Littérature scientifique sur le sujet « Cardiolgoy »

Inteligência artificial é uma denominação ampla, que remete a tecnologias computacionais que objetivam mimetizar o comportamento, ações, cognição e/ou inteligência humanas com um mínimo de intervenção de operadores humanos. A cardiologia intervencionista é um dos ramos da medicina cardiovascular que mais se desenvolveu nas últimas décadas, apresentando um conjunto altamente tecnológico que perfaz um campo propício à incorporação de métodos de inteligência artificial. A cardiologia intervencionista pode ser incrementada por inteligência artificial através de duas principais vertentes: virtual e física. Atualmente e para o futuro próximo, diversos relatos têm demonstrado o surgimento progressivo de tecnologias derivadas de inteligência artificial para ampliar a prática da cardiologia intervencionista no diagnóstico e tratamento de doenças coronárias, intervenções estruturais e a moderna incorporação de braços robóticos.

I pazienti con malattie cardiometaboliche hanno un percorso diagnostico-terapeutico particolarmente complesso, che coinvolge molteplici figure professionali. Cardiologo e diabetologo, i coordinatori di questo processo, devono reciprocamente contribuire alla realizzazione di un percorso virtuoso comune di cure e di assistenza. Con queste premesse è stato costituito un gruppo di miglioramento formato da cardiologi ARCA (Associazioni Regionali Cardiologi Ambulatoriali) e diabetologi AMD (Associazione Medici Diabetologici) che operano in Campania, per definire le criticità della realtà in cui si opera e realizzare un PDTA dedicato, che consideri i diversi stadi clinici dell’associazione Scompenso Cardiaco (SC) e Diabete e proponga processi diagnostici e terapeutici condivisi. Il documento ripercorre le evidenze disponibili e raccoglie le opinioni del gruppo circa l’individuazione di pazienti a più alto rischio di diabete e/o scompenso e il management del paziente con diagnosi nota di diabete mellito e scompenso cardiaco.

The first topic addressed in this thesis was the characterization of a new hybrid PET/CT scanner (Discovery-690); that was later used for all of the studies (experimental and clinical)performed in this work. Subsequently an antropomorphic static cardiac phantom is described. This was used to analyze the performances of different reconstruction algorithms, encompassing di fferent levels of information such as: i) the Time Of Flight (TOF) of the photons and ii) the Point-Spread-Function (PSF) of the PET tomograph. A problem, own of cardiac studies in PET, is the motion blur due to the cardiac beat and to the breath of the patient. To study the e ffects of this combined motion, both quantitatively and qualitatively, a moving mechanical phantom was built, that executed both movements in a separate and controlled way. After this investigation this phantom was exploited to evaluate the e cacy of gating techniques (cardiac and respiratory), by using single and double gating. These techniques were also applied to patient data. Double gating revealed to be able to provide better spatial resolution but with noise levels too high for diagnostic purposes. To overcome this problem while maintaining the full spatial resolution two registration techniques were proposed. The fi rst one consists in an affi ne registration that can be applied to correct only for respiratory motion. The second technique aims at registering all of the gates using an elastic morphing technique. This is achieved by using a map of the myocardial surface to build a Thin-Plate-Spline deformation field, using a segmentation algorithm. Both techniques allowed the reduction of the noise. In both phantom and patient studies promising quality improvements were obtained. The last chapter of the thesis involved the quanti cation of absolute cardiac perfusion analyzing 13NH3 PET studies with kinetic models. Initially the mathematical proprieties of the models proposed to analyze this tracer were assessed. Following the e ect of the image reconstruction algorithms on the parameters quanti ed with a speci c model were assessed. Two di erent software programs that allow perfusion quanti cation were also compared. The results of the studies described allowed the de nition of a clinical 13NH3 PET protocol, currently in use.

La presencia de enfermedad cardiaca puede tener repercusiones serias sobre la salud y el bienestar de los equinos pero el riesgo a las personas, asociado con el desarrollo de colapso cardiovascular o de muerte súbita cardiaca hacen de la cardiología equina una disciplina con implicaciones que van más allá de la salud animal. La tesis aquí presentada trata de aportar conocimientos sobre problemas cardiacos equinos. En el primer estudio de esta tesis se estudió los efectos de la hemorragia aguda en la concentración plasmática de un marcador específico de daño miocárdico, como es la troponina cardiaca I, y en el desarrollo de arritmias cardiacas. Para realizar este estudio diseñamos un estudio prospectivo en el que un grupo de caballos con hemorragia aguda se comparó a un grupo control. El estudio determinó que la hemorragia aguda causa daño miocárdico que puede ser detectado midiendo la concentración plasmática de troponina cardiaca I y que la presencia de arritmias es frecuente en caballos hospitalizados debido a la presencia de hemorragia aguda. EL segundo estudio de esta tesis se diseñó para estudiar la apariencia clínica, ecocardiográfica y anatomopatológica de la cardiomiopatía hipertensiva en caballos. Diseñamos un estudio retrospectivo en el cual se revisaron los archivos de la Universidad de Pensilvania desde 1995 a 2011 para encontrar casos con hipertrofia del miocardio del ventrículo izquierdo e hipertensión. A partir de esta información se describió la presencia de cardiomiopatía hipertensiva como una comorbilidad en caballos con laminitis y fallo renal crónico. Este problema clínico no había sido descrito previamente en equinos. La cardiomiopatía hipertensiva debería de considerarse en caballos con hipertensión y se debe añadir a la lista de diagnósticos diferenciales en los caballos que presentan hipertrofia del ventrículo izquierdo. El tercer estudio de esta tesis investigó la presencia de un estado de hipercoagulación en caballos con fibrilación atrial. La fibrilación atrial es la arritmia clínicamente mas relevante en caballos y humanos y en humanos causa un estado de hipercoagulación que provoca que las complicaciones tromboembólicas sean la mayor causa de morbilidad y mortalidad en estos pacientes. Diseñamos un estudio prospectivo control en el cual los tests de coagulación más utilizados en medicina equina se realizaron en muestras de sangre obtenidas de caballos con fibrilación atrial y de un grupo control. La proporción de caballos con D-dímeros, paneles de coagulación y resultados anormales fue mayor en el grupo de caballos con fibrilación atrial. La antitrombina fue significativamente mas baja en el grupo de caballos con fibrilación atrial. Ninguno de los caballos mostró signos clínicos de hipercoagulación o tromboembolismo. Este estudio demostró que los caballos en fibrilación atrial presentan un estado subclínico de hipercoagulacion sin sintomatología clínica de tromboembolismo. Como conclusión, los tres estudios que forman parte de esta tesis doctoral han contestado cuestiones relevantes que no habían sido investigadas previamente. La hemorragia aguda causa daño miocárdico y arritmias en caballos. Caballos con laminitis y enfermedad renal crónica pueden desarrollar cardiomiopatía hipertensiva y los caballos con fibrilación atrial permanecen en un estado de hipercoagulabilidad sin consecuencias tromboembólicas.
The presence of cardiac disease can have serious repercussions to horses’ health and wellbeing but the risks for humans associated with equine cardiovascular collapse or sudden cardiac death make equine cardiology a discipline that has implications that go beyond animal health. The thesis presented here was designed to gain further knowledge in equine cardiac problems The first study of this thesis studied the effects of acute hemorrhage on the plasma concentration of a marker of myocardial injury (cTnI) and in the development of cardiac arrhythmias. We designed a prospective controlled study in which a group of horses presented with acute hemorrhage were compared to a control group. We concluded that acute hemorrhage results in myocardial injury that can be detected by measuring cTnI and that arrhythmias are frequent in hospitalized horses with acute hemorrhage. The goal of the second study of this thesis was to study the clinical, echocardiographic and pathological appearance of hypertensive cardiomyopathy (HC) in horses. To achieve this goal we designed a retrospective study in which the medical records of the University of Pennsylvania’s New Bolton Center (between 1995 and 2011) were searched for the presence of horses with myocardial hypertrophy and hypertension. We described the presence of HC as a comorbid diagnosis in horses with laminitis or chronic renal failure. This clinical entity had not been previously diagnosed in horses. Hypertensive cardiomyopathy should be borne in mind when evaluating horses with hypertension and added to the list of differentials diagnoses for horses that present left ventricular hypertrophy. The third part of this thesis had the motivation of investigating the presence of a hypercoagulable state in horses with atrial fibrillation. Atrial fibrillation is the most common and clinically relevant arrhythmia in horses and in humans. Humans in atrial fibrillation are in a hypercoagulable state that makes stroke and thromboembolism the major cause of morbidity and mortality in patients with this rhythm disturbance. We designed a prospective controlled study in which common tests to evaluate coagulation and fibrinolysis in horses were performed on blood samples obtained from equine patients with atrial fibrillation and in a control group. The proportion of horses with abnormal D-dimer concentrations, abnormal coagulation profiles and the proportion of abnormal coagulation tests was larger in the atrial fibrillation group than in the control group. Antithrombin activity was lower in the atrial fibrillation group. No clinical signs of hypercoagulability or thrombogenesis were detected in any of the horses. This study demonstrated that atrial fibrillation causes a state of hypercoagulability in horses without thromboembolic consequences. In conclusion, the three studies have contributed to the body of knowledge in equine cardiology and have answered relevant questions that had not been previously investigated. Acute hemorrhage causes myocardial injury and arrhythmias during acute hemorrhage in horses. Horses with laminitis or chronic renal failure can develop HC and horses in atrial fibrillation present subclinical hypercoagulation without thromboembolic consequences.

Le travail présenté dans ce document utilise les méthodes de recherche qualitative pour étudier (1) la fin-de-vie et (2) le consentement dans le domaine de la cardiologie. Dans une première étude, nous avons cherché à décrire et comprendre le vécu des médecins, des infirmières et des aides-soignants dans le Service de Cardiologie vis-à-vis des situations de fin-de-vie, en particulier chez les patients souffrant d’insuffisance cardiaque. Nos résultats montrent que globalement, la cardiologie est considérée comme une discipline active et à visée curative ; cette attitude est particulièrement prononcée chez les médecins, qui ont peu l’habitude d’affronter des situations de fin-de-vie et qui sont parfois réticents à l’idée d’initier des discussions sur ce sujet avec les patients. Les infirmières et les aides-soignants ont un rôle plus axé sur le soin et le confort, et sont donc plus ouverts à la possibilité de discuter de la fin-de-vie avec les malades. Cependant, l’intervention des infirmières et des aides-soignants ne peut se concevoir que dans les limites qui sont posées par les médecins : les infirmières ne prendraient jamais l’initiative d’aborder le sujet de la fin-de-vie avec un malade si le médecin ne l’a pas déjà fait. Les perspectives possibles pour harmoniser les approches vis-à-vis des situations de fin-de-vie incluent l’éducation des futurs médecins, des interventions pour améliorer les connaissances des soignants et augmenter leur confiance, ainsi que des projets de recherche pour identifier le moment opportun pour initier des discussions sur la fin-de-vie chez les patients avec insuffisance cardiaque, et les facteurs qui doivent inciter le cardiologue à demander une consultation spécialisée en soins palliatifs pour le malade. Enfin, une formation en communication serait de nature à améliorer les compétences des soignants en termes de communication sur la fin-de-vie en cardiologie.La deuxième partie de ce travail utilise la méthodologie de la théorie ancrée pour étudier les facteurs qui déterminent la décision d’un patient âgé d’accepter ou de refuser de participer à la recherche clinique. Nos résultats indiquent que les caractéristiques spécifiques de l’étude ne sont pas déterminantes dans la décision de participer ou non. Les patients qui ont d’autres préoccupations majeures (e.g. un deuil récent, ou un proche à soigner) n’ont pas les ressources mentales et/ou physiques nécessaires pour permettre la participation. Parmi les patients qui disposent des ressources mentales et/ou physiques nécessaires, il y a certains patients qui font preuve de beaucoup de confiance envers les professionnels de la santé. Ces patients s’engagent peu dans les décisions les concernant et suivent facilement les recommandations de ceux en qui ils ont confiance ; ils ont plutôt tendance à accepter. A l’inverse, certains patients s’engagement très activement dans leur propre santé et s’informent abusivement, sans prendre en considération la qualité scientifique des informations. Ils ne font pas confiance aux professionnels de la santé et ont plutôt tendance à refuser de participer à la recherche clinique. Enfin, dans une autre publication, nous discutons des dilemmes éthiques posés par la recherche de consentement pour la recherche clinique chez les patients gravement malades
The work presented in this thesis uses qualitative research methods in the field of cardiology to investigate (1) end of life issues and (2) consent issues. In a first study, we investigated the experiences and perceptions of physicians, nurses and nurses’ aides vis-à-vis end-of-life situations in the Cardiology department, with particular focus on heart failure patients. We found that overall, there is a predominantly active and curative attitude in cardiology, particularly among physicians, who are not accustomed to dealing with end-of-life situations and often reluctant to initiate these discussions with patients. Nurses and nurses’ aides have a more comfort-giving role, and as such, are more open to holding end-of-life conversations with patients and families. However, their actions are limited by what the physicians have previously discussed with the patient. Nurses do not address end-of-life questions with the patient if the physician has not already done so. Perspectives to harmonize the approach to end-of-life care in our Department include education of future healthcare providers, interventions to increase knowledge and boost confidence among healthcare providers, and research into the optimal time to initiate palliative care in heart failure patients, and consensual triggers that should prompt referral to specialist palliative care. Finally, training in communication would help to enhance healthcare providers’ skills in dealing with end-of-life issues in cardiology.In the second part of this work, using grounded theory methodology, we sought to investigate the factors that influenced the decision to accept or decline to participate in clinical research in elderly patients. Our results indicate that the individual characteristics of the trial are not the main determinants in the decision. Patients who have other major occupations in their life (e.g. recent bereavement, or a caregiving role for a spouse or relative) do not have sufficient mental and/or physical resources to be able to accept research participation. Among those who have the sufficient mental and/or physical resources, there are patients with high trust in the medical profession, who engage little in their own health and trust the healthcare provider to guide their decision; these patients tend to accept. Conversely, at the other end of the spectrum are patients who engage actively in their own health, read a lot, and ask many questions, and have low trust in the medical profession. These patients tend to refuse to participate in research. Finally, in a separate publication, we also discuss the ethical considerations related to obtaining consent in seriously ill patients

Background: Despite the favourable effects of new therapeutic approaches during the acute phase of cardiac diseases and consequent favourable short-term outcomes, post-acute management and long term prognosis still remain unsatisfactory. Cardiac rehabilitation (CR) is a multidisciplinary treatment with established beneficial effects for the vast majority of cardiac patients and universally considered an important aspect of secondary prevention. Although it has been shown to reduce both morbidity and mortality and it is a class I recommendation in the guidelines, its use remains still rather limited in Europe and in the rest of the world. Aim: The aim of this PhD research was to examine some aspects still little known, or unknown at all, in this field. In particular, the research aimed to evaluate safety and efficacy of a structured, exercise-based, CR in specific cohorts of patients: after transcatheter aortic valve implantation (TAVI), after left ventricular assist device (LVAD) implantation, and early after an acute myocardial infarction (AMI) in high risk subjects. Methods: All patients (78 TAVI, mean age 82.1±3.6 years, 42 LVAD, 63.4 ± 7.4 years, and 376 AMI, 64.4±12.3 years) were referred to the Institute Codivilla-Putti (in Cortina d’Ampezzo, BL, Italy) for a two week, in-hospital, CR training and comprehensive risk factors interventions early after the acute event (within two weeks TAVI and AMI, within two months after LVAD implantation). TAVI patients were compared with 80 consecutive peer patients who were admitted for CR in the same period after surgical aortic valve replacement (sAVR) and LVAD patients compared with 47 coeval chronic heart failure (CHF) patients who were admitted for CR in the same period after an acute heart failure event. In LVAD cohort, cardiac autonomic function was evaluated by means of heart rate variability. AMI patients were divided into 2 groups according to a 40% left ventricular ejection fraction (LVEF) cut-off at enrolment, in order to evaluate the influence of a reduced LVEF on the rehabilitative process; furthermore, in 326 patients a glucometabolic characterization was obtained by means of a standard oral glucose tolerance test (OGTT) in patients without known diabetes. In all patients the training protocol consisted of a low-medium intensity exercise protocol developed in three sets of exercises, 6 days per week: 30 min of respiratory workout, followed by an aerobic session on a cyclette (or on an arm ergometer in those patients who were not able to cycle) in the morning and, in the afternoon, 30 min of callisthenic exercises. Each session was supervised by a physician and a physiotherapist and all patients were ECG monitored by a telemetry system. Functional capacity was assessed by a six min walking test (6MWT) on admission, and a second test at discharge; when possible, a cardiopulmonary exercise test (CPET) was also performed. The Barthel Index (BI) was used as an autonomy index in TAVI and LVAD cohorts. In AMI patients rate of death, hospitalizations, smoke cessation, physical activity and adherence to pharmacological treatment were recorded at follow up (up to 5 years, median 2 years). Results: Despite the high risk profile of the population, the drop out rate was quite low (1.3% of TAVI, 1.1% of AMI and 11.9% of LVAD patients had to be transferred due to non fatal complications). All the subjects who completed the program had enhanced independence, mobility and functional capacity (mean BI increment was 9.9±12.6, p<0.01 and 11.9±10.5, p<0.01, in TAVI and LVAD patients respectively; mean 6MWT gain was 60.4±46.4 mt, p<0.01, 83.2±36.0 mt, p<0.05, 70.7±55.7 mt, p<0.01, in TAVI, LVAD and AMI patients, respectively). Analysing the specific cohorts, a smaller proportion of TAVI patients, compared with sAVR, was able to complete at least a 6MWT (82% vs 92%) or a CPET (61% vs 95%) but, in those who did, the distance walked at 6MWT at discharge did not significantly differ between the groups (272.7±108 vs. 294.2±101 mt, p=0.42), neither did the exercise capacity assessed by CPET (peak-VO2 12.5±3.6 vs. 13.9±2.7 ml/kg/min, p=0.16). At the end of the program, physical performance in LVAD patients was still generally poor, but not dissimilar from that found in CHF patients (peak-VO2 reached at CPET was 12.5±3.0 vs. 13.6±2.9 ml/kg/min, p=0.20). Evaluating AMI patients, subjects with LVEF<40% achieved significantly lower peak-VO2 at CPET than the controls (15.2±3.9 vs. 18.2±5.2 ml/kg/min, p<0.01). After OGTT administration, a high prevalence of abnormal glucose metabolism was found (54%). As expected, exercise capacity was poorer in diabetic and pre-diabetic patients when compared with normoglicemic (peak-VO2 at CPET 15.3±4.1 vs 17.9±4.8 vs 19.4±5.5 ml/kg/min, p<0.01). At follow up 73% of the subjects reported to exercise regularly, 77% of the smokers definitively quitted and a high adherence to the therapy was registered. Cardiac and all cause mortality resulted 5.0% and 8.0 % at 1 year and 8.0 % and 13.0 % at 5 years, respectively and resulted higher in older people and in those with lower LVEF. Conclusions: Patients who underwent TAVI and LVAD implantation are characterized by a long-term deconditioning status. In this perspective, benefit is not automatically achieved through high-technology interventions and pharmacological management alone. This study have shown that a short-term, supervised, exercise-based CR is feasible, safe and effective in elderly patients after TAVI, as well as after traditional surgery, and after LVAD implantation. An early CR programme enhances independence, mobility and functional capacity and should be encouraged in these subjects. An early and intensive CR, based on physical activity and counselling, resulted to be safe and effective also in high risk patients after AMI, both in the short and in the long period. Indeed, a significant improvement in functional capacity in the short term - independent from the basal ventricular function or glucometabolic status - and a high adherence to therapy and to lifestyle modifications in the long term were achieved. Despite the high risk profile of these patients, this produced a favourable effect on cardiac and total mortality.
Introduzione: Nonostante gli effetti favorevoli di nuovi approcci terapeutici durante la fase acuta delle malattie cardiache e conseguente prognosi più favorevole nel breve termine, la gestione della fase post-acuta di tali patologie e la prognosi a lungo termine rimane ancora insoddisfacente. La Riabilitazione Cardiologica (RC) è un trattamento multidisciplinare con chiari effetti benefici nella stragrande maggioranza dei pazienti cardiologici ed universalmente considerata un aspetto importante della prevenzione secondaria. Sebbene si sia dimostrata in grado di ridurre morbidità e mortalità e sia ormai un trattamento raccomandato in I classe nelle linee guida, il suo uso rimane ancora piuttosto limitato in Europa e nel resto del mondo. Scopo: Lo scopo del presente programma di ricerca è stato esaminare alcuni aspetti ancora pochi noti, se non del tutto sconosciuti, in questo campo. In particolare, la presente ricerca ha avuto lo scopo di valutare sicurezza ed efficacia di una RC strutturata, basata sull’esercizio fisico, in specifiche coorti di pazienti: dopo impianto di valvola aortica transcatetere (TAVI), dopo impianto di assistenza ventricolare sinistra (LVAD), e subito dopo infarto miocardico acuto (AMI) in soggetti ad alto rischio. Metodi: Tutti i pazienti (78 TAVI, età media 82.1±3.6 anni, 42 LVAD, 63.4 ± 7.4 anni, e 376 AMI, 64.4±12.3 anni) sono stati inviati presso l’Istituto Codivilla-Putti (Cortina d’Ampezzo, BL, Italia) per un periodo di riabilitazione cardiologica degenziale di due settimane, basato sull’allenamento fisico ed interventi sui fattori di rischio cardiovascolare, subito dopo l’evento acuto (entro due settimane dopo TAVI ed AMI, entro due mesi dopo impianto di LVAD). I pazienti TAVI sono stati confrontati con 80 pazienti di pari caratteristiche che nello stesso periodo giungevano in riabilitazione dopo sostituzione valvolare aortica per via tradizionale (sAVR); i pazienti LVAD sono stati confrontati con 47 pazienti di pari età affetti da scompenso cardiaco cronico (CHF) che giungevano nello stesso periodo dopo una riacutizzazione di scompenso. Nella coorte dei LVAD è stata inoltre valutata la funzione autonomica mediante lo studio dell’ heart rate variability. Per valutare gli effetti di una depressione della frazione d’eiezione del ventricolo sinistro (LVEF) sul processo riabilitativo, i pazienti AMI sono stati divisi in 2 gruppi in base alla LVEF (cut-off 40%). Inoltre, in 326 pazienti, è stata ottenuta una caratterizzazione glumetabolica mediante una curva da carico di glucosio standard (OGTT) somministrata ai soggetti senza diabete noto. Tutti i pazienti sono stati sottoposti ad un ciclo di ricondizionamento fisico con esercizi prevalentemente aerobici, distribuiti in 3 sessioni quotidiane per 6 giorni alla settimana (30 minuti di ginnastica respiratoria, seguiti da una sessione sulla cyclette, o su un arm-ergometro in coloro che non erano in grado di pedalare, nel pomeriggio 30 minuti di esercizi callistenici), sotto stretto monitoraggio telemetrico e diretta supervisione medica e fisioterapica. La capacità funzionale è stata valutata mediante six min walking test (6MWT) all’ingresso e alla dimissione e un test cardiopolmonare (CPET). Nelle coorti TAVI e LVAD è stata usata la scala di Barthel (Barthel Index, BI) per valutare il grado di autonomia. Nei pazienti AMI è stato registrato al follow up (fino a 5 anni, mediana 2 anni) l’incidenza di morte, nuove ospedalizzazioni, cessazione del fumo, attività fisica ed aderenza alla terapia. Risultati: Nonostante l’alto profilo di rischio della popolazione, il tasso di abbandono dal programma è risultato piuttosto basso (nell’ 1.3% dei pazienti TAVI, 1.1% degli AMI e 11.9% dei LVAD si è reso necessario il trasferimento all’ospedale per acuti per complicazioni non fatali). Tutti i soggetti che hanno completato il programma hanno migliorato la propria indipendenza, mobilità e capacità funzionale (incremento medio del BI 9.9±12.6, p<0.01 e 11.9±10.5, p<0.01, nei pazienti TAVI e LVAD rispettivamente; guadagno medio al 6MWT 60.4±46.4 mt, p<0.01, 83.2±36.0 mt, p<0.05, 70.7±55.7 mt, p<0.01, nei pazienti TAVI, LVAD and AMI, rispettivamente). Analizzando le specifiche coorti, una percentuale più bassa di pazienti TAVI rispetto a quelli del gruppo sAVR sono stati in grado di completare almeno un 6MWT (82% vs 92%) o un CPET (61% vs 95%) ma, in coloro che vi sono riusciti, non vi erano differenze significative tra i due gruppi in termini di distanza percorsa al 6MWT alla dimissione (272.7±108 vs 294.2±101 mt, p=0.42) e capacità funzionale al CPET (VO2 al picco 12.5±3.6 vs 13.9±2.7 ml/kg/min, p=0.16). Al termine del programma la performance fisica nei pazienti LVAD era generalmente scarsa, ma non dissimile da quella dei pazienti CHF (VO2 al picco al CPET 12.5±3.0 vs 13.6±2.9 ml/kg/min, p=0.20). Tra i pazienti AMI, coloro con LVEF<40% hanno raggiunto al CPET un VO2 al picco dell’esercizio significativamente più basso rispetto ai controlli (15.2±3.9 vs 18.2±5.2 ml/kg/min, p<0.01). Dopo somministrazione dell’OGTT è stata riscontrata un’alta prevalenza di alterazioni del metabolismo glucidico non precedente note (54%). Come atteso la capacità fisica era inferiore nei diabetici e nei prediabetici in confronto ai normoglicemici (al CPET VO2 al picco 15.3±4.1 vs 17.9±4.8 vs 19.4±5.5 ml/kg/min, p<0.01). Al follow up 73% dei soggetti hanno riferito di svolgere un’attività fisica regolare, 77% dei fumatori hanno definitivamente smesso ed è stata registrata un’alta aderenza alla terapia. La mortalità cardiaca e per tutte le cause è risultata 5.0% e 8.0% ad 1 anno, 8.0% e 13.0% a 5 anni, rispettivamente, ed è risultata più elevata nei soggetti più anziani ed in quelli con ridotta LVEF. Conclusioni: I pazienti che sono andati incontro ad intervento di TAVI e LVAD sono caratterizzati da un notevole grado di decondizionamento fisico. In tale prospettiva non si può automaticamente raggiungere un beneficio con il solo intervento ad alta tecnologia o con il trattamento farmacologico. Un breve periodo di RC, con supervisione medica, si è dimostrato fattibile, sicuro ed efficace in pazienti anziani dopo TAVI, così come dopo chirurgia aortica tradizionale, e dopo impianto di LVAD. Un programma precoce di RC aumenta l’indipendenza, la mobilità e la capacità funzionale ed andrebbe sicuramente incoraggiato in questi soggetti. Una RC intensiva e precoce basata sull’attività fisica e sul counselling è risultata sicura ed efficace anche in soggetti ad alto rischio dopo AMI, sia nel breve che nel lungo termine. Infatti è stato raggiunto un significativo miglioramento della capacità funzionale nel breve periodo - indipendentemente dalla funzione ventricolare sinistra residua o dallo stato glucometabolico - ed un’elevata aderenza alla terapia e alle modifiche dello stile di vita proposte. Nonostante l’elevato profilo di rischio di tali pazienti, questo può aver prodotto un effetto favorevole sulla mortalità.

This thesis details the measurement and simulation of patient skin doses arising from X-ray exposure during interventional cardiology procedures. Interventional cardiology procedures can be long and complex resulting in high skin doses, to the extent that radiation burns may be produced. Twenty patients were used in the study consisting of 10 coronary angiogram and 10 coronary angioplasty procedures. Radiochromic films were used to measure skin dose directly. The Gafchromic® XR-RV2 film was chosen for its suitability for this project. The key characteristics of this film were experimentally determined including: dose response, energy dependence, polarisation and post-exposure growth. The dose range was found to be ideally suited for the doses encountered in this study. Energy dependence was found to be ~14% between 60 and 125 kVp at 1 Gy and introduced an unavoidable uncertainty into dose calculations from unknown beam energies. Document scanner characteristics were also been investigated and a scanning protocol is determined. A mathematical model was created to use the geometry and exposure information encoded into acquisition files to reconstruct dose and dose distributions. The model requires a set of study files encoded according to the DICOM format, as well as user input for fluoroscopic estimations. The output is a dose map and dose summary. Simulation parameters were varied and results compared with film measurements to provide the most accurate model. From the data collected the relation between dose area product, maximum skin dose and fluoroscopic time were also investigated. The results demonstrated that a model based on acquisition information can accurately predict maximum skin dose and provide useful geometrical information. The model is currently being developed into a standalone program for use by the Medical Physics and Bioengineering department.

Background: The dental health of paediatric cardiology patients has been shown to be poorer than that of healthy children. Multiple factors could be implicated with dental anxiety potentially playing a major role. However, there is no published research specifically looking at dental anxiety amongst paediatric cardiology patients. Aims: The primary aim was to determine whether there was a difference in the level of dental anxiety between paediatric cardiology patients and a group of healthy children. The secondary aim was to establish whether dental anxiety was affected by previous medical history as measured by number of overnight hospital admissions, number of general anaesthetics and cardiac complexity category. Materials and Methods: Fifty-four participants were recruited into the study group from the outpatient cardiology clinic at Leeds General Infirmary. The control group comprised 53 children who attended consultant-led new patient orthodontic clinics. All participants were aged 8-16 years old. The children completed the Modified Child Dental Anxiety Scale (faces version) and their parents completed the Modified Dental Anxiety Scale along with a questionnaire regarding their child‟s medical and dental histories. Results: The mean level of dental anxiety was significantly higher in the study group (p<0.05). Other significant findings between the two groups related to socio-economic status, exodontia experience, overnight hospital admissions and general anaesthetic history. Analysis of covariance indicated that only the admission history might have had an effect upon child dental anxiety in this study. Conclusion: Paediatric cardiology patients had significantly increased levels of dental anxiety. It is likely that aspects of their medical history, notably overnight hospital admissions, are moderating factors but due to the multifactorial aetiology of dental anxiety, further research is required in order to identify specific factors involved.

Recent work has demonstrated substantial progress in capabilities for patient-specific cardiovascular flow simulations. In particular, pediatric cardiology is a field that stands to benefit particularly from patient specific simulations and design capabilities due to the large variation in anatomy among patients and challenging hemodynamics. Recent simulations in pediatric cardiology have emphasized the importance of exercise and respiration, and have been used to test newly proposed surgical designs.

Авторы данного электронного образовательного ресурса разработали систему упражнений, нацеленных на овладение студентами профессиональной медицинской лексикой и формирование навыков работы с аутентичными текстами по тематике «Случаи в кардиологии». Данный образовательный ресурс включает в себя семь модулей, описывающих случаи в кардиологической практике (cases). Каждый модуль содержит аутентичные тексты, позволяющие студентам ознакомиться с вышеуказанной тематикой на английском языке. Отличительной чертой данного ЭОРа является то, что после каждого текста представлен ряд лексико-грамматических упражнений на формирование навыков работы с медицинской лексикой, а также ряд упражнений, направленных на формирование навыков работы с содержанием текста и пониманием ключевой информации. Помимо этого, каждый раздел содержит активную лексику (active vocabulary), который включает в себя лексические единицы по изучаемой тематике. Глоссарий в конце данного образовательного ресурса содержит все ключевые слова и выражения, представленные в каждом модуле. Структура электронного образовательного ресурса позволяет в полной мере выполнять задачи овладения медицинской профессиональной лексикой и навыками устной речи. Данный электронный ресурс позволяет студентам заниматься как в аудитории, так и самостоятельно.

Review question / Objective: P（Population) ：Patients with coronary heart disease; I（Intervention) : Statins treatment in combination with Shexiang Baoxin pill; C（Comparison): Statins alone; O（Outcome）: Improvement of symptoms and blood lipids; S（Study design）：Clinical randomized trials. Eligibility criteria: To be included, trials were required to meet the following criteria: (1) patients were included in the studies according to diagnostic criteria of coronary heart disease established by the WHO, InternationalSociety of Cardiology and Association (ISCA), Internal Medicine, 7th edition ( IM-7th), Practice of InternalMedicine, 14th edition ( PIM-14th), Guidelines for the Diagnosis of Cardiovascular Diseases in InternalMedicine, 3rd edition (GIM-3rd) or conventional diagnostic criteria (CDC) including assessment of anginapectoris and electrocardiogram (ECG) results; (2) the study was conducted as a randomized controlled trial.