Introduction: Following ST-elevation myocardial infarction (STEMI) and treatment with Primary Percutaneous Coronary Intervention (PPCI), some patients re-present with potential ischaemic heart disease (IHD) symptoms. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition, which share similar symptoms and may lead patients to seek help via acute services. The purpose of the study was to investigate the proportion of PPCI patients who re-presented to acute services due to potential IHD symptoms within 6 months of STEMI, and to explore associated factors. Methods: An explanatory mixed methods study was conducted. Quantitative data were collected at baseline and 6 months from consecutive patients attending two centres in Manchester. Variables were carefully considered based on a conceptual model for re-presentation. These included potential IHD symptom and psychological health assessments using self-report measures: the Seattle Angina Questionnaire (SAQ) and the Hospital and Anxiety and Depression Scale (HADS). Physiological health was measured using the Global Registry of Acute Coronary Events (GRACE) and the Charleson Comorbidity Index (CCI) at baseline. At 6 months re-presentation data were collected using patient records, a telephone interview and a self-report diary card. The experiences of some who re-presented (purposeful sampling) were explored through semi-structured interviews conducted at least 6 months following PPCI. Framework analysis was adopted to analyse data. Results: 202 PPCI patients returned baseline questionnaires [mean age 59.7 years (SD 13.9), 75.7% male]; 38 (18.8%; 95% CI 14.0% to 24.8%) participants re-presented due to potential IHD symptoms at 6 months; 16 (42.1%) re-presented due to a cardiac event and 22 (57.9%) did not receive a diagnosis. At both baseline and 6 months, mean HADS anxiety scores were higher for the re-presentation group compared to the non-representation group (baseline 9.5 vs 7.1, p=0.006; 6 months 9.4 vs 6.0, p<0.001). Angina symptoms were stable and infrequent at both time points for the groups. Multivariate regression modelling with the inclusion of predictors HADS anxiety, SAQ angina stability, SAQ angina frequency, GRACE and CCI, determined HADS anxiety as a predictor of re-presentation with an adjusted odds ratio of 1.12 (95% CI 1.03 to 1.22, p=0.008). The qualitative interviews with re-presenters included 25 participants (14 men, 27-79 years). Four themes were identified: fear of experiencing a further heart attack, uncertainty and inability to determine cause of symptoms, insufficient opportunity to validate self-construction of illness and difficulty adapting to life after a heart attack. Conclusion: Elevated levels of anxiety at baseline were predictive of re-presentation with potential IHD symptoms at 6 months. Factors such as shock at experiencing a heart attack, hypervigilance of symptoms and difficulty with symptom attribution appeared to play a role in raised anxiety levels for the re-presentation group. Findings suggested that changes are needed to cardiac rehabilitation and post-STEMI follow-up to address educational needs and psychological issues and changes in STEMI treatment.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23057号 / 医博第4684号 / 新制||医||1048(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 森田 智視, 教授 湊谷 謙司, 教授 川上 浩司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Purpose of Review: This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. Recent Findings: In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13–2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. Summary: A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.

Purpose of Review: Patients with stable coronary artery disease (CAD) and a high risk of bleeding are not ideal candidates for a polymer-based drug-eluting stent (DES) because it requires 6–12 months of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI). The purpose of this review is to assess the angiographic and clinical outcomes of polymer-free drug-coated stents (PF-DCS) in stable CAD patients with a high bleeding risk. Recent Findings: Several randomized controlled trials (RCTs) have compared angiographic and clinical outcomes of PF-DCS with bare-metal stents (BMS), permanent polymer (PP)-DES, or biodegradable polymer (BP)-DES. However, none of these studies particularly recruited patients with stable CAD and a high risk of bleeding. Furthermore, there are limited data available on duration of DAPT following PF-DCS placement. Summary: PF-DCS has a better efficacy and similar safety as compared with BMS. PF-DCS with dual drug is noninferior to currently available PP-DES. Further RCTs are needed to assess the safety and efficacy of PF-DCS to BP-DES and PP-DES comparing shorter to standard durations of DAPT.

Every year, hundreds of thousands of patients have coronary angiograms performed in the United States. The Impella is a percutaneous ventricular support device that provides hemodynamic support for patients if hemodynamic instability occurs during the procedure. The critical care nurse is responsible for the recovery and management of the patient with the Impella device in place. The purpose of this scholarly project is to provide registered nurses (RN) who have not previously managed the Impella device with the appropriate education in order to demonstrate competency. The program demonstrated improved RN knowledge about the Impella and increased confidence when managing the Impella device and controller. King's goal attainment theory was used as a framework to develop nurse-patient collaboration. Kirkpatrick's 4-level training evaluation model provided the framework for evaluation of the RN educational program. The sources of evidence included literature and an expert panel that was recruited to evaluate the material prior to implementation of the educational program. The data were analyzed by comparing the results of the preeducational and posteducational questionnaires. The paired t test demonstrated statistical significance based on the scores from the pre- and post-tests taken by the RNs before and after the Impella educational program as p < .001. Increased RN confidence was demonstrated by p < .001, while a change in RN attitude towards the Impella established improvement by p < .001. Providing professional development opportunities has been shown to benefit RNs to allow the delivery of safe care while allowing for positive social change by impacting patient lifestyle and outcomes.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第12999号 / 論医博第2107号 / 新制||医||1016(附属図書館) / 32927 / (主査)教授 川上 浩司, 教授 古川 壽亮, 教授 小池 薫 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19549号 / 医博第4056号 / 新制||医||1012(附属図書館) / 32585 / 京都大学大学院医学研究科医学専攻 / (主査)教授 福原 俊一, 教授 吉村 長久, 教授 山下 潤 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). Methods: This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post-PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. Conclusion: Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.

Cangrelor is a relatively new antiplatelet drug that has been approved for use as an adjunct therapy to percutaneous coronary intervention (PCI) to decrease peri-procedural myocardial infarction (MI), coronary revascularization, and stent thrombosis. Cangrelor is an adenosine triphosphate analogue with a pharmacokinetic mechanism based on a reversible, dose-dependent inhibition adenosine diphosphate (ADP)-induced platelet aggregation. This drug has lately been in the spotlight as a possible bridge therapy for anti-platelet medication prior to cardiac and non-cardiac surgeries. Platelet function is usually restored within sixty minutes of cessation of therapy, thereby decreasing the risk of bleeding while providing adequate pre-procedural coverage to reduce ischemic events. This manuscript reviews the literature on cangrelor and summarizes its role as a peri-procedural bridge.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23822号 / 社医博第122号 / 新制||社医||12(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 木村 剛, 教授 西浦 博, 教授 長尾 美紀 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM