ökad förståelse för erfarenheter efter en hjärtinfarkt samt bidra med kunskap om hur eftervården kan utformas. / Background: The nursing profession includes promoting health, preventing disease, restoring health and relieving suffering. A heart attack is a dizzying event and several thousand are affected every year, because such a crisis often leaves people unprepared. A heart attack can cause sudden, severe pain and anxiety and is caused by a blockage in a coronary artery, which leads to a lack of oxygen in the heart. Relatives felt a great responsibility and lacked information from the health service. They also felt a concern that their loved ones would suffer another heart attack.Aim: To describe women's and men's experiences after a heart attack.Method: The results of this literature review consisted of ten qualitative articles identified in the PubMed database.Main results: It turned out that several consequences were experienced after the heart attack, such as fatigue, anxiety, worry and fear of being hit again, which gave limitations in life. After the heart attack, life could be marked by a fear of straining the diseased heart and diminished belief in the heart's ability. Furthermore, the need for more information from the health service emerged. Relatives proved to be of great importance for recovery and the opportunity to meet others in the same situation. For many, the heart attack was an alarm clock that provided insight into the important things in life and could motivate them to make lifestyle changes.Conclusion: The heart attack had many consequences. Despite a fear of straining the sick heart, the event could motivate a lifestyle change. Relatives were a great support in the recovery, however, there was a desire for more support and information from the health care. This literature study can give the care staff an increased understanding of experiences after a heart attack and contribute with knowledge of how aftercare can be designed.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22381号 / 社医博第103号 / 新制||社||医11(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 中山 健夫, 教授 小池 薫, 教授 福原 俊一 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Wnt/β-catenin signaling is activated in the heart after myocardial infarction (MI). This study aims to investigate if β-catenin deletion affects post-MI ion channel gene alterations and ventricular tachycardias (VT). MI was induced by permanent ligation of left anterior descending artery in wild-type (WT) and cardiomyocyte-specific β-catenin knockout (KO) mice. KO mice showed reduced susceptibility to VT (18% vs. 77% in WT) at 8 weeks after MI, associated with reduced scar size and attenuated chamber dilation. qPCR analyses of both myocardial tissues and purified cardiomyocytes demonstrated upregulation of Wnt pathway genes in border and infarct regions after MI, including Wnt ligands (such as Wnt4) and receptors (such as Fzd1 and Fzd2). At 1 week after MI, cardiac sodium channel gene (Scn5a) transcript was reduced in WT but not in KO hearts, consistent with previous studies showing Scn5a inhibition by Wnt/β-catenin signaling. At 8 weeks after MI when Wnt genes have declined, Scn5a returned to near sham levels and K⁺ channel gene downregulations were not different between WT and KO mice. This study demonstrated that VT susceptibility in the chronic phase after MI is reduced in mice with cardiomyocyte-specific β-catenin deletion primarily through attenuated structural remodeling, but not ion channel gene alterations.

Unplanned readmissions to the hospital are a problem faced by most health care organizations in the United States; hospitals are penalized for such readmissions. The project site identified high readmission rates for patients who were discharged after acute myocardial infarction (AMI), making careful transition home a necessity for post-AMI patients. The focus of this quality improvement (QI) project was implementation of an early follow-up appointment of AMI patients following discharge. The purpose of this project was to evaluate the effectiveness of changing follow-up appointments for patients with an AMI from 14-30 days to 7-14 days post discharge to reduce unplanned readmission rates. Bandura’s self- efficacy theory provided the theoretical framework for this project. An evaluation of the QI project was completed by comparing patient readmission rates 6 months before and 6 months after implementation of the early follow-up appointments. Data analysis demonstrated that the readmission rate was not improved in the first 6 months post QI project implementation. Using the plan-do-check-act process, a multifactorial approach was recommended to refine the QI project and address the system-wide readmission rates. The implications of this project for positive social change include providing early analysis of the readmission QI project, which allowed the hospital to restructure the QI approach and improve the plan for preventing readmission.

Depuis plus de 30 ans, les progrès thérapeutiques ont permis de réduire la morbi-mortalité liée à l’infarctus du myocarde. La reperfusion est une étape essentielle dans la prise en charge des patients, mais est également à l’origine de lésions tissulaires cardiaques. Plusieurs travaux ont montré que le conditionnement ischémique ou pharmacologique du coeur permet de réduire ces lésions de reperfusion, mais que cet effet bénéfique reste limité dans un contexte de diabète.Dans ce travail, nous avons tout d’abord étudié l’impact du diabète de type 2 sur la fonction mitochondriale. Les études ont été réalisées sur des trabécules d’oreillette humaine, et dans deux sous-populations mitochondriales, les mitochondries sous-sarcolemmales (SSM) et interfibrillaires (IFM), par des approches polarographique, spectrophotométrique et protéomique. Alors que des différences sont observées en termes d’activité enzymatique et d’expression protéique entre SSM et IFM, nous n’avons pas observé d’effet lié au diabète sur la fonction mitochondriale.Dans un second temps, nous avons développé un modèle d’étude des lésions d’ischémie reperfusion chez la souris en utilisant la technique de Langendorff. Nous avons étudié les effets sur la fonction cardiaque et sur le volume de nécrose, du post-conditionnement pharmacologique par différents agonistes et antagonistes opioïdes (morphine, [D-Pen2,D-Pen5]-enkephaline (DPDPE), naloxone, naltrindole) après une ischémie globale. Chacune des molécules testées réduit le volume de nécrose. La fonction cardiaque était également améliorée après 60 minutes de reperfusion en présence de morphine seule, de naloxone seule, et des associations morphine-naloxone et DPDPE-naltrindole. Les mécanismes moléculaires impliqués dans ces effets cardioprotecteurs nécessitent d’être mieux compris avant d'envisager une application chez l’Homme, en particulier chez le patient diabétique, afin de limiter les lésions de reperfusion dans un contexte d’infarctus du myocarde. / The morbidity and the mortality of the heart stroke have been reduced over the last 30 years and it was related to an improvement of patient care. The early reperfusion of the heart is an essential step, but is responsible for ischemia-reperfusion injuries. Both ischemic and pharmacological conditionings were shown to increase heart function, but these beneficial effects are reduced in a context of diabetes mellitus.First, we studied the effect of type 2 diabetes mellitus on mitochondrial function. Studies were performed on heart trabeculae, and in subsarcolemmal (SSM) or interfibrillar (IFM) mitochondria extracted from human atrial appendages using polarographic, spectrophotometric and proteomic analyses. Whereas differences on enzymatic activities and in protein expression were observed between SSM and IFM, we did not find any deleterious effect of diabetes mellitus on mitochondrial function. Second, using a Langendorff’s apparatus, we developed an experimental model in mouse to study ischemia-reperfusion injuries. Pharmacological post-conditioning was tested by using various opioid agonists and antagonists, including morphine, [D-Pen2,D-Pen5]-enkephalin (DPDPE), naloxone, and naltrindole. The effects were observed on heart function and the volume of necrosis. All treatments were effective to reduce the necrosis in the heart compared to control condition. After 60 minutes of reperfusion, cardiac function was also improved with morphine, naloxone, and the association of morphine-naloxone, and DPDPE-naltrindole. A better understanding of the molecular mechanisms is needed to improve pharmacological post-conditioning in patients, particularly in diabetics, presenting with heart stroke.

L’objectif de ce travail est de présenter et évaluer une nouvelle méthode, PGRx,systématique cas-référents en pharmaco-épidémiologie avec son application à l’étudede l’infarctus du myocarde (IDM). Elle se distingue par la collecte systématique etcontinue de cas d’événements dans des centres spécialisés et d’un pool de référenceen médecine générale dont sont tirés les témoins appariés aux cas. L’évaluation durisque d’IDM associé au diclofénac (OR 1.5) et celle du bénéfice associé aux statines(OR 0.75) montrent des résultats similaires à ceux publiés (respectivement OR 1.4 etOR 0.74). Nous montrons que les référents sont un échantillon représentatif de lapopulation française en termes de motif de consultation et valide en termesd’évaluation de facteurs de risque. La concordance entre la mesure de l’exposition parla déclaration du patient et par les prescriptions médicales est excellente pour lesmédicaments cardiovasculaires (95%). Notre travail sur une série d’études montre quela collecte systématique de cas et d’un pool de référence, selon la méthode PGRx, estfaisable, reproductible et valide en termes de résultats et d’indicateurs de qualité. / The objective of this work is to present and assess PGRx, a new systematic case-referentsmethod in pharmacoepidemiology and its application on the study of themyocardial infarction (MI). The originality of PGRx is the systematic and on-goingcollect of cases of events in a network of specialized centres and of a pool of referentsin general practice (GP), from which controls are selected by matching to the cases.The assessment of the risk of MI associated with diclofenac (OR 1.5) and of thebenefit on MI associated with statins (OR 0.75) displays similar results than theliterature (respectively OR 1.4 and OR 0.74).We show that the pool of referents is arepresentative sample of the French population in terms of reasons of consulting a GPand valid in terms of risk factors’assessment. Agreement between the measure ofexposure from patients’ self-report and from physician’s report of their prescriptionsis excellent on cardiovascular drugs (95%). Our work, through several studies, showsthat the systematic collect of cases and of a reference pool by the PGRx method isfeasible, reproducible and valid in terms of results and quality indicators.

Le pronostic à long-terme actuel après un accident ischémique transitoire (AIT) ou un infarctus cérébral reste mal connu. Ainsi, j’ai déterminé les risques absolus à long-terme de récidive d’infarctus cérébral et d’évènement coronarien aigu après un AIT ou un infarctus cérébral et identifié les individus qui restent à haut risque absolu de récidive ischémique malgré la prévention secondaire actuelle.Dans une cohorte populationnelle contemporaine de patients ayant eu un AIT ou un infarctus cérébral (OXVASC study, 2002-2014), les risques absolus de récidive d’infarctus cérébral et d’infarctus du myocarde après un AIT/infarctus cérébral ont significativement diminué au cours de la période d’étude, très probablement du fait de l’amélioration de la prévention secondaire avec le temps. Cependant, malgré la prévention secondaire actuelle les sous-groupes de patients avec un antécédent de pathologie coronarienne et ceux sans antécédent coronaire mais avec un score Essen 4 sont exposés à un risque absolu de récidive d’évènement ischémique suffisamment élevé pour justifier d’une intensification du traitement. Néanmoins, les thérapeutiques de prévention secondaire futures nécessitent de permettre d’obtenir une réduction absolue du risque de récidive d’évènement ischémique importante pour compenser un risque augmenté d’effets indésirables ou de surcoût par rapport aux thérapeutiques actuelles. En effet, chez ces sous-groupes de patients à haut risque de récidive ischémique, une réduction plus intensive du taux de cholestérol avec les inhibiteurs des PCSK-9 parait tout à fait justifiée, cependant nous avons montré que le coût de ces traitements excède la limite du rapport coût-efficacité généralement accepté tandis que le bénéfice d’une majoration du traitement antithrombotique semble contrebalancé par l’augmentation du risque hémorragique extracrânien. / The current long-term prognosis after transient ischaemic attack (TIA) or ischaemic stroke is not well known. I aimed to determine the long-term absolute residual risks of recurrent stroke and coronary events after TIA or ischaemic stroke and identify individuals who remain at high absolute risk of recurrent ischaemic events despite current secondary prevention management.In a population-based cohort of consecutive TIA or ischaemic stroke patients (OXVASC study, 2002-2014), the overall absolute risks of recurrent ischaemic stroke and coronary events after TIA/ischaemic stroke have decreased over the study period, and are likely to be explained by the improvement of secondary prevention over time. However, despite current secondary prevention, the subgroups of patients with prior coronary artery disease and those without prior coronary artery disease but with an Essen score of 4 remain at sufficiently high absolute risk of recurrent ischaemic events to justify more intensive treatment. Nevertheless, future secondary prevention therapies would need to achieve a substantial absolute risk reduction to outweigh increased side effects or cost compared to current therapies. Indeed, in these high-risk subgroups, more intensive lipid-lowering therapies might be justified, but we showed that the total cost of PCSK-9 inhibitors seems to exceed the generally accepted cost-effectiveness threshold while benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.

Zusammenfassung der Arbeit Dissertation zur Erlangung des akademischen Grades Dr. med. Zusammenhang zwischen dem sozioökonomischem Status und der Entwicklung akuter ST – Strecken – Elevations – Myokardinfarkte eingereicht von Susanne Seide, geb. Gärtner, 02.12.1979 in München angefertigt am Institut für Herz- und Kreislaufforschung des Klinikum Links der Weser Bremen Klinik für Kardiologie und Angiologie Senator Wessling Strasse 1 28277 Bremen Betreuer: Prof. Dr. med. Rainer Hambrecht eingereicht im Februar 2015 An der Entwicklung der koronaren Herzkrankheit und dem damit verbundenen Auftreten akuter ST – Strecken – Elevations – Myokardinfarkte sind neben klassischen Risikofaktoren wie Bluthochdruck, Rauchen, Diabetes mellitus, Übergewicht und Fettstoffwechselstörungen andere Faktoren, wie Alter, Geschlecht, Bewegungsmangel und der psychosoziale Status beteiligt. Frühere Untersuchungen haben darüber hinaus gezeigt, dass die Entwicklung kardiovaskulärer Erkrankungen in einem Zusammenhang mit dem sozioökonomischen Hintergrundes steht. Inwieweit die Zugehörigkeit zu einer bestimmten sozialen Schicht Einfluss auf die Infarktrate der Bremer Bevölkerung hat, und ob es Unterschiede im Risikoprofil, in der Behandlung und Prognose von Patienten aus unterschiedlichen sozialen Milieus gibt, sollte mit dieser Arbeit untersucht werden. Hierzu wurden Daten von 2062 Patienten aus dem STEMI Register des Herzzentrums Bremen ausgewertet. Die Patienten aus dem Stadtgebiet Bremen wurden anhand der Postleitzahl ihrer Heimatadresse einer von vier Gruppen zugeordnet. Hiernach wurde für sie ein hoher sozioökonomischer Status (G1), ein intermediär hoher sozioökonomischer Status (G2), ein intermediär niedrig sozioökonomischer Status (G3) oder ein niedriger sozioökonomischer Status (G4) ermittelt. Der sozioökonomische Status der jeweiligen Gruppe wurde mit Hilfe des so genannten „Bremer Benachteiligungsindexes“, einem Maß für die soziale Stellung eines Stadtteiles, und anhand von Einkommensstatistiken der Bremer Stadtteile bestimmt. Die vier Gruppen wurden hinsichtlich ihrer Infarktinzidenzen verglichen. Innerhalb der Patientengruppen wurden Baselinecharakteristika (Alter zum Infarktzeitpunkt, Geschlecht, Vorerkrankungen, kardiovaskuläre Risikofaktoren), Surrogat – Parameter der Krankheitsausprägung (Mehrgefäßerkrankung, hämodynamische Stabilität, linksventrikuläre Ejektionsfraktion nach Myokardinfarkt), und der Therapie (PTCA, ACVB – Operation, Door – to – balloon Zeiten und Medikamentengabe) sowie Prognosedaten (30 Tage – Mortalität, 5 Jahres – Überleben) erhoben und die Gruppen anhand dieser Ergebnisse miteinander verglichen. Die wesentlichen Ergebnisse lassen sich wie folgt zusammenfassen: ➢ Die alters- und geschlechtsadjustierte Inzidenz akuter transmuraler Myokardinfarkte war in den sozial benachteiligten Bremer Stadtteilen signifikant höher als in Stadtbezirken mit geringerer Benachteiligung (G1: 47 ± 5 STEMIs pro 100.000 Einwohner pro Jahr versus G4: 66 ± 5 STEMIs pro 100.000 Einwohner pro Jahr; p < 0,01). ➢ Insbesondere junge Menschen waren von diesem sozialen Abwärtsgradienten betroffen (18 – 49 Jahre RR G4 2,01 versus 65 – 79 Jahre RR G4: 1,39). ➢ Herzinfarktpatienten aus sozial benachteiligten Stadtteilen waren zum Infarktzeitpunkt signifikant jünger (G1: 67±13 Jahre versus G4: 63±13 Jahre; p = 0,026), häufiger Raucher (G1: 35,9% versus G4: 51,2%; p < 0,01) und übergewichtig (G1:.15,3% BMI > 30 kg/qm versus G4: 26,1% BMI > 30 kg/qm; p < 0,01). ➢ Bezüglich der Infarktschwere und der Therapie zeigten sich keine wesentlichen Unterschiede zwischen den Gruppen (Mehrgefäßerkrankung G1: 62,4% versus G4: 57,0%; p = 0,27; Killip – Stadium III/IV G1: 12,5% versus G4: 13,0%; p = 0,84; LVEF nach Myokardinfarkt < 30% G1: 6,0% versus G4: 7,6%; p = 0,4; primäre PTCA G1: 89,8% versus G4: 89,8%; p = 0,92; ACVB - Operation G1: 11,6% versus G4: 12,6%; p = 0,13; Door – to – balloon Zeit G1: 54±38 min. versus G4 52±41 min.; p = 0,74; ASS G1: 94,4% versus G4: 94,7%; p = 0,64; ADP – Antagonist G1: 90,0% versus G4: 93,8%;p = 0,23; Betablocker G1 82,8% versus G4 83,9%; p = 0,25; Statin G1: 85,8% versus G4: 86,4%; p = 0,97; ACE – Hemmer oder AT1 – Rezeptorantagonisten G1: 77,4% versus G4: 79,3%; p = 0,90). ➢ Die alters– und geschlechtsadjustierte inhospitale Mortalität war in allen Gruppen vergleichbar hoch (G1: 4,8% versus G4: 3,9%; p = 0,3), für Patienten aus den sozioökonomisch am stärksten benachteiligten Stadtgebieten zeigte sich aber ein starker Trend hin zu einem geringeren 5 Jahres – Überleben (G4 versus G1: HR 1,55, 95% KI 0,98-2,5, p = 0,067). Die Ergebnisse dieser Studie demonstrieren, dass das relative Risiko für einen ST – Strecken – Elevations – Myokardinfarkt mit abnehmendem sozioökonomischem Status der Bevölkerung steigt, und dass das kardiovaskuläre Risikoprofil von Patienten aus sozioökonomisch benachteiligten Stadtteilen ausgeprägter ist. Trotz gleicher Initialtherapie aller STEMI Patienten, unabhängig von der sozialen Herkunft, haben diejenigen aus sozioökonomisch benachteiligten Wohnbezirken eine deutlich schlechtere Prognose. Daher besteht unseres Erachtens vor allem in den sozioökonomisch benachteiligten Stadtteilen nicht nur in Bremen ein erhöhter Handlungsbedarf hinsichtlich konsequenter primär– und sekundärpräventiver Maßnahmen.