馮慧　潘化平

211100 南京，南京醫(yī)科大學(xué)附屬江寧醫(yī)院康復(fù)醫(yī)學(xué)科

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腦卒中的心血管康復(fù)現(xiàn)狀與進(jìn)展

馮慧潘化平

211100 南京，南京醫(yī)科大學(xué)附屬江寧醫(yī)院康復(fù)醫(yī)學(xué)科

Exercise tolerance test; Exercise therapy

腦卒中是一種由多種血管性危險(xiǎn)因素引起的臨床綜合征，患者普遍存在冠狀動(dòng)脈粥樣硬化性心臟病(冠心病)、高血壓病、糖尿病、脂肪代謝紊亂以及心功能不全等心血管和代謝性疾病，控制這些危險(xiǎn)因素在腦卒中的康復(fù)治療中具有極其重要的意義[1]。

一、腦卒中與心血管和代謝性疾病

1.腦卒中與心臟疾病

冠心病是誘發(fā)腦卒中的高危因素，合并有心臟病的人群，腦卒中發(fā)病率是健康人群的3倍以上[2]。心房纖顫與腦卒中發(fā)生關(guān)系密切，是誘發(fā)缺血性腦卒中的獨(dú)立危險(xiǎn)因素，約50%的心源性缺血性腦卒中是由心房纖顫引起[3-4]。高血壓病是引起腦卒中最重要的獨(dú)立危險(xiǎn)因素，也是腦卒中不良預(yù)后的獨(dú)立危險(xiǎn)因素[5-6]。高血壓病與腦卒中再發(fā)密切相關(guān)[7]。隨著左心室重量的增加，高血壓病患者腦卒中的發(fā)病率及病死率也成比例增加。研究發(fā)現(xiàn)收縮壓對(duì)腦卒中的影響超過(guò)舒張壓，隨著年齡增加，血壓的作用逐漸減弱，適當(dāng)升高血壓可降低老年人腦卒中的發(fā)病率[8-10]。

2.腦卒中與心功能不全

70歲以上的腦卒中患者心功能不全的發(fā)病率可高達(dá)50%[11]。伴有心功能不全的腦卒中更易復(fù)發(fā)，且病死率更高。但心功能不全的臨床癥狀常受患者的主觀性影響，體征缺乏特異性,另外臨床醫(yī)師過(guò)度關(guān)注自已專科的疾病，而未能很好地識(shí)別心功能不全，導(dǎo)致未予及時(shí)診斷或治療的情況很常見(jiàn)，有的甚至引起惡性后果。

3.腦卒中與糖尿病

超過(guò)三分之二的慢性腦卒中患者和超過(guò)三分之一的急性腦卒中患者合并有高血糖癥[12]。美國(guó)一項(xiàng)研究顯示，在所有年齡段，特別是小于65歲的人群，伴有糖尿病的患者腦卒中發(fā)病風(fēng)險(xiǎn)顯著增加[13]。當(dāng)糖尿病病程超過(guò)10年時(shí)缺血性腦卒中發(fā)病風(fēng)險(xiǎn)增加3倍[14]。高血糖對(duì)心血管系統(tǒng)的危害與多種直接和間接的通路加速動(dòng)脈粥樣硬化有關(guān)[15]。雖然目前關(guān)于糖尿病及糖尿病前期與腦卒中的關(guān)系研究結(jié)論并不一致，但是糖尿病是腦卒中的獨(dú)立危險(xiǎn)因素還是得到公認(rèn)的，糖尿病及糖尿病前期均為腦卒中不良結(jié)局的獨(dú)立危險(xiǎn)因素，兩者均能增加腦卒中的發(fā)病風(fēng)險(xiǎn)[16-20]。

4.腦卒中與血脂代謝

血脂代謝異常與腦卒中的關(guān)系比較復(fù)雜。一般認(rèn)為總膽固醇、甘油三酯、HDL-C、LDL-C是缺血性腦卒中的危險(xiǎn)因素[21-22]。LDL-C與絕經(jīng)后女性腦卒中的發(fā)生密切相關(guān)[23]。由于老年患者受長(zhǎng)期的高血壓病、糖尿病、血脂異常、吸煙等多種因素的影響，LDL-C成為了老年人腦卒中的重要危險(xiǎn)因素。

二、腦卒中的心血管問(wèn)題

腦卒中導(dǎo)致心、肺功能下降已獲得共識(shí)，但其潛在的生理學(xué)機(jī)制并未獲得系統(tǒng)的研究。研究顯示75%腦卒中幸存者合并心臟病[24]。對(duì)于無(wú)合并心血管疾病的初發(fā)腦卒中患者，同樣存在心、肺功能下降的情況，除了可能因中樞神經(jīng)系統(tǒng)損傷導(dǎo)致的中樞驅(qū)動(dòng)能力下降外，還可能由于其它外周機(jī)制導(dǎo)致了心、肺功能的下降，其中包括骨骼肌萎縮、肌纖維表型的改變、偏癱側(cè)肢體血液供應(yīng)的減少以及胰島素抵抗[25-29]。

1.急性腦卒中的心血管損傷

關(guān)于急性腦卒中患者心功能改變的研究結(jié)果差別較大。一般認(rèn)為急性腦卒中引起的心臟損害主要表現(xiàn)為心電圖異常(AMI、心肌缺血、心律失常)、心內(nèi)膜下出血或心力衰竭等[30]。急性腦卒中患者中心電圖異常的發(fā)生率可高達(dá)60%，約6%～34%患者出現(xiàn)血漿肌鈣蛋白I和肌鈣蛋白T濃度增加。

對(duì)于冠心病患者，急性腦卒中與冠心病在心肌損傷中可能起協(xié)同作用。美國(guó)成年人心血管風(fēng)險(xiǎn)評(píng)估指南建議所有無(wú)冠心病和腦卒中的成年人都應(yīng)進(jìn)行心血管風(fēng)險(xiǎn)評(píng)估，中國(guó)心血管病預(yù)防指南建議利用各種機(jī)會(huì)為患者進(jìn)行心腦血管病風(fēng)險(xiǎn)評(píng)估[31-32]。

2.制　動(dòng)

腦卒中發(fā)生后，心血管系統(tǒng)與肌肉組織會(huì)發(fā)生一系列病理變化，血容量及左心室舒張末期容量減少6%~11%，每搏量和心輸出量降低6%~13%[33]。由于血容量下降，心功能減退，運(yùn)動(dòng)能力也隨之減退。同時(shí)制動(dòng)會(huì)導(dǎo)致肌肉萎縮和肌肉內(nèi)脂肪含量增加，肌肉血液循環(huán)障礙，諸多因素共同作用對(duì)患者的恢復(fù)造成不利影響。

3.運(yùn)動(dòng)模式異常的耗能增加

腦卒中患者普遍存在耐力減退，從事各種活動(dòng)所消耗的能量較正常人明顯增加。一項(xiàng)關(guān)于偏癱患者的研究表明，與正常對(duì)照組相比，偏癱步態(tài)的耗能較正常步態(tài)增加55%～100%[34-35]。這項(xiàng)研究還顯示偏癱患者難以自然維持其最有效的步行速度，提示耐力的減退反過(guò)來(lái)制約了運(yùn)動(dòng)功能的改善[36-37]。

三、腦卒中的心血管功能評(píng)定

腦卒中患者心臟康復(fù)前應(yīng)常規(guī)進(jìn)行各項(xiàng)功能評(píng)估，尤其是心功能評(píng)估。評(píng)估心功能應(yīng)結(jié)合病史、癥狀、體征及輔助檢査綜合判斷。常用的輔助檢查包括：靜息心電圖、心臟彩色多普勒超聲檢查(彩超)、運(yùn)動(dòng)負(fù)荷心電圖、心肺運(yùn)動(dòng)試驗(yàn)(CPET)、定距離測(cè)定(6 min步行試驗(yàn)、10 m步行試驗(yàn))等。

CPET通過(guò)測(cè)定人體在靜息、運(yùn)動(dòng)及運(yùn)動(dòng)結(jié)束時(shí)每一次呼吸的氧攝取量、二氧化碳排出量和通氣量，及心率、血壓、心電圖變化和患者運(yùn)動(dòng)時(shí)出現(xiàn)的癥狀, 客觀地評(píng)價(jià)循環(huán)呼吸功能和體力的廢用性變化。CPET主要參數(shù)有：最大運(yùn)動(dòng)負(fù)荷、峰值攝氧量(VO2max)、無(wú)氧閾、峰值耗氧量(VO2peak)、換氣比值、心率、血壓、心電圖ST改變等[38-43]。由于患側(cè)肢體運(yùn)動(dòng)功能障礙，腦卒中偏癱患者的VO2max難以達(dá)到高平臺(tái)，有學(xué)者通過(guò)平板步行負(fù)荷遞增的方式評(píng)估了131例后遺癥期偏癱患者的VO2peak，結(jié)果為(13.6±4)ml/(mg·min) ，而在年齡匹配，同樣缺乏運(yùn)動(dòng)的健康對(duì)照組中，其VO2peak可達(dá)到25~30 ml/(mg·min),提示偏癱患者的VO2peak較健康人下降一半以上[45-46]。臨床實(shí)踐中一般常用VO2peak或無(wú)氧閾。其他的指標(biāo)也常被用于臨床研究中，如：①最大心搏數(shù)(HRmax,220-年齡)；②HRmax時(shí)VO2；③VO2(100)或VO2(120)；④氧脈(每搏氧輸送量)；⑤氧負(fù)債；⑥生理耗能指數(shù)(PCI)，等等。

腦卒中患者進(jìn)行CPET，可以明確心血管功能狀態(tài)，判斷心臟康復(fù)風(fēng)險(xiǎn)，同時(shí)能明確運(yùn)動(dòng)受限原因，準(zhǔn)確評(píng)估運(yùn)動(dòng)能力，從而判斷運(yùn)動(dòng)允許量，制定合理運(yùn)動(dòng)處方[47-48]。還可獲得心律變時(shí)性反應(yīng)、運(yùn)動(dòng)血壓和心率恢復(fù)等非心電圖參數(shù)，越來(lái)越多的文獻(xiàn)支持這些參數(shù)對(duì)患者預(yù)后判斷的作用優(yōu)于傳統(tǒng)評(píng)價(jià)方式[49-51]。

偏癱患者常用的運(yùn)動(dòng)負(fù)荷試驗(yàn)方案分為遞增負(fù)荷法和恒定負(fù)荷法。遞增負(fù)荷法可選用的方式有：跑臺(tái)、功率自行車、ShwinniAr-Dyne能量測(cè)力計(jì)、上肢測(cè)力計(jì)、軀干前后屈運(yùn)動(dòng)、反復(fù)起立運(yùn)動(dòng)。跑臺(tái)僅適用于步行能力接近于正常人的患者，功率自行車比跑臺(tái)適應(yīng)范圍廣, 但不適用于軀干控制較差或存在下肢伸肌痙攣的患者。健側(cè)上肢測(cè)力計(jì)可用于重度步行障礙者, 且簡(jiǎn)單易行。在VO2max測(cè)定困難的情況下可以通過(guò)軀干前后屈運(yùn)動(dòng)和反復(fù)起立運(yùn)動(dòng)來(lái)測(cè)定體力指標(biāo)。

當(dāng)無(wú)法開(kāi)展CPET時(shí)，為了評(píng)價(jià)腦卒中患者的活動(dòng)能力，6 min步行試驗(yàn)是很好的選擇，可反映受試者亞極量運(yùn)動(dòng)的能力[52]。6 min步行試驗(yàn)與CPET的最大運(yùn)動(dòng)能力存在相關(guān)性，可以用來(lái)預(yù)測(cè)受試者的VO2max[53]。

四、腦卒中患者的心血管康復(fù)

通常情況下, 腦卒中康復(fù)是以改善患者運(yùn)動(dòng)功能、提高其日常生活活動(dòng)能力為主要目標(biāo)，重點(diǎn)在神經(jīng)功能障礙的評(píng)估和治療上[54]?；颊咝枰鎸?duì)因?yàn)槌掷m(xù)活動(dòng)減少而引起的體力減退、活動(dòng)能力下降而導(dǎo)致的慢性殘疾以及心血管的功能障礙[46]。

研究證明早期行心臟康復(fù)可顯著提高患者的VO2max和6 min步行試驗(yàn)距離，運(yùn)動(dòng)能力每增加l METs可降低12%病死率[43]。有學(xué)者觀察了20 例患者在接受現(xiàn)有的康復(fù)訓(xùn)練過(guò)程中物理療法和作業(yè)療法所引起的心血管應(yīng)激水平，結(jié)果顯示，每次治療期間患者心率達(dá)到預(yù)定目標(biāo)心率的時(shí)間極短, 提示這些治療所產(chǎn)生的心血管應(yīng)激反應(yīng)不足以產(chǎn)生訓(xùn)練效應(yīng)。事實(shí)證明，現(xiàn)有的康復(fù)模式不能系統(tǒng)地提供充足的訓(xùn)練量來(lái)逆轉(zhuǎn)患者體力的減退, 也不能提供足夠的重復(fù)性活動(dòng)達(dá)到運(yùn)動(dòng)學(xué)習(xí)的最佳化, 無(wú)法做到持續(xù)鍛煉以保障腦卒中患者的健康。

針對(duì)腦卒中的心血管康復(fù)治療，應(yīng)根據(jù)患者肢體活動(dòng)障礙情況選擇徒手、踏車或手足聯(lián)動(dòng)踏車等；阻抗運(yùn)動(dòng)、柔韌性訓(xùn)練和平衡訓(xùn)練是必要的補(bǔ)充，但這些項(xiàng)目可能與神經(jīng)康復(fù)訓(xùn)練項(xiàng)目存在重疊，應(yīng)酌情減量。

五、腦卒中心血管康復(fù)的風(fēng)險(xiǎn)

腦卒中患者的心臟康復(fù)與單純心臟病患者的心臟康復(fù)存在一定的區(qū)別，腦卒中大多數(shù)是在高血壓病、冠心病、糖尿病、心房纖顫等基礎(chǔ)上發(fā)生的，而且腦卒中后機(jī)體的各種病理生理變化也容易引發(fā)心血管并發(fā)癥，這在相當(dāng)程度上增加了腦卒中患者的治療風(fēng)險(xiǎn)及康復(fù)治療的復(fù)雜程度。一方面是疾病的隱匿性，腦卒中患者一般以神經(jīng)系統(tǒng)癥狀為主訴入院，常常無(wú)心臟病的臨床癥狀，是否合并心臟病常需進(jìn)一步行評(píng)估發(fā)現(xiàn)；另一方面，腦卒中患者亞極量負(fù)荷時(shí)的氧耗常高于正常人，達(dá)到疲勞時(shí)的VO2max、負(fù)荷量、心率、收縮壓均低于正常人。在急性腦卒中患者中，心律失常導(dǎo)致猝死的幾率為6%，且這種猝死的風(fēng)險(xiǎn)持續(xù)約1個(gè)月。心律失常中心率增快與缺血性腦卒中后致殘率及智能障礙有密切關(guān)系，可能預(yù)示著患者潛在的心血管病及高血壓病的可能。

在進(jìn)行心血管康復(fù)前，應(yīng)結(jié)合心功能評(píng)估結(jié)果制定腦卒中患者的運(yùn)動(dòng)處方，強(qiáng)調(diào)個(gè)體化、被動(dòng)訓(xùn)練與主動(dòng)訓(xùn)練相結(jié)合，急性期及高危患者必須在心電、血壓、血氧飽和度監(jiān)護(hù)下進(jìn)行。通過(guò)監(jiān)測(cè)運(yùn)動(dòng)中的心率來(lái)確定訓(xùn)練強(qiáng)度，常根據(jù)運(yùn)動(dòng)負(fù)荷試驗(yàn)測(cè)得的最大心率來(lái)制定，即(最大心率-靜息心率)×運(yùn)動(dòng)強(qiáng)度+靜息心率。一般強(qiáng)度為40%～80%，3～5次/周，30～60 min/次。如無(wú)條件進(jìn)行運(yùn)動(dòng)負(fù)荷試驗(yàn)的可在靜息心率基礎(chǔ)上增加20～30次/分，一般來(lái)說(shuō)心率增加20次/分是較安全的。應(yīng)結(jié)合運(yùn)動(dòng)前狀態(tài)及運(yùn)動(dòng)中的表現(xiàn)、自我感知?jiǎng)诶鄢潭仍u(píng)分(如Borg評(píng)分)，實(shí)時(shí)適當(dāng)調(diào)整運(yùn)動(dòng)方案，確保訓(xùn)練安全、有效。

六、展望

進(jìn)行康復(fù)治療的腦卒中患者應(yīng)盡早完善心血管功能評(píng)估，積極識(shí)別和處理心血管疾病。心血管康復(fù)訓(xùn)練不僅有利于改善腦卒中患者的運(yùn)動(dòng)能力，提高其生活質(zhì)量，而且可以降低其心因性死亡風(fēng)險(xiǎn)及全因死亡風(fēng)險(xiǎn)，改善其遠(yuǎn)期預(yù)后。但有關(guān)腦卒中患者的心血管康復(fù)還面臨以下幾個(gè)問(wèn)題：①腦卒中病程與運(yùn)動(dòng)功能分級(jí)對(duì)心血管康復(fù)的影響，腦卒中患者肢體功能的不同，尤其是下肢肌力、肌張力、平衡功能的差異會(huì)對(duì)患者有氧訓(xùn)練實(shí)際完成量和效果產(chǎn)生重要影響，康復(fù)治療方案有待行大樣本多中心的研究探討；②腦卒中患者運(yùn)動(dòng)治療與心血管康復(fù)的量效關(guān)系，不同訓(xùn)練方式、強(qiáng)度、時(shí)間和時(shí)程對(duì)腦卒中患者心血管效應(yīng)的比較研究目前尚較少，需要加強(qiáng)研究；③缺乏殘疾狀態(tài)的腦卒中患者心血管康復(fù)研究，目前缺少在殘疾狀態(tài)下腦卒中患者進(jìn)行心血管康復(fù)訓(xùn)練的研究，這個(gè)階段的心血管康復(fù)訓(xùn)練不僅可以降低患者殘疾程度，提高其日常生活活動(dòng)能力，而且對(duì)腦卒中的二級(jí)預(yù)防有著積極意義，應(yīng)該大力引導(dǎo)與推廣；④需要進(jìn)一步深入研究腦卒中心血管康復(fù)的機(jī)制，目前關(guān)于腦卒中心血管康復(fù)的機(jī)制研究很不充分，腦卒中患者心血管康復(fù)的分子生物學(xué)機(jī)制有待探討，外周肌肉組織特性的改善對(duì)心腦血管疾病有無(wú)改善效應(yīng)等等尚待進(jìn)一步研究證實(shí)；⑤缺乏統(tǒng)一質(zhì)量控制的培訓(xùn)，在CPET實(shí)施過(guò)程中，雖然增補(bǔ)了代謝模擬器，但沒(méi)有設(shè)立核心實(shí)驗(yàn)室對(duì)所有數(shù)據(jù)進(jìn)行二次分析認(rèn)證，各實(shí)驗(yàn)室用自己的CPET系統(tǒng)軟件分析數(shù)據(jù)、報(bào)告結(jié)果，缺乏標(biāo)準(zhǔn)統(tǒng)一的規(guī)范化CPET操作及實(shí)驗(yàn)數(shù)據(jù)的分析與判讀。建議進(jìn)行多中心臨床研究時(shí)，行CPET前必須由專門(mén)設(shè)立的核心實(shí)驗(yàn)室對(duì)實(shí)驗(yàn)室和系統(tǒng)進(jìn)行質(zhì)量認(rèn)證。

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(本文編輯：洪悅民)

·述評(píng)·

【摘要】腦卒中是一種由多種血管性危險(xiǎn)因素引起的臨床綜合征，患者常因肢體活動(dòng)障礙而需長(zhǎng)時(shí)間臥床，日?；顒?dòng)受限，增加了其心血管病發(fā)生的風(fēng)險(xiǎn)。同時(shí)，大部分腦卒中患者合并有心血管疾病，多數(shù)表現(xiàn)為心功能不全或無(wú)癥狀心功能不全。因此，腦卒中的心血管康復(fù)是康復(fù)治療中不可忽視的重要部分，對(duì)腦卒中患者進(jìn)行包括靜息心電圖、心臟彩色多普勒超聲檢查、運(yùn)動(dòng)負(fù)荷心電圖、心肺運(yùn)動(dòng)試驗(yàn)、定距離測(cè)定(6 min步行試驗(yàn)、10 m步行試驗(yàn))等心功能評(píng)估，按照安全有效的運(yùn)動(dòng)處方進(jìn)行規(guī)范的心血管康復(fù)治療，有助于改善腦卒中患者的預(yù)后及預(yù)防其復(fù)發(fā)。

【關(guān)鍵詞】腦卒中; 心血管康復(fù); 心肺運(yùn)動(dòng)試驗(yàn); 運(yùn)動(dòng)負(fù)荷試驗(yàn); 運(yùn)動(dòng)治療

Current state and progress of cardiovascular diseases in patients with strokeFengHui,PanHuaping.DepartmentofRehabilitationMedicine,NanjingJiangningHospitalaffiliatedtoNanjingMedicalUniversity,Nanjing211100，China

Correspondingauthor，PanHuaping，E-mail：panhp007@hotmail.com

【Abstract】Stroke is a clinical syndrome caused by a variety of vascular risk factors. Patients with stroke have to rest in bed due to physical activity barriers, which limit their daily activity and increase the risk of cardiovascular diseases. Meantime, a majority of stroke patients are complicated with cardiovascular diseases, mainly manifested with cardiac insufficiency or asymptomatic cardiac insufficiency. Therefore, rehabilitation of cardiovascular diseases is an essential part of rehabilitation therapy for patients diagnosed with stroke. It is necessary to perform resting electrocardiogram, cardiac color doppler ultrasound, exercise load electrocardiogram, exercise cardiopulmonary test, fixed-distance walking test (6-minute or 10-meter walking test) and alternative cardiac function evaluation for stroke patients. Standard rehabilitation therapy of cardiovascular diseases should be delivered according to safe and effective prescription, which contributes to improving clinical prognosis and preventing stroke recurrence.

【Key words】Stroke; Rehabilitation of cardiovascular disease; Cardiopulmonary exercise testing;

收稿日期：(2015-10-19)

通訊作者，潘化平，E-mail：panhp007@hotmail.com 簡(jiǎn)介：潘化平，博士，主任醫(yī)師，副教授，碩士研究生導(dǎo)師，南京醫(yī)科大學(xué)附屬江寧醫(yī)院康復(fù)醫(yī)學(xué)科主任。曾是德國(guó)Fachklinik Ichenhausen康復(fù)醫(yī)院訪問(wèn)學(xué)者，從事康復(fù)醫(yī)學(xué)醫(yī)療、教學(xué)和科研工作20余年，在治療復(fù)雜腦卒中、高位脊髓損傷、多發(fā)性骨折以及難治性慢性疼痛等方面有較為豐富的臨床經(jīng)驗(yàn)。目前主要從事心腦血管疾病、糖尿病、慢性呼吸系統(tǒng)疾病的臨床康復(fù)工作。研究方向?yàn)檫\(yùn)動(dòng)系統(tǒng)疾病的基礎(chǔ)研究與臨床康復(fù)。主持和參與國(guó)家及省部級(jí)基金課題7項(xiàng)，發(fā)表論文30余篇。

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