Acute coronary syndrome (ACS) is a continuum of disease that includes non-ST-segment elevation ACS and ST-segment elevation myocardial infarction. The purpose of this article is to define the developing role of ticagrelor in ACS and compare it to currently available P2Y12 receptor inhibitors. While clopidogrel remains the "workhorse" P2Y12 receptor inhibitor for many patients with ACS and prasugrel has an established role in select situations, clinicians must now assimilate the evolving role of ticagrelor. Although ticagrelor offers important advances in the management of ACS (eg, reversibility), there are also notable clinical considerations (eg, unique adverse effects such as dyspnea). Based on the current evidence, we propose an algorithm to aid clinicians in the selection of a P2Y12 receptor inhibitor for patients with ACS in various clinical situations.

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Electrocardiography (ECG or EKG) is the process of recording the electrical activity of the heart over a period of time using electrodes placed on a patient’s body. These electrodes detect the tiny electrical changes on the skin that arise from the heart muscle depolarizing during each heartbeat. [1] It is necessary for the diagnosis and prompt initiation of therapy in patients with acute coronary syndromes (ACS) and is the most accurate means of diagnosing conduction disturbances and arrhythmias. [2]ECG is an irreplaceable diagnostic method in clinical practice. It offers great diagnostic value at minimal costs while being a relatively quick, painless and noninvasive process. The quality of the resulting graph is depending on the accurate placement of the electrodes on the patients' body and that the patient lies absolutely still to avoid any muscle contractions which may lead to distortions of the graph.The interpretation of ECGs is a highly complex topic which requires lots of training and experience. Although there has been plenty of research on the topic of automated interpretation and pattern recognition of ECGs by computer algorithms and neural networks, a reliable interpretation of complex ECGs cannot be guaranteed as of today. While the trend seems to favor automated ECG interpretation, a clear prediction when these technologies have saturated the market cannot be given. One reason for this, similar to autonomous vehicles, is the issue of where liability can be found when an incorrect diagnosis leads to harming of a patient. For the foreseeable future we will most likely rely on the skill and experience of humans to interpret ECGs. [1] https://en.wikipedia.org/wiki/Electrocardiography [2] The British Journal of Primary Care Nursing: Taking an ECG: Getting the best possible recording

Orientador: Beatriz Bojikian Matsubara / Banca: João Carlos Braga / Banca: Katashi Okoshi / Banca: João Carlos Hueb / Banca: Pedro Silvio Farsky / Resumo: Existe grande número de estudos mostrando preditores de mortalidade e outros desfechos desfavoráveis nas síndromes coronarianas agudas (SCA). A mortalidade é aumentada nos pacientes com insuficiência cardíaca (IC), principalmente em classe funcional III e IV de Killip. Contudo, esses pacientes representam a minoria da população internada devido a um evento coronariano agudo. Além disso, a maioria dos estudos inclui apenas pacientes com uma das apresentações das SCAs e todas as classes de Killip. Assim, seria importante estabelecer critérios de estratificação de risco em pacientes com quaisquer das SCAs e sem edema pulmonar ou falência hemodinâmica. No presente estudo, formulou-se a hipótese de que o conjunto de variáveis clínicas e laboratoriais, obtidas na internação, pode predizer desfechos desfavoráveis no paciente com síndrome coronária aguda e em classes funcionais de Killip I ou II. O objetivo primário foi identificar variáveis clínicas, laboratoriais e anatômicas coronarianas, associadas com risco de desfechos desfavoráveis nesses pacientes. Os objetivos secundários foram descrever as alterações clínicas e laboratoriais precoces e identificar as diferenças relacionadas ao sexo. Estudo observacional prospectivo e longitudinal que incluiu 370 pacientes consecutivos (224 homens e 146 mulheres, p < 0,001), admitidos com angina instável (AI), infarto agudo do miocárdio sem supradesnivelamento do segmento ST (IAMSSST) ou infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMST), diagnosticados até quarenta e oito horas após o início dos sintomas. As admissões ocorreram na Unidade de Terapia Intensiva do Pronto-Socorro e na Unidade Coronariana do Hospital das Clínicas da Faculdade de Medicina de Botucatu, no período de março de 2003 a dezembro de 2006. As diferenças entre subgrupos... (REsumo completo, clicar acesso eletrônico abaixo) / Abstract: A large number of studies report mortality predictors and other unfavorable outcomes in acute coronary syndromes (ACSs). Mortality is increased in patients with heart failure (HF), particularly in Killip class III or IV. However, these patients represent the minority of the population hospitalized with acute coronary event. Furthermore, most studies analyzed only patients with one of the ACS presentations, including all Killip classes. Hence, it would be important to establish risk-stratification criteria in patients with any of the ACSs and without pulmonary edema or hemodynamic failure. In the present study, we hypothesized that the set of clinical and laboratory variables obtained at hospitalization can predict unfavorable outcomes in patients with acute coronary syndromes and in Killip classes I or II. The primary aim was to identify clinical, laboratory and coronary anatomical variables associated with the risk for unfavorable outcomes in these patients. The secondary objectives were to describe early clinical and laboratory alterations and to identify gender-related differences. This is a prospective and longitudinal observational study comprising 370 consecutive patients (224 males and 146 females, p < 0.001) admitted to hospital with unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI) diagnosed up to forty-eight hours after commencement of symptoms. Admissions occurred at the Intensive Care Unit of the Emergency Hospital and at the Coronary Unit of the University Hospital of the Botucatu School of Medicine from March, 2003 to December 2006. The differences between sub-groups were evaluated by Student's t or the... (Complete abstract click electronic access below) / Doutor

Obesity, assessed by body mass index (BMI), is considered a major public health problem worldwide. Studies in people without CVD, have shown that BMI between 22.5 to 24.9 kg/m2 is associated with the lowest risk of death in healthy non-smoker populations. However, studies in patients with acute coronary syndrome (ACS) have shown that overweight and obese patients have better survival than those in the normal BMI range. This phenomenon has been called the “obesity paradox”. This thesis has two main components: a systematic review with meta-analysis of the current literature of BMI and ACS, and an individual patient data meta-analysis from 8 randomized trials whose data base was accessible at the PHRI involving ACS patients. The study-level systematic review (35 studies) and meta-analysis (19 studies) demonstrates that there is a statistically significant adjusted 20% risk lower mortality among overweight and obese participants considered normal weight. Nevertheless, there was moderate to high heterogeneity of pooled estimates that could not be explained in subgroup analyses. Also, the systematic review detected major limitations in the current literature, including missing BMI and covariates data, lost to follow-up, enough number of events in high BMI categories, warranting more research in the area. The second component, the individual patient data meta-analysis (n = 81,553), confirmed a 20% lower mortality risk in the overweight and type I obesity categories, compared to the normal the BMI range. This lower risk was robust and remained consistent within several sensitivity analyses. Analysis of secondary outcomes suggests that a reduced risk of bleeding, and probably a reduced risk of ischemia and heart failure related deaths, are the responsible mechanisms. Given the limitations of observational research, prospective randomized interventional trials are required to clarify the optimal range of BMI in those with ACS. / Thesis / Master of Health Sciences (MSc)

Made available in DSpace on 2014-06-11T19:31:01Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-06-19Bitstream added on 2014-06-13T19:40:43Z : No. of bitstreams: 1 destefano_lm_dr_botfm.pdf: 490806 bytes, checksum: f659b28e6ba872a145cbdf6395681b73 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Existe grande número de estudos mostrando preditores de mortalidade e outros desfechos desfavoráveis nas síndromes coronarianas agudas (SCA). A mortalidade é aumentada nos pacientes com insuficiência cardíaca (IC), principalmente em classe funcional III e IV de Killip. Contudo, esses pacientes representam a minoria da população internada devido a um evento coronariano agudo. Além disso, a maioria dos estudos inclui apenas pacientes com uma das apresentações das SCAs e todas as classes de Killip. Assim, seria importante estabelecer critérios de estratificação de risco em pacientes com quaisquer das SCAs e sem edema pulmonar ou falência hemodinâmica. No presente estudo, formulou-se a hipótese de que o conjunto de variáveis clínicas e laboratoriais, obtidas na internação, pode predizer desfechos desfavoráveis no paciente com síndrome coronária aguda e em classes funcionais de Killip I ou II. O objetivo primário foi identificar variáveis clínicas, laboratoriais e anatômicas coronarianas, associadas com risco de desfechos desfavoráveis nesses pacientes. Os objetivos secundários foram descrever as alterações clínicas e laboratoriais precoces e identificar as diferenças relacionadas ao sexo. Estudo observacional prospectivo e longitudinal que incluiu 370 pacientes consecutivos (224 homens e 146 mulheres, p < 0,001), admitidos com angina instável (AI), infarto agudo do miocárdio sem supradesnivelamento do segmento ST (IAMSSST) ou infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMST), diagnosticados até quarenta e oito horas após o início dos sintomas. As admissões ocorreram na Unidade de Terapia Intensiva do Pronto-Socorro e na Unidade Coronariana do Hospital das Clínicas da Faculdade de Medicina de Botucatu, no período de março de 2003 a dezembro de 2006. As diferenças entre subgrupos... / A large number of studies report mortality predictors and other unfavorable outcomes in acute coronary syndromes (ACSs). Mortality is increased in patients with heart failure (HF), particularly in Killip class III or IV. However, these patients represent the minority of the population hospitalized with acute coronary event. Furthermore, most studies analyzed only patients with one of the ACS presentations, including all Killip classes. Hence, it would be important to establish risk-stratification criteria in patients with any of the ACSs and without pulmonary edema or hemodynamic failure. In the present study, we hypothesized that the set of clinical and laboratory variables obtained at hospitalization can predict unfavorable outcomes in patients with acute coronary syndromes and in Killip classes I or II. The primary aim was to identify clinical, laboratory and coronary anatomical variables associated with the risk for unfavorable outcomes in these patients. The secondary objectives were to describe early clinical and laboratory alterations and to identify gender-related differences. This is a prospective and longitudinal observational study comprising 370 consecutive patients (224 males and 146 females, p < 0.001) admitted to hospital with unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI) diagnosed up to forty-eight hours after commencement of symptoms. Admissions occurred at the Intensive Care Unit of the Emergency Hospital and at the Coronary Unit of the University Hospital of the Botucatu School of Medicine from March, 2003 to December 2006. The differences between sub-groups were evaluated by Student’s t or the... (Complete abstract click electronic access below)

Background: Glycated hemoglobin is the indicator of long-term diabetes control and a value below 7 percent is recommended by the American Diabetes Association (ADA) to reduce cardiovascular complications. Diabetic patients have a two- to four-fold risk of cardiovascular disease and approximately two-thirds of diabetic patients die as a result of cardiovascular complications. Three large prospective randomized controlled long-term trials within the last decade reported no significant reduction in cardiovascular complications in type 2 diabetic patients by intensive glycemic control. To the author's knowledge, no known retrospective studies have examined the association between mean serial glycated hemoglobin and coronary atherosclerosis (CA) or acute coronary syndromes (ACS). Objective: This study was designed to determine the association between mean serial glycated hemoglobin with incident CA or ACS in type 2 diabetic patients after controlling for age, gender, hypertension, low density lipoprotein cholesterol (LDL-C), microalbuminuria, aspirin use, statin use, insulin use, tobacco use, and body mass index (BMI). Methods: The study was a retrospective cohort database analysis using the Austin Travis County CommUnityCare[trademark] clinics' electronic medical record for the time period between October 1, 2004 and September 30, 2009. The primary outcome of the study was the incidence of CA or ACS and the primary independent variable was glycated hemoglobin (<7% vs. [greater than or equal to]7%). The study subjects included type 2 diabetic patients aged 30 to 80 years with at least one glycated hemoglobin value per year for a minimum of two consecutive years. Study subjects were excluded if CA or ACS occurred within six months of the index date (i.e., first glycated hemoglobin). Logistic regression analysis was used to address the study objective. Results: Overall, 3069 subjects met the study inclusion criteria with a mean follow-up period of approximately two years. Two percent (N=62) of the subjects had incident CA or ACS. After controlling for age, gender, hypertension diagnosis, LDL-C, microalbuminuria, aspirin use, statin use, insulin use, tobacco use and BMI, there was no significant association (OR=1.026, 95% CI=0.589-1.785, p=0.9289) between mean serial glycated hemoglobin and the incident diagnosis of CA or ACS. Increasing age (OR=1.051, 95% CI=1.025-1.077, p<0.0001), male gender (OR=1.855, 95% CI=1.105-3.115, p=0.0195) and normal weight (normal or underweight compared to obese: OR=0.122, 95% CI=0.017-0.895, p=0.0438) were significantly associated with incident CA or ACS. Conclusions: Mean serial glycated hemoglobin (comparing [greater than or equal to]7% to <7%) was not significantly associated with CA or ACS over a mean follow-up period of approximately two years. Until more evidence becomes available, clinicians and diabetic patients should target glycated hemoglobin level below or close to 7 percent as recommended by the ADA soon after diagnosis while concomitantly controlling nonglycemic risk factors of cardiovascular disease (statin use, aspirin use, blood pressure control, smoking cessation and life style modification), to reduce their long-term risk of incident CA or ACS. / text

Fundamento: Os níveis plasmáticos da mieloperoxidase (MPO) estão elevados em pacientes com síndrome coronariana aguda (SCA) como conseqüência de intensa ativação neutrofílica. A capacidade da MPO em predizer a gravidade da doença arterial coronariana (DAC) nos pacientes com SCA é alvo de controvérsia. Objetivo: Avaliar a associação entre os níveis plasmáticos da MPO e a gravidade das lesões ateroscleróticas coronarianas em pacientes com SCA sem elevação de ST. Métodos: Pacientes com SCA de alto risco que foram submetidos à angiografia coronariana durante as primeiras 72 horas do início dos sintomas, realizaram uma única dosagem plasmática de MPO. O escore de Gensini foi utilizado para avaliar a gravidade angiográfica da DAC. Resultados: Entre os 48 pacientes estudados, 85,4% tinham níveis elevados de troponina. As medianas dos níveis da MPO e do escore de Gensini foram 6,9 ng/mL (mínima= 4,4; máxima= 73,5), e 10 (mínima= 0; máxima= 87,5), respectivamente. O coeficiente de Spearman não mostrou correlação significativa entre os níveis de MPO e o escore de Gensini (rs= 0,2; P= 0,177). Os pacientes com níveis de MPO ≤ 6,9 ng/mL apresentaram um escore de Gensini de 8,3, enquanto que aqueles com a MPO > 6,9 ng/mL apresentaram um escore de 13,8, (P= 0,386). Os pacientes com escore de Gensini ≤ 10 apresentaram níveis de MPO de 6,6 ng/mL, enquanto aqueles com escore > 10 apresentaram níveis de MPO de 8,5 ng/mL (P= 0,126). Não houve associação entre os níveis de MPO e a extensão da lesão coronariana (rs= 0,047; P= 0,756). Na análise multivariada a MPO não mostrou correlação com nenhuma outra variável. Conclusões: Não houve associação entre os níveis plasmáticos de MPO e a gravidade angiográfica da DAC em pacientes com SCA com indicação de estratificação invasiva. Esse achado sugere que a expressão da MPO como um biomarcador inflamatório está dissociada da gravidade anatômica das lesões coronarianas. / Background: Myeloperoxidase (MPO) plasma levels are elevated in patients with acute coronary syndrome (ACS) as a consequence of intense neutrophilic activity. MPO capacity to predict the severity of coronary artery disease (CAD) in ACS patients is controversial. Objective: To evaluate the association between MPO plasma levels and severity of coronary atherosclerotic lesions in non-ST elevation ACS patients. Methods: High-risk ACS patients who were submitted to coronary angiography within the first 72 hours after onset of symptoms had one single MPO plasma measurement. Gensini score was used to evaluate angiographic CAD severity. Results: Among the 48 patients studied, 85.4% had elevated troponin levels. MPO plasma levels and Gensini median values were 6.9 ng/mL (range 4.4 to 73.5), and 10 (range 0 to 87.5), respectively. Spearman’s coefficient did not show a significant correlation between MPO levels and Gensini score (rs = 0.2; P = 0.177). Patients with MPO levels ≤ 6.9 ng/mL had a Gensini score of 8.3, whereas the patients with MPO levels > 6.9 ng/mL had a Gensini score of 13.8 (P = 0.386). Patients who presented a Gensini score ≤ 10 had MPO levels of 6.6 ng/mL, while the patients with Gensini score > 10 presented MPO levels of 8.5 ng/mL (P = 0.126). There was no significant association between MPO plasma levels and coronary lesion length (rs= 0.047; P= 0.756). On multivariate analysis there was not association between MPO and any other variable. Conclusion: There was no association between plasma MPO levels and CAD angiographic severity in ACS patients with indication of invasive stratification. This finding suggests that MPO expression as an inflammatory biomarker is dissociated from the anatomical severity of the coronary lesions.

Fundamento: Os níveis plasmáticos da mieloperoxidase (MPO) estão elevados em pacientes com síndrome coronariana aguda (SCA) como conseqüência de intensa ativação neutrofílica. A capacidade da MPO em predizer a gravidade da doença arterial coronariana (DAC) nos pacientes com SCA é alvo de controvérsia. Objetivo: Avaliar a associação entre os níveis plasmáticos da MPO e a gravidade das lesões ateroscleróticas coronarianas em pacientes com SCA sem elevação de ST. Métodos: Pacientes com SCA de alto risco que foram submetidos à angiografia coronariana durante as primeiras 72 horas do início dos sintomas, realizaram uma única dosagem plasmática de MPO. O escore de Gensini foi utilizado para avaliar a gravidade angiográfica da DAC. Resultados: Entre os 48 pacientes estudados, 85,4% tinham níveis elevados de troponina. As medianas dos níveis da MPO e do escore de Gensini foram 6,9 ng/mL (mínima= 4,4; máxima= 73,5), e 10 (mínima= 0; máxima= 87,5), respectivamente. O coeficiente de Spearman não mostrou correlação significativa entre os níveis de MPO e o escore de Gensini (rs= 0,2; P= 0,177). Os pacientes com níveis de MPO ≤ 6,9 ng/mL apresentaram um escore de Gensini de 8,3, enquanto que aqueles com a MPO > 6,9 ng/mL apresentaram um escore de 13,8, (P= 0,386). Os pacientes com escore de Gensini ≤ 10 apresentaram níveis de MPO de 6,6 ng/mL, enquanto aqueles com escore > 10 apresentaram níveis de MPO de 8,5 ng/mL (P= 0,126). Não houve associação entre os níveis de MPO e a extensão da lesão coronariana (rs= 0,047; P= 0,756). Na análise multivariada a MPO não mostrou correlação com nenhuma outra variável. Conclusões: Não houve associação entre os níveis plasmáticos de MPO e a gravidade angiográfica da DAC em pacientes com SCA com indicação de estratificação invasiva. Esse achado sugere que a expressão da MPO como um biomarcador inflamatório está dissociada da gravidade anatômica das lesões coronarianas. / Background: Myeloperoxidase (MPO) plasma levels are elevated in patients with acute coronary syndrome (ACS) as a consequence of intense neutrophilic activity. MPO capacity to predict the severity of coronary artery disease (CAD) in ACS patients is controversial. Objective: To evaluate the association between MPO plasma levels and severity of coronary atherosclerotic lesions in non-ST elevation ACS patients. Methods: High-risk ACS patients who were submitted to coronary angiography within the first 72 hours after onset of symptoms had one single MPO plasma measurement. Gensini score was used to evaluate angiographic CAD severity. Results: Among the 48 patients studied, 85.4% had elevated troponin levels. MPO plasma levels and Gensini median values were 6.9 ng/mL (range 4.4 to 73.5), and 10 (range 0 to 87.5), respectively. Spearman’s coefficient did not show a significant correlation between MPO levels and Gensini score (rs = 0.2; P = 0.177). Patients with MPO levels ≤ 6.9 ng/mL had a Gensini score of 8.3, whereas the patients with MPO levels > 6.9 ng/mL had a Gensini score of 13.8 (P = 0.386). Patients who presented a Gensini score ≤ 10 had MPO levels of 6.6 ng/mL, while the patients with Gensini score > 10 presented MPO levels of 8.5 ng/mL (P = 0.126). There was no significant association between MPO plasma levels and coronary lesion length (rs= 0.047; P= 0.756). On multivariate analysis there was not association between MPO and any other variable. Conclusion: There was no association between plasma MPO levels and CAD angiographic severity in ACS patients with indication of invasive stratification. This finding suggests that MPO expression as an inflammatory biomarker is dissociated from the anatomical severity of the coronary lesions.

Fundamento: Os níveis plasmáticos da mieloperoxidase (MPO) estão elevados em pacientes com síndrome coronariana aguda (SCA) como conseqüência de intensa ativação neutrofílica. A capacidade da MPO em predizer a gravidade da doença arterial coronariana (DAC) nos pacientes com SCA é alvo de controvérsia. Objetivo: Avaliar a associação entre os níveis plasmáticos da MPO e a gravidade das lesões ateroscleróticas coronarianas em pacientes com SCA sem elevação de ST. Métodos: Pacientes com SCA de alto risco que foram submetidos à angiografia coronariana durante as primeiras 72 horas do início dos sintomas, realizaram uma única dosagem plasmática de MPO. O escore de Gensini foi utilizado para avaliar a gravidade angiográfica da DAC. Resultados: Entre os 48 pacientes estudados, 85,4% tinham níveis elevados de troponina. As medianas dos níveis da MPO e do escore de Gensini foram 6,9 ng/mL (mínima= 4,4; máxima= 73,5), e 10 (mínima= 0; máxima= 87,5), respectivamente. O coeficiente de Spearman não mostrou correlação significativa entre os níveis de MPO e o escore de Gensini (rs= 0,2; P= 0,177). Os pacientes com níveis de MPO ≤ 6,9 ng/mL apresentaram um escore de Gensini de 8,3, enquanto que aqueles com a MPO > 6,9 ng/mL apresentaram um escore de 13,8, (P= 0,386). Os pacientes com escore de Gensini ≤ 10 apresentaram níveis de MPO de 6,6 ng/mL, enquanto aqueles com escore > 10 apresentaram níveis de MPO de 8,5 ng/mL (P= 0,126). Não houve associação entre os níveis de MPO e a extensão da lesão coronariana (rs= 0,047; P= 0,756). Na análise multivariada a MPO não mostrou correlação com nenhuma outra variável. Conclusões: Não houve associação entre os níveis plasmáticos de MPO e a gravidade angiográfica da DAC em pacientes com SCA com indicação de estratificação invasiva. Esse achado sugere que a expressão da MPO como um biomarcador inflamatório está dissociada da gravidade anatômica das lesões coronarianas. / Background: Myeloperoxidase (MPO) plasma levels are elevated in patients with acute coronary syndrome (ACS) as a consequence of intense neutrophilic activity. MPO capacity to predict the severity of coronary artery disease (CAD) in ACS patients is controversial. Objective: To evaluate the association between MPO plasma levels and severity of coronary atherosclerotic lesions in non-ST elevation ACS patients. Methods: High-risk ACS patients who were submitted to coronary angiography within the first 72 hours after onset of symptoms had one single MPO plasma measurement. Gensini score was used to evaluate angiographic CAD severity. Results: Among the 48 patients studied, 85.4% had elevated troponin levels. MPO plasma levels and Gensini median values were 6.9 ng/mL (range 4.4 to 73.5), and 10 (range 0 to 87.5), respectively. Spearman’s coefficient did not show a significant correlation between MPO levels and Gensini score (rs = 0.2; P = 0.177). Patients with MPO levels ≤ 6.9 ng/mL had a Gensini score of 8.3, whereas the patients with MPO levels > 6.9 ng/mL had a Gensini score of 13.8 (P = 0.386). Patients who presented a Gensini score ≤ 10 had MPO levels of 6.6 ng/mL, while the patients with Gensini score > 10 presented MPO levels of 8.5 ng/mL (P = 0.126). There was no significant association between MPO plasma levels and coronary lesion length (rs= 0.047; P= 0.756). On multivariate analysis there was not association between MPO and any other variable. Conclusion: There was no association between plasma MPO levels and CAD angiographic severity in ACS patients with indication of invasive stratification. This finding suggests that MPO expression as an inflammatory biomarker is dissociated from the anatomical severity of the coronary lesions.