Made available in DSpace on 2015-05-14T12:47:17Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 586705 bytes, checksum: e2df6b052b2e7ab20112a9b97360900e (MD5) Previous issue date: 2014-02-27 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Percutaneous coronary intervention (PCI) is today the most commonly employed revascularization modality in the treatment of acute myocardial infarction with non ST segment (IAMCST). In the specialized literature there are few studies on the association between risk factors and the ICP. Therefore, the goal of this research was to design a predictive model to assist the decision of performing an ICP, from the identification of the existence and of the hierarchy of risk factors that make up the profile of adult individuals infracted. This is a cross-sectional study, descriptive and inferential statistics, quantitative approach. The data were collected in the State's Heart Institute (INCOR) in the city of João Pessoa, in the period from January to September 2013. Were included in the survey individuals infracted confirmed by ECG and laboratory examination (positive Troponin). The logistic regression model was used to obtain and adequacy of the predictive model and all the data were analyzed in the statistical software R ®, version 3.0.2. 100 patients participated in the study with IAMCST, of whom 55% underwent catheterization and 45% angioplasty. The performed the catheterization, the median age was 63.1 years (± 10.45 years), and 56% are male and 44% female. In relation to undergoing angioplasty, the average age was of 64.22 years (± 12.51 years), with 53 percent men and 47 percent women. Has been identified as risk factors for the ICP, the individual with a history of cardiac catheterization (OR = 6.08); family history of angioplasty (OR = 4.52) and body mass index (BMI) and the waist-hip ratio (WHR) high with, OR = 1.61 and OR = 1.37, respectively. We conclude from the data processed in our research that an individual chest pain which gives entry to the INCOR-PB and presents history of cardiac catheterization, angioplasty, family history of BMI and WHR high, must be forwarded immediately to the hemodynamic room because presents 88.9% chance of needing an ICP. This study suggests and reinforces the importance and necessity of further studies evaluating the risk factors associated with ICP and not just the profile of patients who make up this group, to the populations of different Brazilian regions, in order to guide and guide to medical practice, reducing mortality and spending on unnecessary procedures. / A intervenção coronariana percutânea (ICP) é hoje a modalidade de revascularização mais comumente empregada no tratamento do infarto agudo do miocárdio com supradesnivelamento do seguimento ST (IAMCST). Resultados precoces e tardios da ICP são fortemente modulados pelas características clínicas e anatômicas dos indivíduos tratados. Na literatura especializada há poucos estudos com a associação entre os fatores de risco e a ICP. Portanto, o objetivo dessa pesquisa foi projetar um Modelo Preditivo para auxiliar à decisão da realização de uma ICP, a partir da identificação da existência e da hierarquia dos fatores de risco que compõem o perfil dos indivíduos adultos infartados. Trata-se de um estudo transversal, descritivo e inferencial, com abordagem quantitativa. Os dados foram coletados no Instituto do Coração do Estado (INCOR-PB) na cidade de João Pessoa, no período de janeiro à setembro de 2013. Foram incluídos na pesquisa os indivíduos infartados confirmado pelo eletrocardiograma (ECG) e pelo exame laboratorial (Troponina positiva). O modelo de regressão logística foi utilizado para obtenção e adequação do modelo preditivo e todos os dados foram analisados no software estatístico R®, versão 3.0.2.Foram avaliados 100 pacientes com IAMCST, dos quais 55% foram submetidos ao cateterismo e 45% a angioplastia. Dos que realizaram o cateterismo, a média de idade foi de 63,1 anos (±10,45 anos), sendo 56% do sexo masculino e 44% do sexo feminino. Em relação aos submetidos à angioplastia, a média de idade foi de 64,22 anos (±12,51 anos), sendo 53% homens e 47% mulheres. Foram identificados como fatores de risco para a ICP, o indivíduo ter histórico de cateterismo (OR=6.08), ter histórico familiar de angioplastia (OR=4.52) e ter o índice de massa corporal (IMC) e a relação cintura-quadril (RCQ) elevados com, OR=1.61 e OR=1.37, respectivamente. Concluímos a partir dos dados processados em nossa pesquisa que um indivíduo infartado que dá entrada no INCOR-PB e apresenta histórico de cateterismo, histórico familiar de angioplastia, IMC e RCQ elevados, deve ser encaminhado imediatamente para a sala de hemodinâmica, pois apresenta 88,9% de chance de necessitar de uma ICP. Este estudo sugere e reforça, a importância e necessidade de mais estudos avaliando os fatores de riscos associados a ICP e não apenas o perfil dos pacientes que compõem esse grupo, para as populações da diferentes regiões brasileiras, a fim de guiar e orientar a prática médica, reduzindo a mortalidade e os gastos com procedimentos desnecessários.

FUNDAMENTOS: Com a expressiva ampliação do uso dos stents farmacológicos (SF), nos diversos cenários em que se apresenta a doença arterial coronária (DAC), e diante de todas as evoluções das diferentes formas de tratamento, levantou-se o questionamento sobre a propriedade de indicação da intervenção coronária percutânea (ICP), à busca do discernimento sobre quais pacientes (P) com DAC apresentam o melhor balanço risco/benefício. Visando a sistematizar as indicações para procedimentos de RM, e tomando como referência as Diretrizes Internacionais baseadas nos principais estudos e ensaios clínicos desta área, em 2009, pela primeira vez, ACC/AHA/SCAI/AATS publicaram um documento sugerindo, frente aos diversos cenários clínicos e anatômicos da DAC, critérios de propriedade de indicação para os procedimentos de RM, permitindo classificá-los quanto à indicação em: A - apropriado, PA - pode ser apropriado ou RA - raramente apropriado. OBJETIVOS: O objetivo primário foi avaliar o grau de propriedade de indicação da ICP com SF nos pacientes do Registro DESIRE, no período de Janeiro de 2012 a Dezembro de 2013, correlacionando com a ocorrência de eventos cardíacos maiores (ECAM) (óbito, infarto e revascularização da lesão-alvo), num seguimento clínico de dois anos. Os objetivos secundários foram: comparar o grau de propriedade de indicação da ICP entre pacientes com apresentação clínica estável versus aqueles com síndrome coronária aguda (SCA); e a ocorrência isolada de óbito cardíaco (OC), infarto agudo do miocárdio não-fatal (IM), revascularização da lesão-alvo (RLA) e trombose do stent no período de follow-up. CASUÍSTICA E MÉTODOS: Foram incluídos todos os pacientes, consecutivamente tratados no HCor-ASS com ICP e implante de pelo menos um SF, entre 01/01/2012 a 31/12/2013. A coleta de dados foi feita do banco de dados do Registro DESIRE, em cujo programa constam dados pormenorizados das características clínicas, angiográficas e informações técnicas da intervenção, incluindo complicações, de cada um dos P registrados, além dos dados evolutivos obtidos nos períodos definidos após o procedimento-índice (1, 6, 12 meses e anualmente a partir de então). Fez-se a validação desses critérios, usando-se o aplicativo SCAI-QIT®, que permite a definição, ao serem incluídas as variáveis do P, do grau de propriedade de indicação para o implante do SF. Este aplicativo é facilmente acessado via internet, no seguinte site: http://scai-qit.org/. Após ser feita a classificação dos critérios de propriedade de indicação, os dados foram analisados estatisticamente, para obtenção dos objetivos e resultados do estudo em questão. RESULTADOS: Dentre os 1.108 P do Registro DESIRE analisados, usando-se o aplicativo SCAI-QIT®, observou-se que: 375 (33,8%) tiveram indicações Apropriada (Grupo I); 480 (43,3%) tiveram indicação Pode Ser Apropriada (Grupo II) e 215 (19,4%) tiveram indicação Raramente Apropriada (Grupo III). No Grupo I, 22,7% tinham isquemia silenciosa, 13,3% angina estável, 36,8 % SCAssST e 27,2% SCAcsST. No Grupo II, 34,0% tinha isquemia silenciosa, 11,9% angina estável, 33,3% SCAssST e 20,8% SCAcsST. No Grupo III, 82,3% tinham isquemia silenciosa, 4,2% angina estável, 0% SCAssST e 13,5% SCAcsST. A ocorrência de IM (definido como aumento da CKMB massa >3X o percentil 99) foi de 9,6%, 9,6%% e 7,0% (p= 0,652) nos Grupos I, II e III, respectivamente. A RLA foi de 1,9%, 2,1% e 0,9% (p= 0,592) e a taxa de trombose do stent foi 0,3%, 0,6% e 1,4% (p=0,406). Comparando os 3 grupos não foi estatisticamente significativo as taxas de OC e ECAM no follow-up de 2 anos. CONCLUSÕES: Os resultados deste estudo demonstram que apesar das taxas de PCI em pacientes estáveis e instáveis, destoarem das esperadas e das já documentadas, isso não teve relevância nos eventos maiores e sobrevida dos pacientes no follow-up clínico. / BACKGROUND: With the significant expansion of the use of drug-eluting stents in different scenarios as presented coronary artery disease (CAD), and before all the developments of different forms of treatment, rose the questioning on the indication of ownership of percutaneous coronary intervention (PCI), the pursuit of insight into which patients (P) with CAD have the best balance risk/benefit. Aiming to systematize indications for coronary revascularization procedures, and by reference to the International Guidelines based on the main studies and clinical trials in this area, in 2009 for the first time, ACC/AHA/SCAI/AATS published a paper suggesting, compared to various clinical and anatomical scenarios of CAD, criteria for appropriate indication of coronary revascularization procedures, allowing to classify them as the indicated in: A - Appropriate, PA - May be appropriate or RA - Rarely appropriate. OBJECTIVES: The primary objective was to evaluate the degree of appropriateness of the ICP with pharmacological stents in patients of DESIRE Registry, in the period from January 2012 to December 2013, correlating with the occurrence of major cardiac events (MACE)(death, myocardial infarction and target vessel revascularization), in the clinical follow-up of two years. The secondary objective were: to compare the degree of appropriateness of PCI indication among patients with clinical presentation satble versus those with acute coronary syndrome to isolated occurrence of cardiac death, myocardial infarction (MI), new target lesion revascularization (TLR) and stent thrombosis in follow-up period. METHODS: We included all patients consecutively treated in HCor-ASS with ICP and implantation of at least one drug-eluting stent, between 01/01/2012 to 31/12/2013. Data collection was made of the DESIRE Registry data base in whose program includes these full details of clinical features, and technical information of the intervention, including complications, each of registered patients in addition to the rolling data over defined periods after the index procedure (1, 6 12 months and annually thereafter). It was made the validation of these criteria, using the application SCAI-QIT, which allows definition, when the patient variables are include, the degree of appropriateness implantation of drug-eluting stent. This application is easily accessed via the internet, at the following site: http://scai-qit.org/. After being made the classification of statement of appropriateness criteria, data were statistically analyzed to obtain the objectives and results of the study in question. RESULTS: Among the 1.108 P of DESIRE Registry analyzed using the SCAI-QIT® application, it was observed that: 375 (33,8%) had Appropriate(Group I) indication; 480 (43,3%) had May be appropriate (Group II) indication and 215 (19,4%) had Rarely appropriate (Group II) indication. In Group I, 22,7% had silent ischemia, 13,3% stable angina, 36,8% SCAssST e 27,2% SCAcsST. In Group II, 34,0% had silent ischemia, 11,9% stable angina, 33,3% SCAssST e 20,8% SCAcsST. No Group III, 82,3% had silent ischemia, 4,2% stable angina, 0% SCAssST e 13,5% SCAcsST. The occurrence of MI (defined as increase of CKMB mass >3x the 99 percentile) was 9,6%, 9,6%% and 7,0% (p= 0,652) in Groups I, II e III, respectively. The TLR was 1,9%, 2,1% and 0,9% (p= 0,592) and stent thrombosis rate was 0,3%, 0,6% and 1,4% (p=0,406). Comparing the 3 groups was not statistically significant the rates of mortality and mace in follow-up of 2 years. CONCLUSIONS: The results of this study demonstrate that despite PCI in stable and unstable patients, diverges the expected and already documented, it had no relevance in major events and survival of patients in the clinical follow-up.

No description available.

Purpose of Review: This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD). Recent Findings: A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. Summary: An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

Background: Drug eluting stents (DES) are preferred over bare metal stents (BMS) for native coronary artery revascularization unless contraindicated. However, the preferred stent choice for saphenous venous graft (SVG) percutaneous coronary interventions (PCI) is unclear due to conflicting results. Methods: PubMed, Clinical trials registry and the Cochrane Center Register of Controlled Trials were searched through June 2018. Seven studies (n = 1639) comparing DES versus BMS in SVG-PCI were included. Endpoints were major adverse cardiac events (MACE), cardiovascular mortality, all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), in-stent thrombosis, binary in-stent restenosis, and late lumen loss (LLL). Results: Overall, during a mean follow up of 32.1 months, there was no significant difference in the risk of MACE, cardiovascular mortality, all-cause mortality, MI, stent thrombosis, TVR and TLR between DES and BMS. However, short-term follow up (mean 11 months) showed lower rate of MACE (OR 0.66 [0.51, 0.85]; p = 0.002), TVR (OR 0.47 [0.23, 0.97]; p = 0.04) and binary in-stent restenosis (OR 0.14 [0.06, 0.37]; p < 0.0001) in DES as compared with BMS. This benefit was lost on long-term follow up with a mean follow up 35.5 months. Conclusion: In this meta-analysis of SVG-PCI, DES use was associated with similar MACE, cardiovascular mortality, all-cause mortality, MI, in-stent thrombosis, TVR and TLR compared with BMS during long-term follow up. There was high incidence of MACE noted in both DES and BMS suggesting a need for exploring novel strategies to treat SVG disease to improve clinical outcomes.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20228号 / 医博第4187号 / 新制||医||1019(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小池 薫, 教授 福原 俊一, 教授 湊谷 謙司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24474号 / 医博第4916号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 石見 拓, 教授 永井 洋士, 教授 大鶴 繁 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Purpose of Review: Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) have emerged as the invasive diagnostic tools of choice for hemodynamic assessment of the severity of CAD (coronary artery disease). We sought to comprehensively review the evidence on the utility of hemodynamic assessment of the coronary stenoses after percutaneous coronary intervention (PCI) using FFR/iFR, mechanisms of positive post-PCI iFR/FFR, and the clinical impact of significant residual ischemia. Recent Findings: The evidence on the utility of the post-PCI hemodynamic assessment has accumulated over the last few years. The post hoc analysis from the FAME 1 and FAME 2 data shows that higher post-PCI FFR is associated with better symptomatic improvement and lower event rate with larger increase in delta FFR (∆ FFR: post-PCI FFR – pre-PCI FFR). Unlike pre-PCI FFR, a consensus has not been established on the optimal value of post-PCI FFR, though multiple studies point toward better clinical outcomes with higher post-PCI FFR and larger ∆ FFR. Summary: Visual assessment of adequate stent apposition by coronary angiography is insufficient in evaluating for residual ischemia. The hemodynamic evaluation of residual ischemia by post-PCI FFR/iFR yields clinically relevant data and allows for appropriate post PCI optimization.

Bakgrund: Perkutan koronar intervention (PCI) är en etablerad behandling vid myokardiell infarkt men utförs även som planerat ingrepp vid angina pectoris. Efter en PCI kan patienten uppleva en förändrad livsvärld vilket kan påverka den psykiska hälsan negativt. Syfte: Syftet var att beskriva kranskärlspatienters upplevelser av psykisk hälsa inom det första året efter att ha genomgått PCI. Metod: En litteraturöversikt genomfördes som utgick från tolv artiklar med kvalitativ design där resultatet var byggt utifrån ett patientperspektiv. Publicering av artiklarna gjordes från 2008 till 2021. Data samlades in via databaserna Cinahl och Pubmed, vilken analyserades med hjälp av Fribergs analysmetod. Resultat: I resultatet framkom tre kategorier; ängslan över återhämtning efter utskrivning efter PCI, oro och rädsla över återgång till vardagen efter PCI samt en förändrad syn på livet efter PCI. Vidare identifierades sex underkategorier; behov av stöd och rehabilitering första tiden efter behandlingen, önskan om tillgänglig rådgivning om kvarvarande symtom och medicinering, osäkerhet i fysiska förmågor, rädsla över nya hjärthändelser, ökad meningsfullhet och drivkraft i att ta ansvar över levnadsvanor. Slutsats: Studien visar att behovet av tillgänglig rådgivning och uppföljning är en viktig faktor att beakta i patientens eftervård för att främja den psykiska hälsan. Vidare forskningsförslag är en intervjustudie för att kartlägga upplevda behov relaterat till tiden efter PCI. / Background: Percutaneous coronary intervention (PCI) is an established treatment of myocardial infarction but is also performed as a planned procedure during angina pectoris. After a PCI the patient may experience a changed life-world, which can negatively affect mental health. Aim: The aim was to describe coronary heart disease patients' experiences of mental health within the first year after undergoing PCI. Method: A literature review with a qualitative design was conducted including twelve studies that focused on the experiences from the perspective of the patients. The articles were published from 2008 to 2021. Data was collected through the databases Cinahl and Pubmed. Data was analyzed by the method of Friberg. Results: The results revealed three categories; anxiety about recovery after discharge after PCI, anxiety and fear over the return to everyday life after PCI, as well as a changed view of life after PCI. Furthermore, six subcategories were identified; need for support and rehabilitation the first time after the treatment, a desire for available advice on residual symptoms and medication, uncertainty in physical abilities, fear of new heart events, increased meaningfulness and the drive to take responsibility for lifestyle habits. Conclusion: The need for available counseling and follow-up is an important factor to consider to promote mental health. Further research to map perceived needs post PCI is needed.

No description available.