王融 王學(xué)磊
【摘要】 目的:探討利用心肺運(yùn)動(dòng)試驗(yàn)(Cardiopulmonary Exercise Testing, CPX)制定無氧域強(qiáng)度運(yùn)動(dòng)處方進(jìn)行的家庭心臟康復(fù)對(duì)經(jīng)皮冠狀動(dòng)脈介入治療(PCI)術(shù)后抑郁患者心理狀態(tài)及心肺功能影響的臨床研究。方法:選取2017年6月-2020年6月在本院心臟康復(fù)科門診就診的PCI術(shù)后抑郁患者60例。按照患者意愿和隨機(jī)原則將其分為對(duì)照組和運(yùn)動(dòng)組,每組30例。對(duì)照組進(jìn)行除運(yùn)動(dòng)處方治療之外的常規(guī)心臟康復(fù)指導(dǎo),運(yùn)動(dòng)組在對(duì)照組基礎(chǔ)上執(zhí)行CPX制定無氧域強(qiáng)度的運(yùn)動(dòng)處方進(jìn)行12周步行運(yùn)動(dòng)。治療前后分別進(jìn)行SDS測(cè)定和CPX檢查,比較相關(guān)指標(biāo)變化。結(jié)果:進(jìn)行12周心臟康復(fù)后,運(yùn)動(dòng)組患者最大通氣量(MVV)、無氧閾氧耗量(VO2AT)、峰值攝氧量(VO2峰值)、無氧域心率(HRAT)和最大負(fù)荷(PeakWR)均較運(yùn)動(dòng)前明顯增高,SDS評(píng)分明顯降低,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。對(duì)照組MVV、VO2AT、VO2峰值、HRAT和PeakWR均較治療前有所增高,SDS評(píng)分較治療前降低,但差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。12周后與對(duì)照組相比,運(yùn)動(dòng)組MVV、VO2AT、VO2峰值、HRAT、PeakWR均增加,SDS評(píng)分降低,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論:以運(yùn)動(dòng)為核心的家庭心臟康復(fù)顯著改善PCI術(shù)后抑郁患者心理狀態(tài)和心肺功能。無氧域強(qiáng)度運(yùn)動(dòng)處方安全有效,值得廣泛推廣。
【關(guān)鍵詞】 家庭心臟康復(fù) 無氧域 經(jīng)皮冠狀動(dòng)脈介入治療 抑郁 心肺功能
[Abstract] Objective: To explore the clinical study on the effect of home-based cardiac rehabilitation with Exercise prescription of anaerobic zone intensity by using Cardiopulmonary Exercise Testing (CPX) on the psychological state and cardiopulmonary function of depressed patients after percutaneous coronary intervention (PCI). Method: A total of 60 patients with post-PCI depression who were admitted to the outpatient department of cardiac rehabilitation of our hospital from June 2017 to June 2020 were selected. Patients were divided into control group and exercise group according to their will and random principle, 30 cases in each group. The control group received routine cardiac rehabilitation guidance except exercise prescription treatment, and the exercise group performed CPX on the basis of the control group to develop exercise prescription without oxygen domain intensity for 12 weeks of walking exercise. SDS and CPX tests were performed before and after treatment, the changes of related indicators were compared. Result: After 12 weeks of cardiac rehabilitation, the maximum volume of gas (MVV), anaerobic threshold oxygen consumption (VO2AT), peak oxygen uptake (VO2peak), heart rate in the anaerobic domain (HRAT) and maximum load (PeakWR) in the exercise group were significantly higher than those before exercise, and the SDS score was significantly lower, with statistical significance (P<0.05). In the control group, MVV, VO2AT, VO2peak, HRAT and PeakWR were increased compared with before treatment, and SDS score was decreased compared with before treatment, but the differences were not statistically significant (P>0.05). After 12 weeks, compared with the control group, MVV, VO2AT, VO2peak, HRAT and PeakWR in the exercise group were increased, and SDS score was decreased, with statistical significance (P<0.05). Conclusion: Home-based cardiac rehabilitation centered on exercise can significantly improve the mental state and cardiopulmonary function of depressed patients after PCI. The prescription of anaerobic intensity exercise is safe and effective and worthy of widespread promotion.
[Key words] Home-based cardiac rehabilitation Anaerobic zone Percutaneous coronary intervention Depression Cardiopulmonary function
First-authors address: Bayannur Hospital, Bayannur 015000, China
doi:10.3969/j.issn.1674-4985.2021.06.043
經(jīng)皮冠狀動(dòng)脈介入(PCI)是冠心病的常用治療方法,其在顯著降低急性心肌梗死致殘率及致死率的同時(shí),常導(dǎo)致患者產(chǎn)生焦慮、抑郁等心理應(yīng)激反應(yīng)[1]。研究證明,運(yùn)動(dòng)為核心的心臟康復(fù)可顯著改善PCI術(shù)后患者心理狀態(tài)及心肺功能[2-3]。500多家心臟康復(fù)中心已在國內(nèi)醫(yī)院成立,但參與心臟康復(fù)的患者呈現(xiàn)出較低的參與性和依從性。家庭心臟康復(fù)(home-based cardiac rehabilitation, HBCR)可顯著提高患者參與性和依從性,已被澳大利亞、加拿大、英國等多國納入國家衛(wèi)生保健體系之中[4]。如何提高HBCR安全性及監(jiān)測(cè)其有效性是需要密切關(guān)注的問題。本研究旨在通過心肺運(yùn)動(dòng)試驗(yàn)(cardiopulmonary exercise testing, CPX)制定無氧域強(qiáng)度運(yùn)動(dòng)處方,指導(dǎo)PCI術(shù)后抑郁患者行HBCR,觀察其對(duì)患者心理狀態(tài)及心肺功能的影響?,F(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料 選取2017年6月-2020年6月在本院心臟康復(fù)科門診就診的PCI術(shù)后抑郁患者60例。(1)納入標(biāo)準(zhǔn):①均行PCI;②符合2013年美國心臟協(xié)會(huì)發(fā)表的運(yùn)動(dòng)試驗(yàn)及訓(xùn)練標(biāo)準(zhǔn)(exercise standards for testing and training)[5],病情穩(wěn)定情況下能且愿意接受心臟康復(fù);③采用抑郁心理障礙診斷標(biāo)準(zhǔn),抑郁自評(píng)量表(SDS)評(píng)分≥53分且焦慮自評(píng)量表(SAS)評(píng)分<50分;④病情穩(wěn)定,無心功能異常的低危冠心病。(2)排除標(biāo)準(zhǔn):急性冠脈綜合征;各種導(dǎo)致血流動(dòng)力學(xué)不穩(wěn)定疾病;慢性阻塞性肺疾病;惡性腫瘤、血液系統(tǒng)疾病、嚴(yán)重肝腎功能不全;體重指數(shù)(BMI)>35 kg/m2;年齡>75歲;血鉀水平異常;語言交流、聽力障礙、精神異常等影響溝通;運(yùn)動(dòng)障礙。分組前評(píng)估PCI術(shù)后患者抑郁焦慮情況,最終納入符合標(biāo)準(zhǔn)的患者60例,按照患者意愿和隨機(jī)原則將其分為對(duì)照組和運(yùn)動(dòng)組,每組30例。本次研究均經(jīng)過患者及其家屬的同意,且通過巴彥淖爾市醫(yī)院倫理委員會(huì)批準(zhǔn)。
1.2 方法
1.2.1 對(duì)照組 綜合評(píng)估患者一般情況后,進(jìn)行健康知識(shí)教育,合理飲食建議,心理情緒干預(yù)、糾正不良行為和冠心病二級(jí)預(yù)防藥物等常規(guī)治療。
1.2.2 運(yùn)動(dòng)組 HBCR定義為系統(tǒng)化、全面綜合和個(gè)性化量身定制的醫(yī)療服務(wù),包含大部分或完全提供傳統(tǒng)心臟康復(fù)的醫(yī)療評(píng)估、運(yùn)動(dòng)處方、心血管疾病危險(xiǎn)因素改善、患者教育和行為激活/咨詢。運(yùn)動(dòng)組在對(duì)照組治療基礎(chǔ)上執(zhí)行CPX制定無氧域強(qiáng)度的運(yùn)動(dòng)處方。根據(jù)CPX測(cè)定AT結(jié)果算出靶心率,并制定精準(zhǔn)的個(gè)體化的運(yùn)動(dòng)處方。本研究以(HRAT-10)bmp為靶心率,且Borg主觀疲勞度量表評(píng)分11~13級(jí),增加運(yùn)動(dòng)安全性。運(yùn)動(dòng)頻率為每周5天,共12周。運(yùn)動(dòng)時(shí)間為30~50 min,過程分為準(zhǔn)備熱身期(5~10 min)、運(yùn)動(dòng)期(20~30 min)和恢復(fù)期(5~10 min)。初期配合美國偉倫Welch Allyn遠(yuǎn)程心電遙測(cè)院內(nèi)步行3次,保證了運(yùn)動(dòng)的安全性。鼓勵(lì)患者盡可能一次完成,但不是必須。
1.2.3 運(yùn)動(dòng)監(jiān)護(hù)和注意事項(xiàng) 知情同意書必須由患者本人在運(yùn)動(dòng)前簽署,充分告知運(yùn)動(dòng)風(fēng)險(xiǎn),患者自主決定參與運(yùn)動(dòng)。運(yùn)動(dòng)組患者前3次治療在醫(yī)院心臟康復(fù)中心進(jìn)行,全程采用美國偉倫Welch Allyn遠(yuǎn)程心電遙測(cè)。運(yùn)動(dòng)過程中無胸痛、面色蒼白、頭暈、乏力、胸悶氣短等不適癥狀出現(xiàn)者方可實(shí)行運(yùn)動(dòng)處方治療。家庭中統(tǒng)一配備急救藥品,運(yùn)動(dòng)前統(tǒng)一進(jìn)行患者疾病癥狀和安全性教育。治療中,采用電話、微信、遠(yuǎn)程監(jiān)護(hù)、家訪等不同措施保證運(yùn)動(dòng)安全及有效。
1.3 觀察指標(biāo)及判定標(biāo)準(zhǔn)
1.3.1 抑郁評(píng)定標(biāo)準(zhǔn) 對(duì)冠心病PCI術(shù)后患者進(jìn)行調(diào)查。所有量表評(píng)估均由經(jīng)過培訓(xùn)的心理??漆t(yī)師完成,兩組治療前后分別進(jìn)行一次SDS評(píng)分。采用William W.K. Zung編制的SDS量表進(jìn)行有效評(píng)估,量表包含20個(gè)項(xiàng)目,每項(xiàng)根據(jù)自身情況進(jìn)行打分,1分表示沒有或者偶爾有,2分表示一小部分時(shí)間有,3分表示相當(dāng)多時(shí)間有,4分表示絕大部分時(shí)間或者一直有。
1.3.2 心肺運(yùn)動(dòng)試驗(yàn) 簽署知情同意書的患者采用瑞士SCHILLER公司CARDIOVIT CS-200型心肺運(yùn)動(dòng)測(cè)試訓(xùn)練系統(tǒng),進(jìn)行癥狀限制性運(yùn)動(dòng)試驗(yàn)評(píng)估。無氧閾(anaerobicthreshold, AT)采用V-slope法測(cè)得,監(jiān)測(cè)指標(biāo)包括MVV、VO2AT、VO2峰值、HRAT和PeakWR。12周康復(fù)結(jié)束后復(fù)測(cè)上述指標(biāo)。
1.4 統(tǒng)計(jì)學(xué)處理 采用SPSS 17.0軟件對(duì)所得數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料用(x±s)表示,組間比較采用t檢驗(yàn),組內(nèi)比較采用配對(duì)t檢驗(yàn);計(jì)數(shù)資料以率(%)表示,比較采用字2檢驗(yàn)。以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組基本資料比較 12周治療結(jié)束后,共有3例患者退出試驗(yàn),運(yùn)動(dòng)組2例(不能堅(jiān)持運(yùn)動(dòng)),對(duì)照組1例(失去聯(lián)系)。運(yùn)動(dòng)組患者運(yùn)動(dòng)過程中未出現(xiàn)心血管事件,無肌肉、骨關(guān)節(jié)等運(yùn)動(dòng)系統(tǒng)的損傷。兩組性別、年齡、BMI比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性,見表1。
2.2 兩組治療前后SDS評(píng)分情況比較 運(yùn)動(dòng)組治療12周后SDS評(píng)分顯著低于治療前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),對(duì)照組SDS評(píng)分略低于治療前,但差異無統(tǒng)計(jì)學(xué)意義(P>0.05),見表2。
2.3 兩組治療前后CPX指標(biāo)比較 與治療前比較,治療后運(yùn)動(dòng)組MVV、VO2AT、VO2峰值、HRAT、PeakWR均升高(P<0.05),對(duì)照組上述指標(biāo)均無顯著變化(P>0.05);運(yùn)動(dòng)組治療后的MVV、VO2AT、VO2峰值、HRAT、PeakWR均高于對(duì)照組(P<0.05)。見表3。
3 討論
2018中國心血管病報(bào)告顯示我國冠心病患者1100萬[6],PCI是國內(nèi)推薦的治療方式,手術(shù)患者逐年增多,但是PCI術(shù)不能緩解冠狀動(dòng)脈粥樣硬化的生物學(xué)進(jìn)程、消除冠心病的危險(xiǎn)因素,患者術(shù)后依然面臨焦慮抑郁、運(yùn)動(dòng)耐量下降、支架內(nèi)再狹窄等問題[7-8]。據(jù)meta分析,降低冠心病患者心源性死亡率和總死亡率必須是以運(yùn)動(dòng)為基礎(chǔ)的心臟康復(fù)。研究表明,HBCR可改善PCI術(shù)后患者心理狀態(tài)和生存質(zhì)量,改善慢性心力衰竭患者心肺功能、運(yùn)動(dòng)耐力,值得大力推廣[9-10]。本研究證實(shí),步行鍛煉為核心的HBCR可顯著改善PCI術(shù)后患者心理狀態(tài)和心肺功能,與文獻(xiàn)[11-12]報(bào)道結(jié)果一致。
心肺功能提高、血管內(nèi)皮功能改善、動(dòng)脈粥樣硬化發(fā)展進(jìn)程延緩、心肌重塑減少、血栓栓塞風(fēng)險(xiǎn)降低、心肌缺血改善、猝死風(fēng)險(xiǎn)降低,是冠心病病人通過運(yùn)動(dòng)康復(fù)的獲益[3]。研究表明對(duì)抑郁癥有效的運(yùn)動(dòng)處方是每周3次以上、中等強(qiáng)度、至少持續(xù)9周的有監(jiān)督的有氧運(yùn)動(dòng)[13]。運(yùn)動(dòng)量增加可使心血管患者的康復(fù)獲益增大,但運(yùn)動(dòng)量過大存在風(fēng)險(xiǎn)[14]。高于AT強(qiáng)度水平的運(yùn)動(dòng)激活交感神經(jīng),抑制副交感神經(jīng)活性,激活無氧糖酵解供能,產(chǎn)生乳酸堆積,導(dǎo)致代謝性酸中毒,電解質(zhì)酸堿失衡,惡性心律失常和心血管事件風(fēng)險(xiǎn)增加[15]。
對(duì)于冠心病患者,AT強(qiáng)度的運(yùn)動(dòng)訓(xùn)練是安全和有效的,且AT值是客觀的,無關(guān)于患者主觀用力程度,尤其適于高風(fēng)險(xiǎn)人群[16]。HBCR首要考慮的問題是安全性,本研究采用CPX制定無氧域強(qiáng)度的運(yùn)動(dòng)處方,保證了運(yùn)動(dòng)的安全性。心血管疾病運(yùn)動(dòng)處方制定由CPX測(cè)得的AT、VO2峰值、峰值心率、Borg主觀疲勞度分級(jí)評(píng)分為依據(jù)[17]。12周運(yùn)動(dòng)后與對(duì)照組相比,運(yùn)動(dòng)組MVV、VO2AT、VO2峰值、HRAT、PeakWR均明顯增加,SDS評(píng)分降低,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05),提示規(guī)律進(jìn)行AT強(qiáng)度運(yùn)動(dòng)康復(fù)對(duì)患者心理狀態(tài)和心肺功能改善優(yōu)于對(duì)照組患者。運(yùn)動(dòng)組患者運(yùn)動(dòng)無不良事件發(fā)生,提示無氧閾強(qiáng)度運(yùn)動(dòng)康復(fù)方式安全、有效。目前的證據(jù)表明,HBCR可以節(jié)省時(shí)間、金錢、精力和資源,可能會(huì)受到患者的青睞[18],并且其應(yīng)用可能具有很高的成本效益[19]。這與本研究結(jié)果一致。
規(guī)律運(yùn)動(dòng)康復(fù)可對(duì)冠心病PCI術(shù)后抑郁患者心理狀態(tài)和心肺功能產(chǎn)生良好的改善作用。無氧閾強(qiáng)度運(yùn)動(dòng)處方進(jìn)行家庭心臟康復(fù)安全有效。所以,PCI術(shù)后合并抑郁患者應(yīng)進(jìn)行規(guī)律無氧閾強(qiáng)度運(yùn)動(dòng)為核心的HBCR,改善患者心理狀態(tài)和心肺功能。
參考文獻(xiàn)
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(收稿日期:2020-12-25) (本文編輯:姬思雨)