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131	Risk Stratification of Acute Coronary Syndrome using Machine Learning : An analysis of CLEOS-CPDS data / Riskbedömning av akuta koronara syndrom med hjälp av maskininlärning : En analys av CLEOPS-CPDS data Ali, Glacier, Gustavsson, Rebecka January 2022 (has links) Chest pain is one of the most common complaints amongst patients seeking urgent medical care at hospitals. Chest pain can be a symptom of serious cardiovascular disease such as acute coronary syndrome (ACS), however, most underlying causes are benign. Risk stratification in early stages of medical evaluation is difficult. As a consequence, many patients with chest pains are unnecessarily admitted to hospitals. There is precedent for using machine learning (ML) to aid in predicting cardiovascular disease. In this thesis, our goal is to investigate the feasibility of using ML as a complement to safely discharge patients. We use data collected by the ‘Clinical Expert Operating System - Chest Pain Danderyd Study’ (CLEOS-CPDS). Several models are developed to predict the risk of ACS following chest pains and for identifying important factors. Our best performing model on the highest risk class uses the random forest algorithm. The model has a recall score of 0.58 on the highest risk class using a subset of the medical history background. It admits 10 out of 12 patients who ultimately suffers from ACS, however, only 7 out of 12 are classified as high risk. Identified important features are mostly known risk factors, some of which are used in current risk calculations. However, less known factors such as chest pain radiation and associated symptoms, are also identified as important. The conclusion is that it is feasible to use a machine learning model to aid in risk stratification of ACS in early stages of evaluation, but that the current model needs improvement. In future work, a larger and more complete dataset with a longer follow-up period of patients may be highly beneficial to improve the model performance and verify the conclusions of this thesis. / En av de vanligaste orsakerna till att patienter söker akut sjukvård är bröstsmärta. Bröstsmärta kan vara ett symptom på livshotande sjukdom såsom akuta koronara syndrom (AKS), vilket innefattar hjärtinfarkt. Men i de allra flesta fall brukar orsakerna vara ofarliga. Det är svårt att bedöma bröstsmärtor i ett tidig skede och som en konsekvens utreds många patienter kanske i onödan, för att inte missa AKS. Vårt mål med den här rapporten är att utreda möjligheten att använda maskininlärning som stöd i riskbedömningen. Vi försöker identifiera viktiga faktorer i ett tidigt skede som kan hjälpa läkare att på ett säkert sätt utesluta allvarlig sjukdom. Detta görs genom att vi utvecklar flera maskininlärningsmodeller och jämför dessa mot varandra. Vi använder oss av data insamlad genom den pågående studien ‘Clinical Expert Operating System - Chest Pain Danderyd Study‘ (CLEOS-CPDS). Modellen bäst på att förutspå hög risk väljs sedan ut och analyseras närmare. Resultatet är en ‘Random Forest‘ modell. Modellen klassificerar åtminstone inläggning i 10 av 12 allvarliga fall, varav 7 av 12 fall klassificeras helt korrekt. Flera välkända riskfaktorer identifieras som viktiga, varav en del, men inte alla, redan ingår i nuvarande riskkalkyler. Vår slutsats är att det finns goda chanser att använda maskininlärning som ett komplement i sjukvården för att kunna utesluta allvarlig sjukdom, men att den nuvarande modellen behöver förbättras. För att säkerställa resultaten från denna rapport och förbättra modellen kan framtida undersökningar med fördel genomföras på mer data i fullständigare skick, samt med längre uppföljningstid på patienterna. Chest pain Acute coronary syndrome Computerized history taking Machine learning Risk stratification Bröstsmärtor Akuta koronara syndrom Maskininlärning Riskbedömning Computer and Information Sciences Data- och informationsvetenskap
132	Magnetic Resonance Imaging and Spectroscopy in the Evaluation and Management of Acute Coronary Syndrome Chang, Henry 21 May 2015 (has links) No description available. Medicine Medical Imaging Biomedical Research Biomedical Engineering acute coronary syndrome magnetic resonance imaging magnetic resonance spectroscopy animal model phosphocreatine t2 mapping
133	Clinical Presentation of Acute Coronary Syndrome: Does Age Make a Difference? Implications for Emergency Nursing Harris, Iesiah M. 11 August 2006 (has links) No description available. Health Sciences, Nursing ACS Acute Coronary Syndrome heart attack elderly age clinical presentation clinical manifestation ICD-9 411 angina chest pain.
134	Atrial Fibrillation in the setting of Coronary Artery Disease : Risks and outcomes with different treatment options Batra, Gorav January 2017 (has links) Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF. atrial fibrillation coronary artery disease acute coronary syndrome myocardial infarction percutaneous coronary intervention coronary artery bypass grafting antithrombotic therapy angiotensin-converting enzyme inhibitors angiotensin II receptor blockers epidemiology Cardiac and Cardiovascular Systems Kardiologi
135	Uticaj sveobuhvatne kardijalne rehabilitacije na dijastolnu disfunkciju i funkcionalni status pacijenata lečenih perkutanom koronarnom intervencijom nakon akutnog koronarnog događaja / The impact of comprehensive cardiac rehabilitation on diastolic dysfunction and the functional status of patients treated with percutaneous coronary intervention after acute coronary event Bjelobrk Marija 10 May 2019 (has links) <p>Uvod: U savremenom svetu koronarna arterijska bolest srca (KABS) je vodeći uzrok obolevanja i umiranja, a akutni koronarni sindrom (AKS) je jedna od njenih najče&scaron;ćih i najopasnijih kliničkih manifestacija. Dijastolna disfunckija leve komore često prati KABS i mogući je doprinosni faktor za lo&scaron; klinički tok i ishod. Postavlja se pitanje u kom obimu je dijastolna disfunkcija leve komore udružena sa koronarnom arterijskom bole&scaron;ću i da li savremeni programi ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR) imaju uticaja na bolju prognozu ove grupe kardiolo&scaron;kih bolesnika. Uprkos &scaron;irokoj primeni revaskularizacionih procedura u svakodnevnoj kardiolo&scaron;koj praksi i brojnih studija koje su ukazale na pozitivne efekte programa SKR na funkcionalni status pacijenata nakon AKS, jo&scaron; uvek postoji mnogo kontroverzi o efektima fizičkog treninga, na srčanu funkciju i pobolj&scaron;anje funkcionalnog kapaciteta kod pacijenata sa KABS i pridruženom dijastolnom disfunkcijom. Cilj istraživanja: bio je da ispita uticaj superviziranih vežbi fizičkim opterećenjem (VFO) u okviru programa ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR), na dijastolnu disfunkciju leve komore (DDLK) i funkcionalni status pacijenata (FS), nakon AKS, re&scaron;enog perkutanom koronarnom intervencijom (PCI), kao i da li, s druge strane, prisustvo i stepen dijastolne disfunkcije na početku istraživanja, utiče na funkcionalni status i pojavu neželjenih kardijalnih događaja, kod ove grupe pacijenata u okviru programa ASKR i van njega  Materijal i metode: Istraživanjem je bilo obuhvaćeno ukupno 85 ispitanika, oba pola, starosti od 18-65 godina, koji su tokom indeksne hospitalizacije lečeni kao klinički dokazani AKS (APNS; NSTEMI; STEMI) i kod kojih je urađena neka od interventnih koronarnih procedura (pPCI; PCI; PTCA). Nakon 4 nedelje od otpusta sa hospitalizacije, zbog NSTEMI ili APNS, odnosno nakon 6 nedelja od otpusta sa hospitalizacije zbog STEMI, pacijenti sa EFLK ≥ 45%, bez značajnih valvularnih i drugih mana i sa nekim od poremećaja dijastolne funkcije, bili su kandidati za uče&scaron;će u istraživanju. Svi ispitanici su podvrgavani &bdquo;ulaznom“ehokardiografskom pregledu (EHO) u cilju procene sistolne funkcije i stepena dijastolne disfunkcije leve komore, kao i &bdquo;ulaznom“ spiroergometrijskom testu (CPET) u cilju procene funkcionalnog statusa, na osnovu kojeg je vr&scaron;ena preskripcija vežbi fizičkim opterećenjem (VFO) u okviru programa ASKR. Program ASKR odvijao se u ukupnom trajanju od 12 nedelja, odnosno 36 pojedinačnih sesija VFO, 3 puta nedeljno u trajanju od po 30 minuta. Kontrolna grupa obuhvatila je grupu pacijenata koja nije živela u blizini IKVBV i koja nije bila u mogućnosti da dolazi redovno na VFO u sklopu ASKR. Njima je bilo pu&scaron;teno na volju da na osnovu urađenog EHO pregleda i CPET, određuju stepen VFO po sopstvenom nahođenju, uz primenu optimalnog medikamentnog lečenja i ostalih mera sekundarne prevencije. Nakon 3 meseca obe grupe pacijenata bile su podrvrgnute novom –“izlaznom” ehokardiografskom i CPET pregledu u cilju komparacije sa rezultatima na početku istraživanja. Rezultati:Istraživanje je pokazalo da nakon 3 meseca superviziranog treninga VFO, u okviru programa ASKR, kod bolesnika nakon AKS, lečenih perkutanom koronarnom intervencijom, dolazi do pobolj&scaron;anja stepena dijastolne disfunkcije leve komore, naročito kroz promene vrednosti ehokardiografskih parametara e’l i E/e’ l. U kontrolnoj grupi e’l se smanjio za (0,003 ± 0,025), a u osnovnoj se povećao za (0,011 ± 0,021). U kontrolnoj grupi e’l se nije značajno promenio (p = 0,515), a u osnovnoj grupi se značajno povećao (p < 0,0005). Na početku istraživanja u osnovnoj grupi e’l je bio (0,097 ± 0,027 m/sec), a na kraju (0,108 ± 0,031 m/sec). E/e’l se nije značajno promenio u kontrolnoj grupi (p = 0,226), a u osnovnoj grupi se značajno smanjio (p = 0,002). Na početku istraživanja u osnovnoj grupi E/e’l je bio (8,02 ± 2,98), a na kraju (6,97 ± 2,17). Takođe je utvrđeno da nakon 3 meseca superviziranog treninga u okviru programa ASKR, dolazi do pobolj&scaron;anja funkcionalnog kapaciteta pacijenata sa KABS i dijastolnom disfunkcijom leve komore, kroz povećanje CPET parametara: peak VO2, VO2 predict i METs. U kontrolnoj grupi peak VO2 se smanjio za (1,79 ± 3,84), a u osnovnoj se povećao za (1,67 ± 4,29). U kontrolnoj grupi peak VO2 se značajno smanjio (p = 0,018), a u osnovnoj grupi se značajno povećao (p = 0,005).Na početku istraživanja u kontrolnoj grupi srednja vrednost peak VO2 iznosila je (23,01 ± 3,99 ml/kgTT/min), a u osnovnoj grupi je iznosila (23,15 ± 4,99 ml/kgTT/min). Na kraju istraživanja u osnovnoj grupi srednja vrednost peak VO2 iznosila (24,82 ± 5,77 ml/kgTT/min), dok je kod kontrolne grupe iznosila (21,21 ± 4,05 ml/kgTT/min). U kontrolnoj grupi ppVO2(%) se smanjio za (5,28 ± 14,39), a u ispitivanoj se povećao za (7,16 ± 18,51). U kontrolnoj grupi ppVO2(%) se nije značajno promenio (p = 0,058), dok se u osnovnoj grupi statistički značajno povećao (p = 0,005). Razlika srednjih vrednosti promena METs između osnovne i kontrolne grupe je bila statistički značajna (p < 0,0005). U kontrolnoj grupi METs se smanjio za (0,55 ± 1,12), a u osnovnoj se povećao za (0,58 ± 1,12). U kontrolnoj grupi METs se značajno smanjio (p = 0,013), a u osnovnoj grupi se značajno povećao (p < 0,0005). Zaključak: Program ambulantne sveobuhvatne kardijalne rehabilitacije, kod bolesnika nakon akutnog koronarnog sindroma, lečenih perkutanom koronarnom intervencijom, utiče na pobolj&scaron;anje faktora rizika kardiovaskularnih bolesti, značajno utiče na pobolj&scaron;anje stepena dijastolne disfunkcije leve komore i na pobolj&scaron;anje funkcionalnog statusa pacijenata, u odnosu na početak istraživanja.</p> / <p><!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>mladen</o:Author> <o:Version>16.00</o:Version> </o:DocumentProperties> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings></xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> 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136	Efetividade de protocolos de dor torácica para alta precoce e segura de adultos com sintomas sugestivos de síndrome coronariana aguda: revisão sistemática e metanálise / Effectiveness of chest pain protocols for early and safe discharge of adults with sugestive symptoms acute coronary syndrome: systematic review and meta-analysis. Duarte, Misa Cadidé 10 August 2018 (has links) Introdução: O manejo inadequado dos pacientes com dor torácica sugestiva de síndrome coronariana aguda (SCA) é fator de risco para morte ou outros eventos cardíacos adversos maiores (ECAM), o que contribui para o aumento da morbidade e mortalidade, do estresse da equipe e do paciente e maiores custos com o uso de serviços de saúde. Os protocolos de dor torácica para alta precoce (protocolos de diagnósticos acelerados ADP) surgem como instrumentos de melhoria da qualidade da assistência em departamentos de emergência (DE), possibilitando alta precoce (em até 6 horas) e segura a esses pacientes. Objetivo: Sintetizar as evidências científicas sobre a efetividade de protocolos de dor torácica na alta precoce e segura de adultos com sintomas sugestivos de SCA em DE, quando comparados ao tratamento usual ou outros protocolos de dor torácica (usual ou de alta precoce). Métodos: Revisão Sistemática (RS) da literatura que seguiu as recomendações do Joanna Briggs Institute. Para a busca dos estudos foi utilizada a estratégia PICOS (P= adultos (> 18 anos) com dor torácica sugestiva de SCA; I e C= protocolos de dor torácica utilizados para alta precoce; O= alta precoce e ECAM em 30 dias; e, S= ensaios clínicos randomizados, nas bases de dados: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, além de banco de teses e dissertações de universidades dos quatro continentes. Não foi determinado limite temporal para a busca e esta foi finalizada em 31 de janeiro de 2018. A seleção inicial, avaliação inicial e qualidade metodológica dos estudos foi realizada por dois revisores independentes e as discordâncias foram resolvidas por consenso. A extração dos dados dos estudos foi feita pelo revisor primário, analisada, discutida e apresentada de forma descritiva e com metanálise. Resultados: Incluídos quatro estudos do tipo ensaio clínico randomizado controlado, sendo que os protocolos para alta precoce utilizadas e testadas nesses estudos foram: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol e 4-Hour Protocol. Porém, devido a alta hetergneidade (I=91%) apenas dois estudos foram agrupados em metanálise e os resultados foram apresentados com gráficos de floresta. Para a alta precoce a estimativa de efeito sugeriu que os benefícios da alta precoce superam os malefícios, recomendando o uso de protocolos acelerados de dor torácica na prática assistencial de departamentos de emergência. Para ECAM, a metanálise foi inconclusiva. Conclusão: Os protocolos estudados são efetivos na alta precoce, porém ainda não há evidência suficiente para afirmar que essa alta precoce seja segura. Contudo, essa RS é um primeiro passo importante para provar que sua utilização é viável e facilitará a alta precoce e segura de DE. / Introduction: Inadequate management of patients with chest pain suggestive of acute coronary syndrome (ACS) is a risk factor for death or other major adverse cardiac events (MACE), which contribute to increased morbidity and mortality, team and patient stress, and a higher expenses with health services. Early-onset chest pain protocols (accelerated diagnostic protocols - ADPs) appear as tools for improving the quality of care in emergency departments (ED), enabling early and safe discharge (up to 6 hours) for these patients. Objective: To synthesize the scientific evidences about the effectiveness of chest pain protocols in the early and safe discharge of adults with symptoms suggestive of ACS in ED, when compared to the usual treatment or other protocols of chest pain (usual or early discharge). Methods: Systematic Review (SR) of the literature that followed the recommendations of the Joanna Briggs Institute. In order to search for the studies, the PICOS strategy was used (P = adults (> 18 years) with chest pain suggestive of ACS, I and C = thoracic pain protocols used for early discharge; O = early discharge and MACE in 30 days and S = randomized clinical trials found in the following databases: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, as well as a thesis and dissertations bank from universities of the four continents. A time limit was not determined to end this research; however this was finalized on January 31, 2018. The initial selection, initial evaluation and methodological quality of the studies were performed by two independent reviewers and the disagreements were resolved by consensus. Data extraction from the studies was done by the primary reviewer, analyzed, discussed and presented in a descriptive form with meta-analysis. Results: Four randomized controlled trials were included, the earlydischarge protocols used and tested in these studies were: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol and 4-Hour Protocol. However, there is high heterogeneity between the studies (I = 91%), only two studies were grouped in meta-analysis and the results present by the funnel plot. For early discharge, the effect estimate suggested that the benefits of early discharge exceed the harm, recommending the use of accelerated chest pain protocols in emergency department assistance practice. For ECAM, the meta-analysis was inconclusive. Is not enough to affirm that early discharge is higher in the experimental groups who were discharged by the new protocol. Conclusion: The protocols studied are effective at early, however there is still insufficient evidence to affirm that this early discharge is safe. But this SR is an important first step to prove that its use is feasible and will facilitate the early and safe discharge of ED. Acute Coronary Syndrome Adult Adultos Alta do paciente Chest pain Clinical Protocols Dor torácica Emergency Service Hospital Meta-analyse Metanálise Patient Discharge Protocolos Clínicos Revisão Sistemática Serviço Hospitalar de Emergência Síndrome Coronariana Aguda Systematic Review
137	Valor prognóstico dos padrões eletrocardiográficos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST: Estudo ERICO-ECG / Prognostic value of electrocardiographic patterns in patients with non ST-elevation acute coronary syndrome Brandão, Rodrigo Martins 30 September 2015 (has links) Introdução: Alguns autores estudaram o valor prognóstico do eletrocardiograma inicial na sobrevida em longo prazo dos pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. O valor prognóstico de outros traçados eletrocardiográficos na fase intra-hospitalar do tratamento foi menos estudado. Objetivos: Avaliar o papel no prognóstico clínico dos registros eletrocardiográficos obtidos durante o evento índice dos participantes do estudo Estratégia de Registro de Insuficiência Coronariana (ERICO) com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Métodos: Foram analisados e classificados, de acordo com o Código de Minnesota, os traçados eletrocardiográficos intra-hospitalares de 634 participantes do estudo ERICO com síndrome coronariana aguda sem supradesnivelamento do segmento ST, no período de fevereiro de 2009 a dezembro de 2013. Foram classificados como alterados os traçados eletrocardiográficos com infradesnivelamento do segmento ST > 1mm e/ou com onda T negativa > 1mm. Foram construídos modelos de regressão de Cox brutos e ajustados, para estudar se o padrão eletrocardiográfico foi um preditor independente de desfechos clínicos (morte por qualquer causa, morte por causa cardiovascular, morte por infarto agudo do miocárdio, e desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal). Resultados: A mediana de seguimento foi de 3 anos. Encontramos uma tendência não significativa para a associação entre a presença de alteração de segmento ST no eletrocardiograma inicial com o desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal [Hazard Ratio (HR) ajustado: 1,64, intervalo de confiança de 95% (IC 95%): 1,00-2,70, p = 0,052]. Encontramos um risco significativamente maior de morte por infarto do miocárdio em indivíduos com alterações do segmento ST no eletrocardiograma final (HR ajustado: 2,04; IC 95%: 1,06-3,92). Os indivíduos com alterações do segmento ST em qualquer traçado durante o evento índice apresentaram risco significativamente maior para desfecho combinado de morte por infarto do miocárdio ou novo infarto do miocárdio não fatal (HR ajustado: 1,71; IC 95%: 1,04-2,79). Quando as alterações de onda T foram incluídas na classificação dos traçados, não houve associação significativa com o prognóstico a longo prazo. Conclusões: Encontramos associações significativas entre as alterações de segmento ST e pior prognóstico em longo prazo. A avaliação sequencial dos traçados eletrocardiográficos durante o evento índice parece adicionar informação prognóstica ao ECG inicial / Introduction: Some authors have studied the prognostic value of initial electrocardiogram in long-term survival of patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The prognostic value of other in-hospital electrocardiographic tracings has been less studied. Objectives: To describe the association between electrocardiogram abnormalities (in ST-segment and T wave) during the index event and outcomes in patients with NSTE ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort. Methods: We analyzed and classified, according to the Minnesota Code, in-hospital ECG tracings of 634 ERICO participants with NSTE-ACS, from February 2009 to December 2013. We considered as altered electrocardiographic tracings with ST-segment depression > 1 mm and / or negative T wave > 1 mm. We built crude and adjusted Cox regression models to study if ECG pattern was an independent predictor for clinical outcomes (death from any cause, death from cardiovascular causes, death from acute myocardial infarction, and combined outcome of fatal or new nonfatal myocardial infarction). Results: Median follow-up was 3 years. We found a trend for the association between initial ECG tracing and the combined outcome of fatal or new nonfatal myocardial infarction [Hazard Ratio (HR) adjusted: 1,64, confidence interval 95% (95% CI): 1,00-2,70, p = 0,052]. We found a significantly higher risk of death due myocardial infarction in patients with ST-segment abnormalities in the final ECG tracing (adjusted HR: 2,04; 95% CI: 1,06 to 3,92). Individuals with ST-segment abnormalities in any tracing had significant higher risk for fatal or new nonfatal myocardial infarction (adjusted HR: 1,71; 95% CI: 1,04 2,79). When the T wave changes were included in the classification, there was no significant association with long-term prognosis. Conclusions: We found significant associations between ECG patterns and worse long-term prognosis. Sequential evaluation of electrocardiographic tracings during the index event seems to add prognostic information to the initial ECG Acute coronary syndrome Acute myocardial infarction Análise de sobrevida Angina instável Angina unstable Electrocardiography Eletrocardiografia Estudo observacional Infarto do miocárdio Mortalidade Mortality Observational study Prognosis Prognóstico Síndrome coronariana aguda Survival analysis
138	Messung von Phospholipase D Metaboliten bei Notfall- und Intensivpatienten mit akutem Koronarsyndrom unter besonderer Berücksichtigung der Therapie mit GPIIb/IIIa-Antagonisten Storm, Christian 01 November 2004 (has links) Im Rahmen dieser Arbeit wurde der Einfluss des GPIIb/IIIa- Antagonisten Tirofiban auf die Vollblut-Konzentration des Phospholipase D Metaboliten Cholin (2- hydroxyethyltrimethylammonium, "whole blood cholin", WBCHO) bei Patienten mit akutem Koronarsyndrom untersucht. Die Phospholipase D hat eine Schlüsselfunktion bei der Destabilisierung atherosklerostischer Plaques, Aktivierung von Thrombozyten und Sekretion von Matrixmetalloproteinasen durch Makrophagen. Als Analyseverfahren für Cholin wurde die Hochleistungsflüssigkeits-Chromatographie (HPLC) in Verbindung mit der Massenspektrometrie (MS) eingesetzt. Die Klassifikation der Patienten erfolgte nach den aktuellen Richtlinien der European Society of Cardiology (ESC) und des American College of Cardiology (ACC) für das akute Koronarsyndrom. Aus einem Kollektiv von 342 Patienten wurden 32 Patienten mit akutem Koronarsyndrom in diese Studie aufgenommen, in zwei Gruppen mit jeweils 16 Patienten mittels matched pairs Technik unterteilt und analysiert. Eine Gruppe erhielt zusätzlich zur Standard- Therapie Tirofiban. Es wurden Blutabnahmen bei Aufnahme, nach 3-6 Stunden und nach 12-24 Stunden gewonnen. Hieraus wurden Troponin I und T, Myoglobin, Kreatinkinase Isoenzym MB, sowie Vollblut-Cholin bestimmt. Es gab einen signifikanten Verlauf der WBCHO- Konzentration (p = 0,006) in der mit Tirofiban behandelten Gruppe im Gegensatz zur Gruppe die nur die Standardtherapie erhielt (p = 0,174). Für den Verlauf der Standardmarker (Myoglobin, Kreatinkinase, Troponin I und T), wurde keine signifikante Beeinflussung durch die Therapie mit Tirofiban nachgewiesen. Im Vergleich zu Troponin I und T, Myoglobin und Kreatinkinase hatte WBCHO das zeitlich früheste Maximum. WBCHO könnte als Markersubstanz der Phospholipase D Aktivität zusätzliche Informationen über die Möglichkeit einer Destabilisierung einer atherosklerotischen Plaque bei Patienten mit akutem Koronarsyndrom geben. Dies könnte in Kombination mit anderen Markern eine verbesserte Risikostratifizierung in der Frühphase des akuten Koronarsyndroms ermöglichen. Zusätzlich scheint ein Monitoring der Tirofiban Therapie durch die WBCHO Konzentration möglich zu sein. / This research work deals with the measurement of the phospholipase D metabolite choline in patients with acute coronary syndrome (ACS) undergoing GPIIb/IIIa antagonist therapy. The influence of GPIIb/IIIa antagonists on concentration levels of the PLD metabolite 2- hydroxyethyltrimethylammonium in blood (whole blood choline, WBCHO) was studied. The activation of phospholipase D (PLD) has a key function in plaque destabilisation, activation of platelets and secretion of matrixmetalloproteinases by macrophages. For the detection of the PLD metabolite WBCHO high pressure liquid chromatography (HPLC) with a mass spectrometer (MS) was used. The classification of patients was performed according to the current guidelines of the European Society of Cardiology (ESC) and the American College of Cardiology (ACC). 32 patients with ACS out of a 342 patient study were included and analysed by matched pairs technique as two groups with 16 patients. One group was treated with Tirofiban (aggrastrat) in addition to standard therapy. Blood samples were taken at admission, after 3-6 hours and after 12-24 hours and in addition to the troponines, myoglobin and creatinkinase Isoenzyme MB, whole blood choline was analyzed. There was a significant (p = 0,006) decrease of WBCHO level in the group treated with Tirofiban in contrast to the reference group with no significant decrease (p = 0,174). The levels of conventional markers as troponin I and T, CK-MB mass and myoglobin had no significant changes in relationship to the Tirofiban therapy. WBCHO had the earliest maximum in contrast to all other markers. We concluded that WBCHO can be used as an additional early risk marker in ACS. Since GPIIb/IIIa- antagonist- therapy may influence WBCHO level, WBCHO has potential to be used for monitoring of therapy. Akutes Koronarsyndrom GPIIb/IIIa-Antagonist Phospholipase D Cholin HPLC-MS Acute coronary Syndrome GPIIb/IIIa-antagonist phospholipase D choline HPLC-MS 610 Medizin 33 Medizin YB 9304 YB 9314 YB 9321 ddc:610
139	Caracterização e análise de desfechos clínicos e eventos adversos em pacientes com síndromes coronarianas agudas incluídos em ensaio clínico multicêntrico randomizado de fase III / Clinical endpoint and adverse event ascertainment in patients with acute coronary syndromes included in a multicenter randomized phase III clinical trial Guimarães, Patricia Oliveira 14 August 2017 (has links) INTRODUÇÃO: A análise de eventos clínicos em um ensaio randomizado estabelece a eficácia e segurança de um novo tratamento. Os eventos clínicos são divididos em eventos adversos (EAs) e desfechos clínicos. A literatura é escassa em informações sobre o processo de coleta de eventos clínicos em estudos, bem como sobre a variabilidade entre os centros de pesquisa em reportar eventos clínicos. OBJETIVOS: Descrever todos os eventos clínicos (EAs e desfechos clínicos) reportados pelos centros participantes do estudo APPRAISE-2 (Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome) e caracterizar a sua seriedade. Avaliar a variabilidade entre os centros de pesquisa em reportar eventos clínicos, além de identificar características basais dos participantes associadas ao ato de reportar eventos. MÉTODOS: Os investigadores clínicos foram responsáveis por reportar todos os eventos apresentados pelos participantes em formulários específicos. Formulários para EAs e para cada um dos desfechos clínicos do estudo foram disponibilizados (infarto agudo do miocárdio ou angina instável, acidente vascular encefálico e sangramento). Suspeitas de desfechos clínicos foram enviadas ao comitê de classificação de eventos clínicos (CEC), que as validou de acordo com critérios pré-estabelecidos. Tanto os desfechos clínicos quanto os EAs foram classificados como \"sérios\" ou \"não-sérios\" pelos investigadores clínicos. Para avaliar a variabilidade em reportar eventos clínicos, somente centros com inclusão de >= 10 participantes foram considerados. Modelos estatísticos foram utilizados para avaliar a influência de região geográfica e de características dos participantes na variabilidade entre os centros em reportar eventos. Os dados coletados estão concentrados no Instituto de Pesquisa Clínica da Universidade de Duke, na Carolina do Norte, Estados Unidos. RESULTADOS: Um total de 13.909 eventos clínicos foram reportados por 858 centros de pesquisa em 39 países. A maioria desses eventos foram EAs (91,6%), sendo os demais desfechos clínicos. Dentre os desfechos clínicos reportados, 66,0% foram confirmados pelo CEC. A maior parte dos desfechos confirmados pelo CEC (94,0%) preencheu critérios de seriedade, enquanto que 63,2% dos desfechos negados pelo CEC foram considerados sérios. De todos os EAs, 17,9% foram sérios. O critério de seriedade mais comumente observado foi hospitalização (N=2594), seguido de morte (N=321). Um ajuste para região geográfica explicou 28,7% e 26,4% da variabilidade entre os centros em reportar desfechos clínicos e EA sérios, respectivamente; a adição de características dos participantes ao modelo explicou mais 25,4% da variabilidade entre os centros em reportar desfechos clínicos e 13,4% em reportar EAs sérios. Os ajustes promoveram pouco impacto em explicar a variabilidade em reportar EAs não-sérios. Diversas características clínicas foram associadas ao ato de reportar eventos clínicos. CONCLUSÃO: Em um ensaio clínico multicêntrico de fase III, a maioria dos eventos clínicos reportados foram EAs não-sérios. Região geográfica e características dos pacientes influenciaram a variabilidade entre os centros em reportar desfechos clínicos e EAs sérios, com pouco impacto em EAs não-sérios. Uma coleta integrada de desfechos clínicos e EAs é viável, informativa e ilustra as características que estes eventos compartilham / BACKGROUND: The collection of adverse events (AEs) and clinical endpoints determines the overall efficacy and safety of the study treatment in clinical trials. However, AEs and clinical endpoints are captured and processed separately with limited information on various aspects of this data collection, its integration, and its variation across sites. OBJECTIVES: To describe all site-reported clinical events in the APPRAISE-2 (Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome) trial and report their seriousness. To evaluate the variability in reporting clinical events across sites and identify characteristics associated with clinical event reporting. METHODS: All clinical events were collected in case report forms (CRF) by site-investigators, as AEs or suspected endpoints. Data on suspected endpoints were collected in specific CRFs (myocardial infarction or unstable angina, cerebrovascular event and bleeding) and sent to review by a clinical events committee (CEC) that adjudicated these events according to predefined criteria. Seriousness criteria was collected for all AEs and suspected endpoints. To explore site-level variability i n event reporting, sites with >=10 participants were i ncluded. Statistical models explored the influence of geographic region and patient characteristics in between-site variability in event reporting. All collected data is centered in the Duke Clinical Research Institute, North Carolina, Unites States. RESULTS: A total of 13.909 clinical events were reported by 858 sites in 39 countries. Most clinical events were AEs (91.6%), followed by suspected endpoints. Of suspected endpoints reviewed by CEC, 66.0% were confirmed. Most CEC-confirmed endpoints met serious criteria (94.0%) and, of CEC-negatively adjudicated endpoints, 63.4% were serious. Of all AEs, 17.9% were considered serious events. Hospitalization was the most common criterion for classification as serious event (N=2594), followed by death (N=321). In models accounting for geographic region, site variation in reporting endpoints and serious AEs was explained by 28.7% and 26.4%, respectively; adding patient characteristics further explained site variation by 25.4% for endpoint reporting and 13.4% for serious AE reporting. Non-serious AE reporting variation was not explained by patient characteristics or region. Several clinical characteristics were associated with clinical event reporting. CONCLUSION: In a multicenter phase III clinical trial, the majority of reported events were non-serious AEs. Geographic region and patient characteristics influenced between-site variability in reporting of clinical endpoints and serious AEs, with limited impact in non-serious AEs. An integrated collection of endpoints and AEs is feasible, possible in a multinational trial and illustrates the shared characteristics of events Acute coronary syndrome Adverse events Cerebral infarction Clinical outcomes Clinical trials Desfechos clínicos Efficacy Eficácia Ensaio clínico Ensaio clínico controlado aleatório Eventos adversos Infarto agudo do miocárdio Infarto cerebral Randomized controlled trial Síndrome coronariana aguda
140	Mecanismos envolvidos no aumento do risco de sangramento em pacientes com acidente vascular cerebral ou ataque isquêmico transitório prévios em uso de antiagregante plaquetário / Mechanisms involved in increasing the risk of bleeding in patients with stroke or transient ischemic attack using antiplatelet agent Barbosa, Carlos José Dornas Gonçalves 23 January 2018 (has links) Introdução: O antecedente de AVCI e/ou AIT está presente em 5% dos pacientes com coronariopatia aguda e em até 17% dos pacientes com coronariopatia crônica. Esta população apresenta elevado risco para eventos cardiovasculares, assim como para desfechos hemorrágicos maiores (principalmente quando em uso de tratamento antitrombótico). A agregabilidade plaquetária apresenta papel fundamental no balanço isquêmico/hemorrágico; entretanto, esse mecanismo é pouco estudado em pacientes com evento cérebro vascular isquêmico prévio. O principal objetivo desse estudo é avaliar se pacientes com DAC e AVCI/ AIT prévio exibem alterações na agregabilidade plaquetária que justifiquem o risco aumentado para sangramento nesses indivíduos. Casuística e Métodos: Entre janeiro de 2013 e abril de 2015, 140 pacientes foram selecionados nos bancos de dados da unidade coronária e do serviço de cirurgia cardíaca do InCor- HCFMUSP. Critérios de inclusão: coronariopatia aguda prévia (há mais de 12 meses), antecedente de AVCI/AIT (anterior ao episódio de coronariopatia aguda), uso crônico de AAS e assinatura do Termo de Consentimento Livre e Esclarecido. Critérios de exclusão: AVCH prévio, uso de antiagregação plaquetária dupla ou anti-inflamatórios não esteroidais, trombofilia ou coagulopatia conhecida, trombocitopenia ou trombocitose, angioplastia ou cirurgia cardíaca nos últimos 6 meses, disfunção renal grave ou qualquer doença terminal. Desenho do estudo: Estudo de caso e controle (1:1), com os grupos caso (AVCI/AIT prévio) e controle (sem AVCI/AIT prévio) pareados por sexo, idade, tipo de coronariopatia aguda e tempo entre a coronariopatia aguda e a inclusão no estudo. A agregabilidade plaquetária foi mensurada pelo VerifyNow Aspirin®, VerifyNow P2Y12®, Agregometria óptica com agonista ADP, Agregometria óptica com agonista adrenalina e tromboelastrografia (Reorox®). Resultados: Os grupos controle (n=70) e caso (n=70), estavam bem pareados em relação à maioria das variáveis analisadas. A idade média da população global foi de 66 anos, 73% apresentavam IAM prévio, e o tempo médio entre o episódio de coronariopatia aguda e a inclusão no presente estudo foi de 5,31 anos. No momento da avaliação os pacientes do grupo caso apresentavam valores mais elevados de pressão arterial sistólica (135,84 ± 16,09 vs 123,68 ± 16,11mmHg, p < 0,001), embora esse grupo utilizasse maior número de antihipertensivos (2,37 ± 1,09 vs 3,0 ± 1,23, p=0,006). Em relação a variáveis metabólicas, o perfil lipídico não presentou diferença significativa entre os grupos, entretanto o grupo caso apresentou maiores valores de creatinina (1,24 ± 0,35 vs 1,11 ± 0,27 mg/dL, p=0,037) e também de glicemia de jejum (116,16 ± 32,03 vs 134,88 ± 57,58 mg/dL, p=0,031). No que se refere à meta principal do estudo, a agregabilidade plaquetária foi similar nos dois grupos por todos os métodos utilizados: VerifyNow Aspirin® (525,00 ± 79,78 vs 530,35 ± 83,81 ARU nos grupos caso e controle, respectivamente, p=0,7), VerifyNow P2Y12® (262,14 ± 43,03 vs 251,74 ± 43,72 PRU, p=0,21), Agregometria óptica com agonista ADP (78,34 ± 9,02 vs 77,55 ± 9,70%, p=0,82), Agregometria óptica com agonista adrenalina (49,01± 23,93% vs 49,34 ± 21,7, p=0,77), e tromboelastografia (Firmeza máxima do coágulo: 2,136,00 ± 569,97 vs 2.001,27 ± 635,68 Pa, p=0,19). Conclusão: Em pacientes com doença arterial coronária crônica a agregabilidade plaquetária foi similar nos indivíduos com ou sem AVCI/AIT. Esses resultados apontam para que outros mecanismos sejam responsáveis pelo elevado risco hemorrágico dessa população / Background: Ischemic stroke (IS) or transient ischemic attack (TIA) history is present in 5% of patients with acute coronary syndrome (ACS) and in 17% of patients with stable atherosclerotic disease (CAD). This population has a higher risk for major cardiovascular events and an increased incidence of major hemorrhagic outcomes when subjected to modern antithrombotic regimens, Platelet aggregability have key role in \"ischemic-hemorrhagic\" balance, however, these factors are little known in the population with prior cerebrovascular event. The aim of this study is to evaluate whether patients with coronary artery disease and previous IS/ TIA exhibit alterations in platelet aggregation, justifying the increased bleeding risk of these individuals. Methods: Between January 2013 and April 2015, 140 participants were selected in the coronary care unit and cardiac surgery service databank. Inclusion criteria: prior ACS (over 12 months), history of IS/ TIA previous to ACS, chronic use of aspirin since ACS and agreement to the consent form. Exclusion criteria: prior hemorrhagic stroke, current dual antiplatelet therapy or anti-inflammatory non-steroidal, any thrombophilia or coagulopathy, thrombocytopenia, thrombocytosis, PCI or CABG in the last 6 months, severe renal impairment and any terminal illness. Study design: Case-control study (1:1), case group (previous IS/TIA) and control group (without previous IS/TIA) matched for sex, age, type of previous ACS, time between ACS and inclusion in the study. Platelet aggregation was assessed by VerifyNow Aspirin®, VerifyNow P2Y12®, Light transmission aggregometry aggonist with agonists adrenaline, Light transmission aggregometry aggonist with ADP, and thromboelastography (Reorox®). Results: The control group (n=70) and case group (n=70), were well matched. The mean age was 63 years, about 73% presented previous AMI and the index ACS occurred 5,31 years before study inclusion. At the evaluation day patients in the case group presented higher SBP levels (135.84 ± 16.09 vs 123.68 ± 16.11 mmHg, p < 0,001), although this group were using more antihypertensive medications (2.37 ± 1.09 vs 3.0 ± 1.23, p=0,006). In relation to metabolic profile, lipid profile did not presented diferences, however, case group presented higher values for creatinine (1.24 ± 0.35 vs 1.11 ± 0.27 mg/dL, p=0.037) and also presented higher values for fasting glucose.(116.16 ± 32.03 vs 134.88 ± 57.58 mg/dL, p=0.031) Platelet aggregation was statistically similar in both groups: VerifyNow Aspirin® (525.00 ± 79.78 vs 530.35 ± 83.81 ARU, p=0.7), VerifyNow P2Y12® (262.14 ± 43.03 vs 251.74 ± 43.72 PRU, p=0.21), Light transmission aggregometry aggonist with agonists ADP (78,34 ± 9,02 vs 77,55 ± 9,70%, p=0,82), Light transmission aggregometry aggonist with adrenaline (49,01 ± 23,93% vs 49,34 ± 21,7, p=0,77) and thromboelastography (maximum clot firmness: 2.136,00 ± 569,97 vs 2.001,27 ± 635,68 Pa, p=0,19). Conclusion: Platlet aggregability is similar in CAD patients with or without previous IS/TIA and this results point at other reasons to justify the high risk for bleeding in this patients Acidente vascular cerebral Acute coronary syndrome Ataque isquêmico transitório Coronary artery disease Doença da artéria coronariana Hemorragia Hemorrhage Ischemic attack transient Platelet function tests Síndrome coronariana aguda Stroke Testes de função plaquetária

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