Es wurden Studien zur biochemischen Evaluierung des akuten Koronarsyndroms unter drei Aspekten unternommen: (1) Die klinische Anwendung der biochemischen Marker zur Diagnosesicherung und Risikostratifizierung bei Patienten mit akutem Koronarsyndrom, (2) die Bedeutung kardialer Troponine unter besonderen physiologischen und pathophysiologischen Bedingungen und (3) die tierexperimentelle Evaluierung passagerer Ischämie mit der Fragestellung, ob eine Erhöhung kardialer Troponine im Plasma bei reversibler Myokardschädigung auftreten kann. Die klinische Anwendung der kardialen Marker kann zuverlässig nach aktuellen Richtlinien erfolgen und sollte immer auch die Messung eines kardialen Troponins beinhalten. Troponin-Testsysteme sollten in klinischen Studien hinsichtlich des diagnostischen und prognostischen Nutzens evaluiert worden sein. Die in dieser Arbeit untersuchten Systeme wiesen nachweisbare Unterschiede auf, die jedoch für den klinischen Einsatz nicht bedeutsam sind. Geringe Troponin T-Erhöhungen bei Patienten mit akutem Koronarsyndrom und eher geringer oder atypischer Symptomatik haben eine eindeutige prognostische Aussagekraft und ergänzen damit signifikant die klinische Einschätzung und das EKG. Kardiale Troponine können bei herzgesunden Probanden unter extremer körperlicher Leistung gering erhöht sein. Die prognostische Bedeutung dieser Befunde ist unklar. Kardiales Troponin kann bei kardial asymptomatischen Patienten mit Niereninsuffizienz ohne sichere prognostische Bedeutung erhöht sein. Tierexperimentell ergeben sich Hinweise darauf, daß es bei reversibler Ischämie im Sinne eines "continuous release" zur Freisetzung von kardialem Troponin bzw. zumindest von Degradationsprodukten desselben kommen kann. Die zukünftige Entwicklung von Richtlinien zum Einsatz biochemischer Marker wird entscheidend davon abhängen, ob auf den erhobenen Befunden therapeutische Strategien mit nachgewiesenem Nutzen im Sinne einer "evidence based medicine" aufbauen. / Three studies with respect to the biochemical evaluation of acute coronary syndromes were undertaken : (1) The clinical application of biochemical markers for diagnosis and risk stratification in patients with acute coronary syndroms. (2) The value of cardiac troponins under different physiological and pathophysiological conditions. (3) Experimental transient myocardial ischemia in an animal model with respect to the question, whether elevation of cardiac troponins in plasma perhaps occur after reversible myocardial damage. The clinical appilication of cardiac markers is sufficiently possible following actual guidelines and should include cardiac troponin measurement. The troponin test-system has to be evaluated in clinical studies with respect to its diagnostic and prognostic properties. In this study significant differences between two cardiac troponin I test-systems could be shown. The differences were below clinical relevance. Mild to moderate elevations of cardiac troponin T in patients with acute coronary syndromes and low grade Braunwald class angina are of prognostic value and add on information obtained by history and ECG. Cardiac troponins may be found elevated in apparently healthy athletes after exhaustive exercise. The prognostic significance of these findings remains unclear. Cardiac troponins are frequently elevated in renal insufficiency patients without cardiac symptoms. These elevations had no prognostic value in our study. The experimental data suggest that troponins are released in reversible myocardial damage during transient ischemia. This adds evidence on the continuous release hypothesis of cardiac troponins and degradation products. The future development of guidelines for the use of cardiac markers in daily routine will strictly depend on therapeutic consequences which base on the analytical results in the sense of evidence based medicine.

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.

La phospholipase A2 liée aux lipoprotéines (Lp-PLA2) est une biomarqueur de plusieurs maladies inflammatoires et une niveau sérique élevé est associé à l’instabilité de la plaque artérioscléreuse. Comme son nom l’indique, la Lp-PLA2 est liée aux lipoprotéines plasmatiques (LDL et HDL) et son rôle est de prévenir l’accumulation de phospholipides oxidés a la surface des lipoprotéines. Toutefois, les produits de dégradation des phospholipides oxidés par la Lp-PLA2 - le lysophosphatidyl choline par les acides gras oxidés peuvent aussi promouvoir l’inflammation. Mieux comprendre le métabolisme de la Lp-PLA2 pourrait nous permettre de mieux apprécier son rôle dans la formation d’une plaque artérioscléreuse instable, car des études antérieures ont démontré une forte expression de la Lp-PLA2 dans la plaque. De plus, il existe une forte corrélation entre les niveaux et l’activité plasmatiques de la Lp-PLA2 et la maladie coronarienne, les accidents cérébraux-vasculaires et la mortalité cardiaque. L’inhibition de la Lp-PLA2 avec une petite molécule, le darapladib, n’a pas démontré de bénéfice sur les évènements cardiovasculaires dans deux études cliniques. Cette thèse présentera d’abord une revue de la littérature sur la Lp-PLA2 et les maladies cardiovasculaires et les deuxième et troisième chapitres, une étude clinique réalisée sur des patients avec un syndrome coronarien aigu. / Lipoprotein associated phospholipase A2 (Lp-PLA2) is a biomarker of several inflammatory diseases and syndromes. An elevated Lp-PLA2 level is associated with unstable atherosclerotic plaques. Bound to plasma lipoproteins (LDL and HDL), Lp-PLA2 prevents the formation of biologically active oxidized phospholipids on their surface such as oxidized phosphatidylcholine (oxPC). Nevertheless, the products of Lp-PLA2 action, lysophosphatidylcholine (LPC) and non-esterified fatty acids (NEFA) are both known to aggravate inflammation. Thus, understanding the metabolism of Lp-PLA2 could help us better understand its role in plaque formation, as studies have shown high expression of Lp-PLA2 and LPCs in unstable plaques. Moreover, studies showed correlation between increased Lp-PLA2 mass and activity and increased risk of coronary artery disease, stroke, and death. The inhibition of Lp-PLA2 with a small molecule, Darapladib, has not demonstrated benefit in reduction of cardiovascular events in two clinical studies. Here, the first chapter will focus on Lp-PLA2 and cardiovascular disease in man, highlighting the latest updates in the literature. The second and third chapters will introduce experimental work on Lp-PLA2 in the setting of acute coronary syndrome.

No description available.

O presente estudo teve como objetivo descrever a dieta e o estado nutricional de uma população com síndrome coronariana aguda no Projeto Estratégia de Registro da Insuficiência Coronariana (Projeto ERICO) na unidade de emergência do Hospital Universitário da Universidade de São Paulo e estimar o número de óbitos em decorrência de doenças cardiovasculares em um ano de acompanhamento desses pacientes. Foram selecionados 290 pacientes de uma população de 841 indivíduos com diagnóstico de síndrome coronariana aguda. Foram avaliados dados demográficos, IMC e variáveis de nutrição a partir de um Questionário de Frequência Alimentar previamente validado e posterior análise do Índice de Qualidade da Dieta Revisado. As variáveis de nutrição utilizadas foram valor calórico total, carboidrato, proteína, lipídeo, ácidos graxos polinsaturados, ácidos graxos monoinsaturados, ácidos graxos saturados, ácidos graxos trans, ácidos graxos linolênico, ácidos graxos linoléico, colesterol e fibras. O cálculo do valor nutritivo dos alimentos consumidos e registrados foi realizado utilizando o programa Virtual Nutri com banco de dados de alimentos da tabela de composição química da United States Departement of Agriculture. Com exceção do colesterol e fibras, todas as variáveis tiveram seus valores absolutos e ajustados para a dieta descritos nas análises. Para a avaliação da qualidade da dieta, foi utilizado o Índice de Qualidade da Dieta Revisado e análise dos 12 componentes que caracterizam diferentes aspectos de uma dieta saudável. Cada componente foi avaliado e uma pontuação foi atribuída variando de zero a vinte. Os valores intermediários foram calculados proporcionalmente à quantidade de alimento consumido. Os indivíduos que possuíram ingestão igual ou superior ao nível recomendado atingiram a pontuação máxima (cinco, dez ou 20 pontos), a depender do componente em questão. No final, a pontuação de todos os componentes foi somada gerando o Índice de Qualidade da Dieta revisado. O valor máximo do Índice de Qualidade da Dieta Revisado é 100 pontos. As variáveis dependentes foram os três tipos de síndrome coronariana aguda: angina instável, infarto agudo do miocárdio sem elevação e infarto agudo do miocárdico com elevação do segmento ST no eletrocardiograma de repouso e para a análise de sobrevida, o óbito após um ano de arrolamento a partir da data de entrada no Hospital Universitário. Para análise dos dados foi feita inicialmente uma análise exploratória dos dados, mostrada em forma de tabelas, gráficos e medidas descritivas, com o intuito de obter uma visualização. Para mensuração do nível de associação entre variáveis nominais (sexo e etnia) com o tipo de síndrome coronariana aguda, foi utilizado o teste de quiquadrado de Pearson. As variáveis contínuas foram categorizadas de acordo com o valor de corte estabelecido na literatura, independente da distribuição dos dados na amostra e para estas, também foi aplicado o teste qui-quadrado com nível de significância (alfa) de 5%, excetuando-se o valor energético total que utilizou a mediana da população. Os dados categóricos foram representados em frequências absoluta (n) e relativa (%). As variáveis quantitativas foram submetidas ao teste Kolmogorov-Smirnov para verificar o grau de aderência à distribuição normal. O teste de variância Levene foi utilizado para analisar a homocedasticidade. As variáveis quantitativas foram descritas por frequências, medidas de tendência central e de dispersão. Os dados paramétricos foram representados por média e desvio padrão e comparados por análise de variância para medidas não repetidas (one way ANOVA) com teste post-hoc de Bonferroni para comparação de três variáveis e teste-T não pareado para comparação de duas variáveis. Os dados foram analisados de acordo com o gênero. Os dados não paramétricos foram representados por mediana e comparados com o teste de Kruskal-Wallis com post-hoc Dunn para comparação de três variáveis e teste de Mann-Whitney para duas variáveis. Para analisar a relação do tipo de síndrome coronariana aguda (variável dependente) com as variáveis de nutrição foi feita uma análise de regressão logística binária, considerando a angina instável e IAM sem supra como uma variável e IAM com supra como outra variável dependente. As análises de regressão foram utilizadas para estimar a odds ratio e intervalo de confiança. Análises não ajustadas foram conduzidas para as variáveis separadamente. As variáveis de cada bloco foram analisadas simultaneamente usando o método Enter. Utilizou-se a abordagem da análise de sobrevivência considerando como evento de interesse o óbito com a probabilidade acumulada de sobrevida em dias. Nenhum paciente perdeu o seguimento durante a duração do estudo. Para a análise de tempo desde o dia de internação até a data de última ligação foi utilizado, inicialmente, o estimador produto limite de Kaplan Meier. Na análise univariada das variáveis qualitativas, para verificar a influência do Índice de Qualidade da Dieta Revisado no óbito, realizou-se a construção de curvas Kaplan-Meier e a comparação estatística foi feita pelo teste log-rank. O tempo de sobrevida foi determinado, contado em dias, entre o dia de entrada no Hospital Universitário e a data de óbito. O nível de significância estabelecido para a análise foi de 0,05. As curvas de Kaplan-Meier foram apresentas segundo o tercil de Índice de Qualidade da Dieta Revisado. A digitação e codificação das informações coletadas foram realizadas no programa Excel; posteriormente os dados foram analisados estatisticamente pelo programa SPSS versão 17.0. Os procedimentos para o desenvolvimento deste estudo respeitaram as diretrizes e normas que regulamentam as pesquisas envolvendo seres humanos, aprovadas pela Resolução n° 169, de 10 de outubro de 1996, do Conselho Nacional de Saúde. Desta forma, no banco de dados da pesquisa principal está mantido o anonimato e a confidencialidade dos dados. A maior parte dos indivíduos foram homens adultos com etnia branca, com sobrepeso e diagnóstico IAM sem supra. A dieta média foi considerada hipercalórica, hipoglicídica, normoprotéica e hiperlipídica com aumento da quantidade do valor calórico total em relação ao aumento da gravidade de síndrome coronariana aguda e relação inversa para proteína. Em relação aos micronutrientes, as quantidades foram adequadas para ácidos graxos polinsaturados, ácidos graxos monoinsaturados, ácidos graxos trans e colesterol e consumos abaixo do recomendado para ácidos graxos linolênicos e ácidos graxos linoleicos. O colesterol teve aumento de consumo médio em relação ao aumento da gravidade de síndrome coronariana aguda, enquanto ácidos graxos polinsaturados, ácidos graxos linoleicos e ácidos graxos trans tiveram aumento em relação à diminuição da gravidade da síndrome coronariana aguda. Além disso, qualidade da dieta necessita melhorar. Para os componentes cereal total, carne e derivados, leguminosas, leite e derivados, óleo e gorduras e sódio, o aumento dos mesmos, aumentou em relação à gravidade da doença. Não foi observada relação com a gravidade de síndrome coronariana aguda para os outros componentes, nem mesmo com a pontuação total do Índice de Qualidade da Dieta Revisado. Os valores médios mais baixos em relação à pontuação total foram para os componentes cereal integral, leite e derivados e gordura saturada enquanto os mais altos foram vegetal total, óleo e derivados e sódio / The present study aimed to describe the diet and nutritional status of a population with acute coronary syndrome in the Project Strategy Registry of Coronary Insufficiency (ERICO study) at the emergency unit of the University Hospital of the University of São Paulo and estimate the number of deaths in due to cardiovascular diseases in one year follow up of these patients. It was selected 290 patients from a population of 841 individuals diagnosed with acute coronary syndrome. It was evaluated variables of demographics, BMI and nutritional variables from a Food Frequency Questionnaire previously validated and further analysis of the Brazilian Healthy Eating Index-Revised. The variables used were total caloric value, carbohydrate, protein, fat, polyunsaturated fatty acids, monounsaturated fatty acids, saturated fatty acids, trans fatty acids, linolenic fatty acids, linoleic fatty acids, cholesterol and fiber. The calculation of the nutritional value of consumed foods was performed using the Virtual Nutri software with the food chemical composition of United States Departement of Agriculture database. With the exception of cholesterol and fiber, all variables and their absolute values described in the analyzes were adjusted to the diet. For the quality of the diet evaluation, the Brazilian Healthy Eating Index-Revised was used with its analysis of the 12 components featuring different aspects of a healthy diet was used. Each component was evaluated and was assigned with a score ranging from zero to twenty. Intermediate values were calculated in proportion to the amount of food consumed. Individuals who had intake with the limit or above the recommended level reached the maximum score (five, ten or 20 points ), according to the component in question . In the end, the scores of all components were added generating the Brazilian Healthy Eating Index-Revised. The maximum value of the Brazilian Healthy Eating Index-Revised is 100 points. The dependent variables were the three types of acute coronary syndrome: unstable angina, acute myocardial infarction STEMI and NSTEMI and for the survival analysi , death after one year of enrollment from the entry date into the University Hospital. For the data analysis, an exploratory analysis was first done and shown in tables, charts and descriptive measures. The level of association between nominal variables (gender and ethnicity) with the type of acute coronary syndrome was measured with the chi-squared test. Continuous variables were categorized according to the cutoff value established in the literature, regardless of the data distribution in the sample and for these, the chi- squared test with a significance level (alfa) of 5% was also applied, excepting the total caloric value which was used with the median value of the population. Categorical data were presented as absolute (n) and relative (%) frequencies. Quantitative variables were assessed by Kolmogorov-Smirnov test to check the level of normal distribution. The variance of Levene\'s test was used to analyze the homoscedasticity. Quantitative variables were described by frequencies, central tendency and dispersion measures. Parametric data were expressed as mean and standard deviation and compared by one way analysis of variance (one way ANOVA) and for post hoc analysis, Bonferroni test was used for comparison of three variables and Student\'s t-test was used for comparison of two variables. The data was analyzed according to gender. The non-parametric data were expressed by median and compared with the Kruskal-Wallis test with its post hoc called Dunn test to compare three variables. The Mann-Whitney test was used to compare two variables. The relationship of the type of acute coronary syndrome (dependent variable) with the variables of nutrition was examined with the binary logistic regression analysis of binary logistic regression, considering the unstable angina and NSTEMI myocardial infarction as a single variable and STEMI myocardial infarction as another dependent variable. Regression analyzes were used to estimate odds ratios and confidence intervals. Unadjusted analyzes were performed separately for the variables. The variables in each group were analyzed simultaneously using the Enter method. We used the approach of survival analysis as the event of interest considering death with a cumulative probability of survival expressed in days. No patients had follow-up lost during the study. It was considered the day of admission at the hospital until the last call date for the time analysis and the Kaplan-Meier method was estimated. To verify the influence of the Brazilian Healthy Eating Index-Revised in death, there was the construction of Kaplan-Meier curves and statistical comparison was done by log-rank test. The level of significance for the analysis was 0.05. The typing and encoding data were performed in Excel and subsequently the data were statistically analyzed using SPSS version 17.0. The procedures for the development of this study are complied with the guidelines and rules that regulate research involving human subjects, approved by 169 Resolution from October 10, 1996 by the National Board of Health. By this way, the database of the research maintained its anonymity and its confidentiality of the data. Most subjects were adults, men, with white ethnicity, overweight diagnosis and with NSTEMI acute myocardial. The average of diet was considered hypercaloric, hypoglycemic, with normal protein value and high in fat with increased amounts of the total caloric value in relation to the increased severity of acute coronary syndrome and inverse relation to protein value. Regarding micronutrients, the quantities were appropriate for polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids and cholesterol intakes below the recommended level for linolenic fatty acids and linoleic fatty acids. The cholesterol had increased average consumption in relation to increased severity of acute coronary syndrome, whereas polyunsaturated fatty acids, linoleic fatty acids and trans fatty acids were increased in relation to reducing the severity of acute coronary syndrome. Furthermore, diet quality needs to improve. For full cereal components, meat products, legumes, dairy products, oils and fats and sodium, an increase of them increased the severity of the disease. There wasn\'t relationship with the severity of acute coronary syndrome for the other components, not even with the total score of the Brazilian Healthy Eating Index-Revised. The lowest average values for the total score were components for whole grain, dairy and saturated fat while the highest were the total vegetable oil and derivatives and sodium

No description available.

O presente estudo teve como objetivo descrever a dieta e o estado nutricional de uma população com síndrome coronariana aguda no Projeto Estratégia de Registro da Insuficiência Coronariana (Projeto ERICO) na unidade de emergência do Hospital Universitário da Universidade de São Paulo e estimar o número de óbitos em decorrência de doenças cardiovasculares em um ano de acompanhamento desses pacientes. Foram selecionados 290 pacientes de uma população de 841 indivíduos com diagnóstico de síndrome coronariana aguda. Foram avaliados dados demográficos, IMC e variáveis de nutrição a partir de um Questionário de Frequência Alimentar previamente validado e posterior análise do Índice de Qualidade da Dieta Revisado. As variáveis de nutrição utilizadas foram valor calórico total, carboidrato, proteína, lipídeo, ácidos graxos polinsaturados, ácidos graxos monoinsaturados, ácidos graxos saturados, ácidos graxos trans, ácidos graxos linolênico, ácidos graxos linoléico, colesterol e fibras. O cálculo do valor nutritivo dos alimentos consumidos e registrados foi realizado utilizando o programa Virtual Nutri com banco de dados de alimentos da tabela de composição química da United States Departement of Agriculture. Com exceção do colesterol e fibras, todas as variáveis tiveram seus valores absolutos e ajustados para a dieta descritos nas análises. Para a avaliação da qualidade da dieta, foi utilizado o Índice de Qualidade da Dieta Revisado e análise dos 12 componentes que caracterizam diferentes aspectos de uma dieta saudável. Cada componente foi avaliado e uma pontuação foi atribuída variando de zero a vinte. Os valores intermediários foram calculados proporcionalmente à quantidade de alimento consumido. Os indivíduos que possuíram ingestão igual ou superior ao nível recomendado atingiram a pontuação máxima (cinco, dez ou 20 pontos), a depender do componente em questão. No final, a pontuação de todos os componentes foi somada gerando o Índice de Qualidade da Dieta revisado. O valor máximo do Índice de Qualidade da Dieta Revisado é 100 pontos. As variáveis dependentes foram os três tipos de síndrome coronariana aguda: angina instável, infarto agudo do miocárdio sem elevação e infarto agudo do miocárdico com elevação do segmento ST no eletrocardiograma de repouso e para a análise de sobrevida, o óbito após um ano de arrolamento a partir da data de entrada no Hospital Universitário. Para análise dos dados foi feita inicialmente uma análise exploratória dos dados, mostrada em forma de tabelas, gráficos e medidas descritivas, com o intuito de obter uma visualização. Para mensuração do nível de associação entre variáveis nominais (sexo e etnia) com o tipo de síndrome coronariana aguda, foi utilizado o teste de quiquadrado de Pearson. As variáveis contínuas foram categorizadas de acordo com o valor de corte estabelecido na literatura, independente da distribuição dos dados na amostra e para estas, também foi aplicado o teste qui-quadrado com nível de significância (alfa) de 5%, excetuando-se o valor energético total que utilizou a mediana da população. Os dados categóricos foram representados em frequências absoluta (n) e relativa (%). As variáveis quantitativas foram submetidas ao teste Kolmogorov-Smirnov para verificar o grau de aderência à distribuição normal. O teste de variância Levene foi utilizado para analisar a homocedasticidade. As variáveis quantitativas foram descritas por frequências, medidas de tendência central e de dispersão. Os dados paramétricos foram representados por média e desvio padrão e comparados por análise de variância para medidas não repetidas (one way ANOVA) com teste post-hoc de Bonferroni para comparação de três variáveis e teste-T não pareado para comparação de duas variáveis. Os dados foram analisados de acordo com o gênero. Os dados não paramétricos foram representados por mediana e comparados com o teste de Kruskal-Wallis com post-hoc Dunn para comparação de três variáveis e teste de Mann-Whitney para duas variáveis. Para analisar a relação do tipo de síndrome coronariana aguda (variável dependente) com as variáveis de nutrição foi feita uma análise de regressão logística binária, considerando a angina instável e IAM sem supra como uma variável e IAM com supra como outra variável dependente. As análises de regressão foram utilizadas para estimar a odds ratio e intervalo de confiança. Análises não ajustadas foram conduzidas para as variáveis separadamente. As variáveis de cada bloco foram analisadas simultaneamente usando o método Enter. Utilizou-se a abordagem da análise de sobrevivência considerando como evento de interesse o óbito com a probabilidade acumulada de sobrevida em dias. Nenhum paciente perdeu o seguimento durante a duração do estudo. Para a análise de tempo desde o dia de internação até a data de última ligação foi utilizado, inicialmente, o estimador produto limite de Kaplan Meier. Na análise univariada das variáveis qualitativas, para verificar a influência do Índice de Qualidade da Dieta Revisado no óbito, realizou-se a construção de curvas Kaplan-Meier e a comparação estatística foi feita pelo teste log-rank. O tempo de sobrevida foi determinado, contado em dias, entre o dia de entrada no Hospital Universitário e a data de óbito. O nível de significância estabelecido para a análise foi de 0,05. As curvas de Kaplan-Meier foram apresentas segundo o tercil de Índice de Qualidade da Dieta Revisado. A digitação e codificação das informações coletadas foram realizadas no programa Excel; posteriormente os dados foram analisados estatisticamente pelo programa SPSS versão 17.0. Os procedimentos para o desenvolvimento deste estudo respeitaram as diretrizes e normas que regulamentam as pesquisas envolvendo seres humanos, aprovadas pela Resolução n° 169, de 10 de outubro de 1996, do Conselho Nacional de Saúde. Desta forma, no banco de dados da pesquisa principal está mantido o anonimato e a confidencialidade dos dados. A maior parte dos indivíduos foram homens adultos com etnia branca, com sobrepeso e diagnóstico IAM sem supra. A dieta média foi considerada hipercalórica, hipoglicídica, normoprotéica e hiperlipídica com aumento da quantidade do valor calórico total em relação ao aumento da gravidade de síndrome coronariana aguda e relação inversa para proteína. Em relação aos micronutrientes, as quantidades foram adequadas para ácidos graxos polinsaturados, ácidos graxos monoinsaturados, ácidos graxos trans e colesterol e consumos abaixo do recomendado para ácidos graxos linolênicos e ácidos graxos linoleicos. O colesterol teve aumento de consumo médio em relação ao aumento da gravidade de síndrome coronariana aguda, enquanto ácidos graxos polinsaturados, ácidos graxos linoleicos e ácidos graxos trans tiveram aumento em relação à diminuição da gravidade da síndrome coronariana aguda. Além disso, qualidade da dieta necessita melhorar. Para os componentes cereal total, carne e derivados, leguminosas, leite e derivados, óleo e gorduras e sódio, o aumento dos mesmos, aumentou em relação à gravidade da doença. Não foi observada relação com a gravidade de síndrome coronariana aguda para os outros componentes, nem mesmo com a pontuação total do Índice de Qualidade da Dieta Revisado. Os valores médios mais baixos em relação à pontuação total foram para os componentes cereal integral, leite e derivados e gordura saturada enquanto os mais altos foram vegetal total, óleo e derivados e sódio / The present study aimed to describe the diet and nutritional status of a population with acute coronary syndrome in the Project Strategy Registry of Coronary Insufficiency (ERICO study) at the emergency unit of the University Hospital of the University of São Paulo and estimate the number of deaths in due to cardiovascular diseases in one year follow up of these patients. It was selected 290 patients from a population of 841 individuals diagnosed with acute coronary syndrome. It was evaluated variables of demographics, BMI and nutritional variables from a Food Frequency Questionnaire previously validated and further analysis of the Brazilian Healthy Eating Index-Revised. The variables used were total caloric value, carbohydrate, protein, fat, polyunsaturated fatty acids, monounsaturated fatty acids, saturated fatty acids, trans fatty acids, linolenic fatty acids, linoleic fatty acids, cholesterol and fiber. The calculation of the nutritional value of consumed foods was performed using the Virtual Nutri software with the food chemical composition of United States Departement of Agriculture database. With the exception of cholesterol and fiber, all variables and their absolute values described in the analyzes were adjusted to the diet. For the quality of the diet evaluation, the Brazilian Healthy Eating Index-Revised was used with its analysis of the 12 components featuring different aspects of a healthy diet was used. Each component was evaluated and was assigned with a score ranging from zero to twenty. Intermediate values were calculated in proportion to the amount of food consumed. Individuals who had intake with the limit or above the recommended level reached the maximum score (five, ten or 20 points ), according to the component in question . In the end, the scores of all components were added generating the Brazilian Healthy Eating Index-Revised. The maximum value of the Brazilian Healthy Eating Index-Revised is 100 points. The dependent variables were the three types of acute coronary syndrome: unstable angina, acute myocardial infarction STEMI and NSTEMI and for the survival analysi , death after one year of enrollment from the entry date into the University Hospital. For the data analysis, an exploratory analysis was first done and shown in tables, charts and descriptive measures. The level of association between nominal variables (gender and ethnicity) with the type of acute coronary syndrome was measured with the chi-squared test. Continuous variables were categorized according to the cutoff value established in the literature, regardless of the data distribution in the sample and for these, the chi- squared test with a significance level (alfa) of 5% was also applied, excepting the total caloric value which was used with the median value of the population. Categorical data were presented as absolute (n) and relative (%) frequencies. Quantitative variables were assessed by Kolmogorov-Smirnov test to check the level of normal distribution. The variance of Levene\'s test was used to analyze the homoscedasticity. Quantitative variables were described by frequencies, central tendency and dispersion measures. Parametric data were expressed as mean and standard deviation and compared by one way analysis of variance (one way ANOVA) and for post hoc analysis, Bonferroni test was used for comparison of three variables and Student\'s t-test was used for comparison of two variables. The data was analyzed according to gender. The non-parametric data were expressed by median and compared with the Kruskal-Wallis test with its post hoc called Dunn test to compare three variables. The Mann-Whitney test was used to compare two variables. The relationship of the type of acute coronary syndrome (dependent variable) with the variables of nutrition was examined with the binary logistic regression analysis of binary logistic regression, considering the unstable angina and NSTEMI myocardial infarction as a single variable and STEMI myocardial infarction as another dependent variable. Regression analyzes were used to estimate odds ratios and confidence intervals. Unadjusted analyzes were performed separately for the variables. The variables in each group were analyzed simultaneously using the Enter method. We used the approach of survival analysis as the event of interest considering death with a cumulative probability of survival expressed in days. No patients had follow-up lost during the study. It was considered the day of admission at the hospital until the last call date for the time analysis and the Kaplan-Meier method was estimated. To verify the influence of the Brazilian Healthy Eating Index-Revised in death, there was the construction of Kaplan-Meier curves and statistical comparison was done by log-rank test. The level of significance for the analysis was 0.05. The typing and encoding data were performed in Excel and subsequently the data were statistically analyzed using SPSS version 17.0. The procedures for the development of this study are complied with the guidelines and rules that regulate research involving human subjects, approved by 169 Resolution from October 10, 1996 by the National Board of Health. By this way, the database of the research maintained its anonymity and its confidentiality of the data. Most subjects were adults, men, with white ethnicity, overweight diagnosis and with NSTEMI acute myocardial. The average of diet was considered hypercaloric, hypoglycemic, with normal protein value and high in fat with increased amounts of the total caloric value in relation to the increased severity of acute coronary syndrome and inverse relation to protein value. Regarding micronutrients, the quantities were appropriate for polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids and cholesterol intakes below the recommended level for linolenic fatty acids and linoleic fatty acids. The cholesterol had increased average consumption in relation to increased severity of acute coronary syndrome, whereas polyunsaturated fatty acids, linoleic fatty acids and trans fatty acids were increased in relation to reducing the severity of acute coronary syndrome. Furthermore, diet quality needs to improve. For full cereal components, meat products, legumes, dairy products, oils and fats and sodium, an increase of them increased the severity of the disease. There wasn\'t relationship with the severity of acute coronary syndrome for the other components, not even with the total score of the Brazilian Healthy Eating Index-Revised. The lowest average values for the total score were components for whole grain, dairy and saturated fat while the highest were the total vegetable oil and derivatives and sodium

<p>Moždani udar predstavlja drugi uzrok smrti u celom svetu i neurolo&scaron;ku bolest sa najvećim stepenom invaliditeta. Za povoljan ishod moždanog udara veoma je važno sprečavanje i lečenje somatskih kompikacija (SK), pri čemu je njihova učestalost i značaj za oporavak pacijenata potcenjena, a uticaj na ishod moždanog udara zanemaren. Ciljevi istraživanja su bili da se utvrdi učestalost pacijenata sa somatskim komplikacijama u akutnoj fazi moždanog udara; zatim da se utvrdi učestalost svake pojedinačne somatske komplikacije: pneumonije, urinarnih infekcija, duboke venske tromboze, tromboembolije pluća, dijarealnog sindroma i akutnog koronarnog sindroma; zatim da se utvrde faktori rizika za nastanak svake pojedinačne SK, kao i da se utvrdi uticaj SK na ishod bolesti - iskazan kroz njihovu povezanost sa funkcionalnim statusom, dužinom hospitalizacije i mortalitetom pacijenata. Istraživanje je sprovedeno kao prospektivno i obuhvatilo je 403 pacijenta hospitalizovanih zbog akutnog moždanog udara na Klinici za neurologiju Kliničkog centra Vojvodine u periodu od godinu dana. Pacijenti su podeljeni u dve grupe, gde su prvu grupu sačinjavali pacijenti sa registrovanom jednom ili vi&scaron;e somatskih komplikacija (n = 162), a drugu su činili pacijenti koji nisu imali somatske komplikacije (n = 241). Evaluacija pacijenata obuhvatila je registrovanje sociodemografskih karakteristika, ličnu i porodičnu anamnezu, karakteristike moždanog udara, neurolo&scaron;ki status na prijemu i otpustu, funkcionalni status na prijemu i otpustu, laboratorijske analize krvi i urina na prijemu, vrstu i vreme nastanka pojedinačne somatske komplikacije, sve relevantne dijagnostičke metode za postavljenje dijagnoze i definisanje potencijalnih faktora rizika. Somatske komplikacije se če&scaron;će javljaju kod starijih osoba, prosečne starosti 72,9 godina, kod osoba ženskog pola i kod pacijenata sa hemoragijskim moždanim udarom. Somatske komplikacije registrovane su kod 40,2% pacijenata, pri tome urinarnu infekciju imalo je 20,3% pacijenata, pneumoniju 16,3%, infarkt miokarda 4,7%, plućnu tromboemboliju 3,4%, duboku vensku trombozu 2,4% i dijarealni sindrom 2,9% pacijenata. Nezavisni prediktori pneumonije su disfagija, naru&scaron;eno stanje svesti, hronična opstruktivna bolest pluća, mRS veći od 3. Prediktori urinarnih infekcija su: podatak o rekurentnim urinarnim infekcijama, ženski pol, starost preko 70 godina, mRS veći od 3 i NIHSS skor veći od 16. Kao nezavisni prediktori plućnog tromboembolizma dobijeni su duboka venska tromboza, naru&scaron;eno stanje svesti i gojaznost, dok se jedinim nezavisnim prediktorom dijarealnog sindroma pokazala starost pacijenta preko 70 godina. Prediktori akutnog koronarnog sindroma su: starost veća od 70 godina i hemoragijski moždani udar. Pacijenti sa SK, na kraju hospitalnog lečenja imaju značajno lo&scaron;iji funkcionalni status u odnosu na pacijente bez somatskih komplikacija. Somatske komplikacije statistički značajno produžavaju hospitalizaciju. Kod četvrtine pacijenata (25,9%) sa somatskim komplikacijama u akutnoj fazi moždanog udara registrovan je letalni ishod. Najveći procenat smrtnih ishoda kod pacijenata sa somatskim komplikacijama registrovan je kod pacijenata sa infarktom miokarda (63,2%), a najmanji kod pacijenata sa urinarnom infekcijom (18,3%).</p> / <p>Stroke is the second cause of death worldwide and neurological disease with the highest level of disability. For a favorable outcome of stroke, the prevention and treatment of somatic complications are of great importance, while their frequency and the importance of the recovery of patients are underestimated, and the influence on the outcome of stroke is neglected. The aims of the study were: to determine the frequency of patients with somatic complications in the acute phase of stroke; to determine the frequency of each somatic complication: pneumonia, urinary infections, deep venous thrombosis, lung thromboembolism, diarrheal syndrome, and acute coronary syndrome; to identify risk factors for the emergence of each somatic complication, as well as to determine the effect of those complications on the outcome of the disease - expressed through their association with the functional status, length of hospitalization and mortality of patients. The study was conducted as a prospective and included 403 patients hospitalized due to acute stroke at the Clinic for Neurology of the Clinical Center of Vojvodina for a period of one year. Patients were divided into two groups; the first group included patients with one or more somatic complications registered (n = 162), and the second group consisted of patients without any somatic complication (n = 241). Patient evaluation included registration of socio-demographic characteristics, personal and family history, stroke characteristics, neurological and functional status at the time of admission and discharge, laboratory analysis of blood and urine at admission, type and time of emergence of each somatic complication, all relevant diagnostic methods for setting diagnosis and defining potential risk factors. Somatic complications are more common in older people (the average age of 72.9 years) in females and in patients with hemorrhagic stroke. Somatic complications were reported in 40.2% of patients, 20.3% of patients had urinary infection, 16.3% pneumonia, 4.7% myocardial infarction, 3.4% pulmonary thromboembolism, deep venous thrombosis 2.4% and diarrheal syndrome 2.9% of patients. Independent predictors of pneumonia were dysphagia, impaired state of consciousness, chronic obstructive pulmonary disease, mRS higher than 3. Predictors of urinary infections were: data on recurrent urinary tract infections, female sex, age over 70 years, mRS higher than 3 and NIHSS score higher than 16. As independent predictors of pulmonary thromboembolism, deep venous thrombosis, impaired state of consciousness and obesity were obtained, while the only independent predictor of diarrheal syndrome proved to be the age of the patient over 70 years. Predictors of acute coronary syndrome were: age over 70 years and haemorrhagic stroke. Patients with somatic complications at the end of hospital treatment had significantly worse functional status compared to patients without somatic complications. Somatic complications statistically significantly prolong hospitalization. A quarter of patients (25.9%) with somatic complications in the acute phase of the stroke had a lethal outcome. The highest percentage of deaths in patients with somatic complications was registered in patients with myocardial infarction (63.2%) and the lowest was registered in patients with urinary tract infections (18.3%).</p>

BackgroundThe prompt seeking of medical care after the onset of symptoms suggestive of acute coronary syndromes (ACS)/acute myocardial infarction (AMI) is associated with the receipt of coronary reperfusion therapy, and effective cardiac medications in patients with an ACS/AMI and is crucial to reducing mortality and the risk of serious clinical complications in these patients. Despite declines in important hospital complications and short-term death rates in patients hospitalized with an ACS/AMI, several patient groups remain at increased risk for these adverse outcomes, including women and the elderly. However, recent trends in age and sex differences in extent of pre-hospital delay, hospital management practices, and short-term outcomes associated with ACS/AMI remain unexplored. The objectives of this study were to examine the overall magnitude, and changing trends therein, of age and sex differences in duration of pre-hospital delay (1986-2005), hospital management practices (1999-2007), and short-terms outcomes (1975-2005) in patients hospitalized with ACS/AMI. MethodsData from 13,663 residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers for AMI 15 biennial periods between 1975 and 2005 (Worcester Heart Attack Study), and from 50,096 patients hospitalized with an ACS in 106 medical centers in 14 countries participating in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007 were used for this investigation. Results In comparison with men years, patients in other age-sex strata exhibited significantly longer pre-hospital delay, with the exception of women < 65 years; had a significantly lower odds of receiving aspirin, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, statins, and undergoing coronary artery bypass graft surgery (CABG) surgery or percutaneous coronary intervention (PCI), and were significantly more likely to develop atrial fibrillation, cardiogenic shock, heart failure, and to die during hospitalization and in the first 30 days after admission. There was a significant interaction between age and sex in relation to the use of several medications and the development of several of these outcomes; in patients Conclusions Our results suggest that the elderly were more likely to experience longer prehospital delay, were less likely to be treated with evidence-based treatments during hospitalization for acute coronary syndrome, and were more likely to develop adverse outcomes compared to younger persons. Younger women were less likely to be treated with effective treatments and were more likely to develop adverse outcomes compared with younger men while there was no sex difference in these outcomes. Interventions targeted at older patients, in particular, are needed to encourage these high-risk patients to seek medical care promptly to maximize the benefits of currently available treatment modalities. More targeted treatment approaches during hospitalization for ACS/AMI for younger women and older patients are needed to improve their hospital prognosis.

Background: Cognitive impairment is prevalent in survivors of acute coronary syndrome (ACS) and increases risk for poor outcomes. Lifestyle changes are recommended to patients after ACS to reduce their risk for recurrent events, but cognitively impaired patients may encounter difficulties initiating these changes. This dissertation had three aims: (1) to examine cognitive status as a predictor of lifestyle changes after ACS, (2) to examine whether caregiver support moderates the association of cognitive status and initiation of lifestyle changes, and (3) to assess the reliability of self-reported lifestyle changes in cognitively impaired patients through comparison of their reports of lifestyle change with those from their caregivers. Methods: For aims 1 and 2, Poisson regression with robust error variance was used to examine the association of cognitive status and caregiver support with patient-reported initiation of five lifestyle changes (improving diet, increasing exercise, quitting smoking, reducing stress, and attending cardiac rehabilitation) in 881 patients from TRACE-CORE, a prospective longitudinal observational study of outcomes in ACS. For aim 3, pilot data from 78 patient-caregiver dyads from TRACE-CARE, an ancillary substudy, were used to examine whether patient-caregiver congruence on reports of lifestyle changes varied according to patients’ cognitive function. Results: Patient-reported rates of lifestyle change did not vary according to cognitive status, except for participation in cardiac rehabilitation. Caregiver support improved patient-reported rates of lifestyle change among cognitively intact patients but not cognitively impaired patients. Patients’ cognitive function was positively associated with patient-caregiver congruence on reports of initiation of lifestyle changes and patients with decreased cognitive function tended to over-report initiation of lifestyle changes compared to reports by their caregivers. Conclusion: Although cognitive status was not associated with initiation of most lifestyle changes and the influence of caregiver support on initiation of lifestyle changes was only beneficial to cognitively intact patients in this cohort of ACS patients, these null findings may be explained by the questionable validity of self-report in cognitively impaired patients. This dissertation yields new knowledge about secondary prevention in ACS patients and provides insight into the challenges of conducting patient-reported outcomes research in cognitively compromised populations.