Bakgrund: Fler män än kvinnor drabbas av hjärtinfarkt, vilket har resulterat i att tidigare forskning kring sjukdomen har baserats på mäns upplevelser. Kvinnor upplever ett större spektrum av symtom och har annorlunda riskfaktorer gentemot män. Tydliga förseningar i kvinnors vårdsökande kan ses. Syfte: Syftet var att belysa kvinnors upplevelser av att drabbas av hjärtinfarkt. Metod: En allmän litteraturstudie genomfördes på 11 artiklar. Innehållet av artiklarna analyserades och teman urskildes. Resultat: Fyra teman identifierades: brist på kunskap, känslan av ansvar, bemötandet av vården och livet efter hjärtinfarkten. I resultatet framkom det att kvinnor upplevde prodromala symtom som var atypiska, vilket försvårade kvinnornas förmåga att identifiera orsaken till symtomen. Kvinnorna prioriterade bort att söka vård, då kvinnorna präglades av känslan av ansvar gentemot sina anhöriga och sitt arbete. Många kvinnor kände sig ignorerade när de till slut sökte vård. Konklusion/implikation: Bristen på kunskap kring kvinnors atypiska symtom kan leda till förseningar i vårdsökande. Genom vidare forskning på kvinnors upplevelser, symtom och riskfaktorer kan kunskap spridas och bidra till att kvinnor får möjlighet till adekvat vård. / Background: More men than women suffer from myocardial infarction, which has resulted in previous research being based on men’s experiences. Women experience a greater spectrum of symptoms and have different risk factors than men. A distinct delay can be seen when women seek care. Aim: The purpose was to shed light on women's experiences when suffering a myocardial infarction. Method: A general literature study approach was conducted on 11 articles. The content of the articles was analyzed, and themes were distinguished. Result: Four themes were identified: lack of knowledge, feeling of responsibility, treatment in healthcare services and life after a myocardial infarction. The result showed that women experienced prodromal symptoms that were atypical, which complicated women’s ability to identify the cause of the symptoms. The women did not prioritize seeking care, as the women were influenced by the feeling of responsibility towards their relatives and work. Many women felt ignored when they finally sought care. Conclusion/implication: The lack of knowledge about women's atypical symptoms can lead to delays in seeking care and diagnosis. Through further research into women's experiences, symptoms and risk factors, knowledge can be spread and contribute to women having the opportunity for adequate care.

The underlying pathological process of coronary artery disease (CAD) is the development of coronary artery atherosclerotic occlusions and associated myocardial infarction. Both increased chronic inflammation and plasma low-density lipoprotein (LDL) cholesterol levels promote atherosclerosis. Inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) is widely known for its role in enhancing LDL receptor (LDLR)-mediated cholesterol lowering when the LDLR-apolipoprotein E (APOE) axis is intact and protecting against atherosclerosis progression by reducing plasma cholesterol levels. In this thesis, we sought to test the effects of PCSK9 inhibition mediated cholesterol lowering on pre-existing CAD as well as the plasma cholesterol independent effects of PCSK9 inhibition on CAD by utilizing different mouse models. One year old scavenger receptor class B type I (Sr-b1) knockout (KO) mice which have an intact LDLR-APOE axis, develop coronary artery atherosclerosis and myocardial fibrosis induced by a high fat, high cholesterol and cholate containing (HFCC) diet. Weekly anti-PCSK9 antibody treatment initiated one week before switching to an HFCC diet increased hepatic LDLR protein levels, and reduced plasma cholesterol levels and the progression of atherosclerosis in both the aortic sinus and coronary arteries in one year old Sr-b1 KO mice (maintained on an HFCC diet for 7 weeks). Weekly anti-PCSK9 antibody treatment initiated 7 weeks after switching to an HFCC diet also increased hepatic LDLR protein levels and reduced plasma cholesterol levels in one year old Sr-b1 KO mice (maintained on an HFCC diet for 12 weeks). More importantly, anti-PCSK9 antibody treatment during the last 5 weeks of the 12-week HFCC diet feeding period also slowed down the growth of pre-existing atherosclerosis in both the aortic sinus and coronary arteries and reduced myocardial fibrosis and damage. Mice deficient in both Sr-b1 and ApoE (Sr-b1/ApoE double KO (dKO) mice) spontaneously and rapidly develop features reminiscent of human CAD. Whole body Pcsk9 genetic KO in both female and male Sr-b1/ApoE dKO mice did not affect plasma cholesterol levels despite increased hepatic LDLR protein levels, presumably due to the lack of APOE. However, genetic Pcsk9 inactivation significantly attenuated atherosclerosis in both the aortic sinus and coronary arteries, myocardial fibrosis and damage, left ventricle (LV) dysfunction and cardiac enlargement in both female and male Sr-b1/ApoE dKO mice. Restoring circulating PCSK9 by a recombinant adeno associated virus 8 (AAV8)-mediated hepatic expression of a Pcsk9 cDNA in Pcsk9/Sr-b1/ApoE triple KO mice reversed the plasma cholesterol independent protective effects of genetic PCSK9 KO on aortic sinus and coronary artery atherosclerosis and myocardial fibrosis and damage in both females and males. Treatment of Sr-b1/ApoE dKO mice with an anti-PCSK9 antibody which disrupts the interaction between the LDLR and PCSK9 protected against aortic sinus and coronary artery atherosclerosis in males but not in females and did not protect either males or females against myocardial fibrosis and damage, LV dysfunction or cardiac enlargement. My thesis demonstrates that anti-PCSK9 antibody mediated plasma cholesterol lowering delays the continued development of pre-existing CAD. My thesis also demonstrates that liver-derived, circulating PCSK9 promotes CAD in a plasma cholesterol independent manner in Sr-b1/ApoE dKO mice and these effects appear to be largely independent of the PCSK9-LDLR interaction, particularly in females. / Thesis / Doctor of Philosophy (PhD)

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24834号 / 医博第5002号 / 新制||医||1067(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 竹内, 理, 教授 上杉, 志成, 教授 金子, 新 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The purpose of this thesis investigation was to evaluate the effectiveness of dynamic strength training as an additional mode of exercise rehabilitation, in patients with coronary artery disease and well documented evidence of a previous myocardial infarction. The effects of 10 weeks (20 sessions) of combined weightlifting and aerobic training (WtAer) (n=10) were compared with aerobic training (Aer) (n=8) alone, on indices of strength and aerobic exercise capacity in 18 male patients with coronary artery disease (CAD). Initial test(s) performance was similar between groups. Post Aer, the maximum weightlifting strength (1RM) in single-arm curl, single-leg press, and single-knee extension exercises increased by 13% (x = 11.8 to 13.3 kg; P < 0.01), 4% (x = 97 to 101 kg; N.S.), and 5% (x = 28.2 to 29.7 kg; N.S.) respectively; corresponding gains with AerWt were 43% (x = 12.2 to 17.4 kg; P < 0.01), 21% (x = 99 to 120 kg; P <0.01) , and 24% (x = 29 to 36 kg; P < 0.01) . Following Aer the initial 1RM could be lifted an average of 4 times, compared to 14 times after AerWt. Neither Aer nor AerWt showed significant improvements in peak torque in either isokinetic single-knee extension at 90°/s and 180°/s or single-leg press exercise at 30°/s and 75°/s. Maximum progressive incremental cycle ergometer performance (Wmax)increased by 2% with Aer (x = 1088 to 1113 kpm/min; N.S.) and by 15% (x = 1030 to 1180 kpm/min; P < 0.05) with AerWt.Cycling time at 80% of initial Wmax before attaining a Borg RPE of 7 for the legs, increased by 11% (x = 604 to 672s; N.S.) and by 109% (x = 541 to 1128s; P < 0.05) with Aer and AerWt respectively. In these patients with CAD, AerWt was a more effective method of increasing aerobic performance and strength than Aer alone. In order for cardiac exercise rehabilitation therapy to optimize the strength and functional capacities of CAD patients it may be useful to incorporate appropriately monitored weightlifting training into the traditional aerobic exercise regimen. / Thesis / Master of Science (MS)

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Sammanfattning Bakgrund: Hjärtinfarkt är ett akut tillstånd och är den vanligaste enskilda orsaken till dödsfall i Sverige. Vid en hjärtinfarkt uppstår en syrebrist i hjärtmuskeln och omedelbar behandling krävs dock väljer många patienter att inte söka akut vård i tid. Kvinnors får atypiska symtom vilket kan bidra till en fördröjd vård.  Syfte: Syftet med denna litteraturstudie var att beskriva kvinnors upplevelse att drabbas av hjärtinfarkt. Metod: Beskrivande litteraturstudie. Tio vetenskapliga artiklar med kvalitativ ansats användes i resultatet.  Huvudresultat: Resultatet visade att kvinnor ofta upplever diffusa och atypiska symtom, vilket ledde till en svårighet att associera symtomen till en hjärtinfarkt. Kvinnorna förminskade ofta symtomen i hopp om att dessa skulle försvinna och utövade många copingstrategier för att hantera symtomen. Kvinnorna väntade med att söka vård tills symtomen blev outhärdliga och blev då ofta uppmanade av anhöriga att söka vård. Många kvinnor upplevde en rädsla för att bli kallad hypokondriker vid uppsökande av vård. Resultatet beskrevs i fyra teman: Kvinnors upplevelse av symtom vid hjärtinfarkt, Kvinnors upplevelse av förnekelse/förminskning av symtomen vid hjärtinfarkt, Kvinnors upplevelse av oro och rädsla i samband med hjärtinfarkt och Kvinnors upplevelser och copingstategier som bidrog till en fördröjd vård. Slutsats: Kvinnor upplevde en svårighet att associera sina symtom till en hjärtinfarkt. Kvinnornas diffusa och otydliga symtom bidrog till en fördröjd vård. Kvinnorna upplevde en rädsla och oro att bli ignorerad och inte bli tagen på allvar av sjukvården i samband med hjärtinfarkten.    Nyckelord: Hjärtinfarkt, kvinnor, upplevelser. / Abstract Background: Myocardial infarction is an acute condition and the most common single cause of death in Sweden. In the event of a myocardial infarction, a lack of oxygen occurs in the heart muscle and immediate treatment is required, however, many patients choose not to seek emergency care in time. Women get atypical symptoms, which can contribute to delayed treatment. Aim: The aim of this literature study was to describe women's experience of suffering a myocardial infarction.Method: Descriptive literature study. Ten scientific articles with a qualitative approach were used in the result. Main Results: The result showed that women often experience diffuse and atypical symptoms, which led to a difficulty in associating the symptoms with a myocardial infarction. The women often downplayed the symptoms in the hope that they would go away and used many coping strategies to deal with the symptoms. The women waited to seek care until the symptoms became unbearable and were then often urged by relatives to seek medical care. Many women experienced a fear of being called a hypochondriac when seeking care. The results were described in four themes: Women's experience of symptoms during a myocardial infarction, Women's experience of denial/reduction of symptoms during a myocardial infarction, Women's experience of anxiety and fear associated with myocardial infarction and Women's experiences and copingstategies that contributed to delayed care.  Conclusion: Women experienced a difficulty in associating their symptoms with a myocardial infarction. The women's diffuse and unclear symptoms contributed to delayed care. The women experienced a fear and worry of being ignored and not being taken seriously by the healthcare system in connection with the myocardial infarction.     Keywords: Experiences, myocardial infarction, women

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