心梗后心臟康復(fù)治療

1、1.改善患者生活質(zhì)量功能評估功能評估心理干預(yù)心理干預(yù)危險因素危險因素矯正矯正營養(yǎng)指導(dǎo)營養(yǎng)指導(dǎo)隨訪隨訪運動處方運動處方不運動的不利影響Age糖尿病肥胖Genetics動脈硬化HypercoagulabilitySmoking高血壓Novel Risk Factors炎癥血脂異常缺少運動Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135min/wk; intermediately active, 136-195 min/wk; and highly active, 195 min/w

2、k)Total Body FatIntra-abdominal FatIrwin ML et al. JAMA 2003;289:323-330173 sedentary, overweight (BMI 24 kg/m2) post-menopausal women randomized to moderate intensity exercise vs. stretching for 1 year中等度的運動減少肥胖Exercise Evidence:Effect on Body CompositionNS 5% 20% 15% 34%* 8% 20%*Change from Baseli

3、ne202171199174197190200188TGMenWomen3956415540503747HDL-CMenWomen118102131120134135138155LDL-CMenWomenYear and Lipid Level (mg/dL)196193210209213223 214239TCMenWomen531BaselineLipidsWarner JG et al. Circulation 1995;92:773-777*P=0.0001 for change in women vs menP=0.03 for change in women vs menHDL-C

4、=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol, TG=TriglycerideExercise Evidence:運動對血脂的影響Hu FB et al. JAMA 2003;289:1785-91Nurses Health Study運動降低肥胖和糖尿病的發(fā)生率Exercise Evidence:運動對肥胖和糖尿病的影響Manson JE et al. NEJM 2002;347:716-25Quintiles of activity (MET-hour/week*)Walki

5、ngRelative Risk of CHDVigorous exercise*Relative Risk of CHDP=0.004P=0.008 1 2 345Womens Health Initiative Observational Study 1 2 3 4 5*Average active hours per week energy expenditure per activity*Includes aerobics, aerobic dancing, jogging, tennis, and swimming lapsCHD=Coronary heart diseaseExerc

6、ise Evidence:運動對冠心病的影響 Wannamethee SG et al. Circulation 2000;102:1358-1363CHD=Coronary heart disease, CVD=Cardiovascular disease中等度的運動降低冠心病患者的死亡率Observational study of self-reported physical activity in 772 men with CHDPhysical Activity:運動對冠心病患者預(yù)后的影響 * Effect of cardiac rehabilitation in randomized

7、 controlled trials following a MIOldridge NB et al. JAMA 1988;260:945-950 *p0.0125心臟康復(fù):運動對心梗后患者的影響運動/心臟康復(fù)可以降低心梗后患者的死亡和事件發(fā)生率CV=CardiovascularMETA分析提示心臟康復(fù)治療使心梗后死亡率降低20%Circulation, 1989左圖為未參加康復(fù)患者，右圖為參加康復(fù)患者，圖中虛線表示預(yù)期生存率，實線表示實際生存率。可見左圖中患者實際生存率與預(yù)期生存率有顯著性差異，而右圖兩者沒有顯著性差異JACC, 2004Clark AM et al. Ann of Inte

8、rn Med 2005;143:659-72Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without exercise programs心臟康復(fù):二級預(yù)防的益處降低CV事件All cause mortalityRecurrent myocardial infarction心臟康復(fù)有利于降低心血管事件的發(fā)生率CV=Cardiovascular康復(fù)治療能夠顯著改善患者的抑郁和低落情緒。圖中顯示的是研究人群中參加康復(fù)治療前后表現(xiàn)出抑郁和

9、低落的患者比例The American Journal of Medicine, 2007The American Journal of Medicine, 2007接受康復(fù)治療抑郁改善的患者死亡率明顯降低心?；颊哌M行康復(fù)治療前的全面評估心梗患者進行康復(fù)治療的危險分層Cardiology Journal, 2008兩種運動試驗的終點指標(biāo)Cardiology Journal, 2008活動項目kJ/minKcal/mmMETs1. 家務(wù)活動整理床鋪7.24.13.4穿衣8.82.11.8沐浴8.82.11.8簡單地清潔房間11.31.82.3治療性活動輕木工活，磨砂板，拋光，紡織籃筐12.63.

10、02.5輕度機械性活動11.72.82.32. 步行2km/h,3km/d9.62.31.93.5km/h遠足11.72.82.35.0km/h遠足15.93.83.23. 園藝勞動用水桶澆水10.02.42.0挖掘7.51.81.5耙地8.82.11.8種花、種菜10.52.52.1n大大提高了運動平板試驗的安全性n評估最大攝氧量VO2max/kgn評估無氧閾ATn評估心臟每搏射血量O2Plusn科學(xué)指導(dǎo)心臟康復(fù)訓(xùn)練是目前心肺運動功能評估最精確的檢查指標(biāo)心肺運動試驗心功能評估標(biāo)準BRUCE方案下VO2和METs的相對關(guān)系Circulation, 2013指南推薦運動強度為12-13級。如患者對運動耐受較好且無并發(fā)癥，可進行強度14-16級的運動中等強度的運動頻率為每周5-7次，每次30min（2000-3500千卡/周）康復(fù)運動期間需要嚴密監(jiān)測患者血壓、心率、自覺癥狀及心電圖變化Circulation, 20126. 療，維持患者良好的精神和生理狀態(tài)，降低冠心病危險因素及指導(dǎo)健康生活方式急性心肌梗死急性心肌梗死介入或非介入治療介入或非介入治療重癥監(jiān)護治療重癥監(jiān)護治療無并發(fā)癥心梗無并發(fā)癥心梗有并發(fā)癥心梗有并發(fā)癥心梗院內(nèi)院內(nèi)2-3天天院內(nèi)院內(nèi)4-7天天院內(nèi)院內(nèi)5-7天天院內(nèi)院內(nèi)10-14天天階段I開始 運動試驗 風(fēng)險評估門診隨訪門診隨訪住院患者住院