运动康复对经皮冠状动脉介入术后急性冠状动脉综合征患者的效果

doi:10.3969/j.issn.1006-9771.2021.02.015

《中国康复理论与实践》 ›› 2021, Vol. 27 ›› Issue (2): 208-215.doi: 10.3969/j.issn.1006-9771.2021.02.015

运动康复对经皮冠状动脉介入术后急性冠状动脉综合征患者的效果

袁玮¹,聂姗¹,贾楠¹,郑志昌²,王浩彦¹()

^1.首都医科大学附属北京友谊医院呼吸内科，北京市 100050
^2.中国康复研究中心北京博爱医院心脏内科，北京市 100068

收稿日期:2020-06-05 修回日期:2020-11-17 出版日期:2021-02-25 发布日期:2021-02-26
通讯作者: 王浩彦 E-mail:haoyanw@126.com
作者简介:袁玮(1983-)，女，汉族，北京市人，硕士研究生，主治医师，主要研究方向：运动心肺功能，心肺康复|王浩彦(1962-)，男，汉族，安徽安庆市人，教授、主任医师，博士生导师，主要研究方向：运动心肺功能，心肺康复。
基金资助:
首都卫生发展科研专项课题(No. 首发 2018-2-2024);北京市李桓英医学基金会人才培养基金项目(LHYJJHRCPY2017-19)

Effect of Exercise-based Cardiac Rehabilitation on Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention

Wei YUAN¹,Shan NIE¹,Nan JIA¹,Zhi-chang ZHENG²,Hao-yan WANG¹()

^1.Respiratory Medicine Department, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
^2.Cardiovascular Medicine Department, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing 100068, China

Received:2020-06-05 Revised:2020-11-17 Published:2021-02-25 Online:2021-02-26
Contact: Hao-yan WANG E-mail:haoyanw@126.com
Supported by:
Capital Funds for Health Improvement and Research(2018-2-2024);Beijing Li Huanying Medical Foundation(LHYJJHRCPY2017-19)

摘要/Abstract

摘要： 目的

通过心脏超声和心肺运动试验(CPET)评估急性期接受经皮冠状动脉介入(PCI)治疗的急性冠脉综合征(ACS)患者进行运动训练为主的心脏康复的疗效，探讨何种类型的ACS患者能从运动康复治疗中更多获益。

方法

连续纳入2017年12月至2019年7月本院PCI术后的ACS患者31例。根据基线期心脏超声所示左心室室壁运动功能分为室壁运动正常组(正常组，n = 14)和存在节段性室壁运动异常组(异常组，n = 17)，以室壁运动积分指数(WMSI)量化室壁运动异常的程度。所有患者在出院后于稳定状态下接受为期3个月的个体化运动康复治疗，运动康复前后均行心脏超声和CPET。

结果

8例脱落，共23例患者完成试验。心脏超声显示，运动康复后异常组WMSI明显降低(Z = -2.852, P = 0.004)；而左室射血分数在两组中均无显著改变(P > 0.05)。CPET显示，运动康复后，正常组仅静息心率减慢(t = -2.268, P = 0.047)；异常组最大运动负荷、峰值摄氧量、峰值摄氧量占预计值百分比、峰值分钟通气量和运动终止后第3分钟的心率恢复均较康复前提高(t > 2.739, P < 0.05)。

结论

急性期接受PCI治疗后存在WMSI异常的ACS患者，在病情恢复期接受运动康复治疗，更易获得心脏功能和运动耐量的进一步改善。WMSI在反映保留射血分数的ACS患者的心脏功能改善方面具有重要意义。

关键词: 急性冠脉综合征, 心脏康复, 室壁运动积分指数, 心肺运动试验

Abstract: Objective

To analyze the effects of exercise-based cardiac rehabilitation (ER) on patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI), and to identify which type of ACS patients would benefit most in terms of cardiovascular functional capacity after ER.

Methods

From December, 2017 to July, 2019, 31 ACS patients who discharged in a stable situation after PCI were studied. All patients were referred to a three-month ER program after discharge. They were divided into normal wall motion group (normal group, n = 14) and abnormal regional wall motion group (abnormal group, n = 17) according to baseline myocardial wall motion reported by echocardiography. The degree of wall motion abnormalities was quantified by the wall motion score index (WMSI). Echocardiography and cardiopulmonary exercise testing (CPET) were performed before and after ER.

Results

Eight patients were dropped, and 23 patients completed the trial. WMSI decreased in the abnormal group (Z = -2.852, P = 0.004), and the left ventricular ejection fraction (LVEF) didn't change in both groups (P > 0.05) after ER. CPET showed that the heart rate at rest decreased in the normal group after ER (t = -2.268, P = 0.047); and the peak work rate, peak oxygen uptake, percentage of predicted value of peak oxygen uptake, peak minute ventilation and the third minute heart rate recovery increased in the abnormal group after ER (t > 2.739, P < 0.05).

Conclusion

ER during recovery period could help more improve the cardiac function and exercise tolerance of ACS patients with abnormal WMSI after PCI. WMSI is an important indicator of cardiac function in ACS patients with preserved ejection fraction.

Key words: acute coronary syndrome, cardiac rehabilitation, wall motion score index, cardiopulmonary exercise testing

中图分类号:

R541.4

袁玮,聂姗,贾楠,郑志昌,王浩彦. 运动康复对经皮冠状动脉介入术后急性冠状动脉综合征患者的效果[J]. 《中国康复理论与实践》, 2021, 27(2): 208-215.

Wei YUAN,Shan NIE,Nan JIA,Zhi-chang ZHENG,Hao-yan WANG. Effect of Exercise-based Cardiac Rehabilitation on Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2021, 27(2): 208-215.

图/表 3

表1

表2

表3

参考文献 38

1	Roffi M, Patrono C, Collet J P, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC) [J]. Eur Heart J, 2016, 37(3): 267-315.
2	Giallauria F, Lucci R, D'Agostino M, et al. Two-year multicomprehensive secondary prevention program: favorable effects on cardiovascular functional capacity and coronary risk profile after acute myocardial infarction [J]. J Cardiovasc Med (Hagerstown), 2009, 10(10): 772-780.
3	Thomas R J, Balady G, Banka G, et al. 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation: a report of the American College of Cardiology/American Heart Association task force on performance measures [J]. J Am Coll Cardiol, 2018, 71(16): 1814-1837.
4	Anderson L, Oldridge N, Thompson D R, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis [J]. J Am Coll Cardiol, 2016, 67(1): 1-12.
5	Kim C, Sung J, Lee J H, et al. Clinical Practice Guideline for Cardiac Rehabilitation in Korea: Recommendations for Cardiac Rehabilitation and Secondary Prevention after Acute Coronary Syndrome [J]. Korean Circ J, 2019, 49(11): 1066-1111.
6	中国康复医学会心血管病专业委员会. 中国心脏康复与二级预防指南2018精要[J]. 中华内科杂志, 2018, 57(11): 802-810.
	Cardiovascular Disease Committee of the Chinese Society of Rehabilitation Medicine. Highlights of Guidelines for Cardiac Rehabilitation and Secondary Prevention in China 2018 [J]. Chin J Internal Med, 2018, 57(11): 802-810.
7	Pouche M, Ruidavets J B, Ferrieres J, et al. Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: the 2005 French FAST-MI study [J]. Arch Cardiovasc Dis, 2016, 109(3): 178-187.
8	Suaya J A, Shepard D S, Normand S L, et al. Use of cardiac rehabilitation by medicare beneficiaries after myocardial infarction or coronary bypass surgery [J]. Circulation, 2007, 116(15): 1653-1662.
9	Ritchey M D, Maresh S, McNeely J, et al. Tracking cardiac rehabilitation participation and completion among medicare beneficiaries to inform the efforts of a national initiative [J]. Circ Cardiovasc Qual Outcomes, 2020, 13(1): e005902.
10	Conraads V M, Deaton C, Piotrowicz E, et al. Adherence of heart failure patients to exercise: barriers and possible solutions [J]. Eur J Heart Fail, 2012, 14(5): 451-458.
11	Wasserman K, Hansen J E, Sue D Y, et al. Measurements during integrative cardiopulmonary exercise testing [M]// Wasserman K, Hansen J E, Sue D Y, et al. Principles of Exercise Testing and Interpretation. 5th ed. Lippincott Williams & Wilkins, 2011: 71-76.
12	陈怡锡,张焕基,吴奋生,等. 心肺运动试验在心脏康复中的应用及研究进展[J]. 岭南心血管病杂志, 2018, 24(3): 355-357.
	Chen Y X, Zhang H J, Wu F S, et al. Application of cardiopulmonary exercise testing in cardiac rehabilitation and research progress [J]. Lingnan J Cardiov Dis, 2018, 24(3): 355-357.
13	桂沛君,吴坚,张勃,等. 急性冠状动脉综合征患者PCI术后综合心脏康复疗效观察 [J]. 临床和实验医学杂志, 2019, 18(18): 1959-1964.
	Gui P J, Wu J, Zhang B, et al. Effectiveness of comprehensive cardiac rehabilitation after PCI in patients with acute coronary syndrome [J]. J Clin Exper Med, 2019, 18(18): 1959-1964.
14	American Thoracic Society, American College of Chest P. ATS/ACCP Statement on cardiopulmonary exercise testing [J]. Am J Respir Crit Care Med, 2003, 167(2): 211-277.
15	Wasserman K, Hansen J E, Sue D Y, et al. Clinical exercise testing [M]// Wasserman K, Hansen J E, Sue D Y, et al. Principles of Exercise Testing and Interpretation. 5th ed. Lippincott Williams & Wilkins, 2011: 141-142.
16	Cerqueira M D, Weissman N J, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association [J]. Circulation, 2002, 105(4): 539-542.
17	Jia D, Hou L, Lv Y, et al. Postinfarction exercise training alleviates cardiac dysfunction and adverse remodeling via mitochondrial biogenesis and SIRT1/PGC-1alpha/PI3K/Akt signaling [J]. J Cell Physiol, 2019, 234(12): 23705-23718.
18	Liao Z, Li D, Chen Y, et al. Early moderate exercise benefits myocardial infarction healing via improvement of inflammation and ventricular remodelling in rats [J]. J Cell Mol Med, 2019, 23(12): 8328-8342.
19	Giallauria F, Acampa W, Ricci F, et al. Effects of exercise training started within 2 weeks after acute myocardial infarction on myocardial perfusion and left ventricular function: a gated SPECT imaging study [J]. Eur J Prev Cardiol, 2012, 19(6): 1410-1419.
20	Giallauria F, Acampa W, Ricci F, et al. Exercise training early after acute myocardial infarction reduces stress-induced hypoperfusion and improves left ventricular function [J]. Eur J Nucl Med Mol Imaging, 2013, 40(3): 315-324.
21	Candelaria D, Randall S, Ladak L, et al. Health-related quality of life and exercise-based cardiac rehabilitation in contemporary acute coronary syndrome patients: a systematic review and meta-analysis [J]. Qual Life Res, 2020, 29(3): 579-592.
22	Thomas R J, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation) [J]. Circulation, 2010, 122(13): 1342-1350.
23	Smith S C, Benjamin E J, Bonow R O, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation [J]. Circulation, 2011, 124(22): 2458-2473.
24	Lee H Y, Hong S J, Jung I H, et al. Effect of cardiac rehabilitation on outcomes in patients with ST-elevation myocardial infarction [J]. Yonsei Med J, 2019, 60(6): 535-541.
25	Dunlay S M, Witt B J, Allison T G, et al. Barriers to participation in cardiac rehabilitation [J]. Am Heart J, 2009, 158(5): 852-859.
26	Tian Y, Deng P, Li B, et al. Treatment models of cardiac rehabilitation in patients with coronary heart disease and related factors affecting patient compliance [J]. Rev Cardiovasc Med, 2019, 20(1): 27-33.
27	Rosa S A, Abreu A, Soares R M, et al. Cardiac rehabilitation after acute coronary syndrome: do all patients derive the same benefit? [J]. Rev Port Cardiol, 2017, 36(3): 169-176.
28	Patel P, Ivanov A, Ramasubbu K. Myocardial viability and revascularization: current understanding and future directions [J]. Curr Atheroscler Rep, 2016, 18(6): 32.
29	Leosco D, Rengo G, Iaccarino G, et al. Prior exercise improves age-dependent vascular endothelial growth factor downregulation and angiogenesis responses to hind-limb ischemia in old rats [J]. J Gerontol A Biol Sci Med Sci, 2007, 62(5): 471-480.
30	Iemitsu M, Maeda S, Jesmin S, et al. Exercise training improves aging-induced downregulation of VEGF angiogenic signaling cascade in hearts [J]. Am J Physiol Heart Circ Physiol, 2006, 291(3): H1290-H1298.
31	Leosco D, Rengo G, Iaccarino G, et al. Exercise promotes angiogenesis and improves beta-adrenergic receptor signalling in the post-ischaemic failing rat heart [J]. Cardiovasc Res, 2008, 78(2): 385-394.
32	Brown M D. Exercise and coronary vascular remodelling in the healthy heart [J]. Exp Physiol, 2003, 88(5): 645-658.
33	Brehm M, Picard F, Ebner P, et al. Effects of exercise training on mobilization and functional activity of blood-derived progenitor cells in patients with acute myocardial infarction [J]. Eur J Med Res, 2009, 14(9): 393-405.
34	Jurado-Roman A, Agudo-Quilez P, Rubio-Alonso B, et al. Superiority of wall motion score index over left ventricle ejection fraction in predicting cardiovascular events after an acute myocardial infarction [J]. Eur Heart J Acute Cardiovasc Care, 2019, 8(1): 78-85.
35	Xiang L, Wang M, You T, et al. Prognostic value of ventricular wall motion score and global registry of acute coronary events score in patients with acute myocardial infarction [J]. Am J Med Sci, 2017, 354(1): 27-32.
36	Eek C, Grenne B, Brunvand H, et al. Strain echocardiography and wall motion score index predicts final infarct size in patients with non-ST-segment-elevation myocardial infarction [J]. Circ Cardiovasc Imaging, 2010, 3(2): 187-194.
37	Eitel I, Stiermaier T, Lange T, et al. Cardiac magnetic resonance myocardial feature tracking for optimized prediction of cardiovascular events following myocardial infarction [J]. JACC Cardiovasc Imaging, 2018, 11(10): 1433-1444.
38	Stone G W, Selker H P, Thiele H, et al. Relationship between infarct size and outcomes following primary PCI: patient-level analysis from 10 randomized trials [J]. J Am Coll Cardiol, 2016, 67(14): 1674-1683.

项目	正常组 (n = 14)	异常组 (n = 17)	t/Z值	P值
性别(男/女，n)	9/5	17/0		0.012
年龄(岁)	61±8	53±12	2.177	0.038
体质量指数(kg/m²)	25.73±2.50	27.53±4.00	-1.456	0.156
目前吸烟者[n(%)]	2(14.3)	9(52.9)		0.057
吸烟量(包年)	0.75(0,9.63)	20(6,27)	-2.168	0.032
并发高血压[n(%)]	11(78.6)	11(64.7)		0.456
并发糖尿病[n(%)]	5(35.7)	6(35.3)		1.000
β受体阻滞剂[n(%)]	8(57.1)	12(70.6)		0.477

项目	正常组(n = 11)		异常组(n = 12)		t/Z 值^a	P值^a	t/Z值^b	P值^b	t/Z值^c	P值^c	t/Z值^d	P值^d
项目	康复前	康复后	康复前	康复后	t/Z 值^a	P值^a	t/Z值^b	P值^b	t/Z值^c	P值^c	t/Z值^d	P值^d
LVEF(%)	66.63±3.07	67.17±1.94	60.91±5.48	62.42±5.52	3.117	0.006	2.290	0.035	0.484	0.649	0.872	0.402
LVEDd (mm)	51.48±3.38	53.38±1.95	52.43±4.45	51.85±5.46	-0.573	0.572	0.906	0.380	1.680	0.123	-0.573	0.578
E/A	0.91±0.43	1.00±0.26	1.16±0.40	1.05±0.21	-1.456	0.160	-0.491	0.628	0.657	0.526	-1.187	0.260
WMSI	1.00(1.00,1.00)	1.00(1.00,1.00)	1.21(1.09,1.29)	1.03(1.00,1.14)	-4.307	<0.001	-2.631	0.044	0.000	1.000	-2.852	0.004

项目	正常组(n = 11)		异常组 (n = 12)		t值^a	P值^a	t值^b	P值^b	t值^c	P值^c	t值^d	P值^d
项目	康复前	康复后	康复前	康复后	t值^a	P值^a	t值^b	P值^b	t值^c	P值^c	t值^d	P值^d
最大运动负荷(W)	108±22	117±26	119±16	137±18	-1.327	0.201	-2.202	0.039	1.833	0.097	4.762	0.001
AT[ml/(min·kg)]	13.40±1.94	14.30±2.89	12.35±2.79	14.13±2.87	1.038	0.311	0.139	0.891	0.951	0.364	2.136	0.056
pVO₂(ml/min)	1468.73±310.04	1490.82±301.24	1604.83±198.31	1814.92±303.09	-1.266	0.220	-2.569	0.018	0.439	0.670	3.872	0.003
pVO₂[ml/(min·kg)]	20.32±3.65	20.58±3.47	19.50±2.50	22.37±3.79	0.639	0.530	-1.173	0.254	0.341	0.741	3.873	0.003
pVO₂pred(%)	78.37±11.32	79.27±9.11	66.00±10.13	77.25±13.06	2.766	0.012	1.069	0.297	0.310	0.763	3.793	0.003
pVE[ml/(min·kg)]	50.91±13.62	52.36±14.85	52.58±10.10	63.08±6.67	-0.042	0.967	-2.200	0.046	0.526	0.611	5.467	< 0.001
O₂pulse	11.97±2.30	12.51±2.61	12.99±1.92	13.68±2.24	-1.159	0.259	-1.160	0.259	1.690	0.122	1.713	0.115
静息心率(次/min)	73±9	66±5	71±8	68±9	0.502	0.621	-0.910	0.375	-2.268	0.047	-1.093	0.298
HRR3(次/min)	31±9	33±10	33±6	44±13	-0.650	0.523	-2.223	0.038	0.787	0.449	2.739	0.019

[1]	王国栋,唐丽,刘杰,林伟,张焱,左雪冰. 冠状动脉临界病变患者心肺运动试验的特点及临床意义[J]. 《中国康复理论与实践》, 2022, 28(7): 833-840.
[2]	秦宁,沈志莹,石双姣,李旭红,钟竹青. 心脏康复转介服务[J]. 《中国康复理论与实践》, 2022, 28(3): 366-372.
[3]	王丹,李瑾,高民,张明,陈猛,张一帆,夏露露,陈伟. 基于WHO-FICs心肺运动试验在肺癌患者中应用的Scoping综述[J]. 《中国康复理论与实践》, 2021, 27(8): 923-935.
[4]	蔡玮,邢文华,梁文平,赵雷,刘萍,滕珲,王国栋. 南皮县经皮冠状动脉介入治疗术后患者心脏康复现状调查[J]. 《中国康复理论与实践》, 2021, 27(8): 966-972.
[5]	郑志昌,袁玮,林伟,刘杰,王晓荣,杨威,于海涛,薛淞,王亚敏,唐丽,王国栋. 稳定型冠心病患者心脏康复的风险分层模型[J]. 《中国康复理论与实践》, 2021, 27(7): 819-828.
[6]	于曼丽,姜衡,李彬,柴丽莉,沈慧,施峰,谢东峰,林兴中. 太极拳对老年心肌梗死后心力衰竭患者心脏功能的效果[J]. 《中国康复理论与实践》, 2020, 26(8): 969-974.
[7]	司旭艳, 王世广, 王鹏. 生理性缺血训练在心脏康复中的研究进展[J]. 《中国康复理论与实践》, 2020, 26(6): 683-686.
[8]	杨威,李寿霖,王国栋,陈思远,刘杰,林伟,郑志昌,王晓荣. 女性高血压患者心肺运动试验中血压经时变化研究[J]. 《中国康复理论与实践》, 2020, 26(6): 711-714.
[9]	朱世立,谢友红,黄玮,孙兴国,王张敏,王晓东,邓维,王若兰. 个体化适度运动改善肺动脉高压患者心肺功能的效果[J]. 《中国康复理论与实践》, 2020, 26(4): 479-486.
[10]	张穗浩, 林峰, 董少红. 高强度间歇训练在急性心肌梗死介入治疗术后的应用现状[J]. 《中国康复理论与实践》, 2019, 25(6): 696-699.
[11]	潘钰，徐泉，杨晓辉，萧演清，吴琼，闫澍妤，屠媛媛. 定量评估有氧运动对脊髓损伤患者心肺功能的影响[J]. 《中国康复理论与实践》, 2017, 23(4): 415-419.
[12]	李寿霖,a，张焱,a，刘杰,a，杨威,a，刘立君,a，郑志昌,a，林伟,a，王晓荣,a，王国栋,a，封丽红,a，陈思远,a，杨祖福,b. 选择性β1受体阻滞剂对高血压患者运动耐力的影响[J]. 《中国康复理论与实践》, 2017, 23(4): 446-448.
[13]	蔡泽坤综述，徐琳，邱健审校. 远程心电监测在心肌梗死患者心脏康复中的应用进展①[J]. 《中国康复理论与实践》, 2016, 22(1): 75-78.
[14]	孙佩伟;马建新 . 冠心病的康复进展[J]. 《中国康复理论与实践》, 2015, 21(12): 1425-1429.
[15]	刘杰;李寿霖;编译;胡大一审校. 左室功能不全所致的慢性心力衰竭患者心肺运动试验声明实施和解释建议（3）[J]. 《中国康复理论与实践》, 2010, 16(9): 880-881.

运动康复对经皮冠状动脉介入术后急性冠状动脉综合征患者的效果

Effect of Exercise-based Cardiac Rehabilitation on Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention

RichHTML

PDF (PC)

可视化

摘要/Abstract

引用本文

使用本文

图/表 3

参考文献 38

相关文章 15

Metrics

本文评价

推荐阅读 0