心梗后心脏康复治疗

1、1.改善患者生活质量功能评估功能评估心理干预心理干预危险因素危险因素矫正矫正营养指导营养指导随访随访运动处方运动处方不运动的不利影响Age糖尿病肥胖Genetics动脉硬化HypercoagulabilitySmoking高血压Novel Risk Factors炎症血脂异常缺少运动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中等度的运动减少肥胖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:运动对血脂的影响Hu FB et al. JAMA 2003;289:1785-91Nurses Health Study运动降低肥胖和糖尿病的发生率Exercise Evidence:运动对肥胖和糖尿病的影响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:运动对冠心病的影响 Wannamethee SG et al. Circulation 2000;102:1358-1363CHD=Coronary heart disease, CVD=Cardiovascular disease中等度的运动降低冠心病患者的死亡率Observational study of self-reported physical activity in 772 men with CHDPhysical Activity:运动对冠心病患者预后的影响 * Effect of cardiac rehabilitation in randomized

7、 controlled trials following a MIOldridge NB et al. JAMA 1988;260:945-950 *p0.0125心脏康复:运动对心梗后患者的影响运动/心脏康复可以降低心梗后患者的死亡和事件发生率CV=CardiovascularMETA分析提示心脏康复治疗使心梗后死亡率降低20%Circulation, 1989左图为未参加康复患者，右图为参加康复患者，图中虚线表示预期生存率，实线表示实际生存率。可见左图中患者实际生存率与预期生存率有显著性差异，而右图两者没有显著性差异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心脏康复:二级预防的益处降低CV事件All cause mortalityRecurrent myocardial infarction心脏康复有利于降低心血管事件的发生率CV=Cardiovascular康复治疗能够显著改善患者的抑郁和低落情绪。图中显示的是研究人群中参加康复治疗前后表现出抑郁和

9、低落的患者比例The American Journal of Medicine, 2007The American Journal of Medicine, 2007接受康复治疗抑郁改善的患者死亡率明显降低心梗患者进行康复治疗前的全面评估心梗患者进行康复治疗的危险分层Cardiology Journal, 2008两种运动试验的终点指标Cardiology Journal, 2008活动项目kJ/minKcal/mmMETs1. 家务活动整理床铺7.24.13.4穿衣8.82.11.8沐浴8.82.11.8简单地清洁房间11.31.82.3治疗性活动轻木工活，磨砂板，抛光，纺织篮筐12.63.

10、02.5轻度机械性活动11.72.82.32. 步行2km/h,3km/d9.62.31.93.5km/h远足11.72.82.35.0km/h远足15.93.83.23. 园艺劳动用水桶浇水10.02.42.0挖掘7.51.81.5耙地8.82.11.8种花、种菜10.52.52.1n大大提高了运动平板试验的安全性n评估最大摄氧量VO2max/kgn评估无氧阈ATn评估心脏每搏射血量O2Plusn科学指导心脏康复训练是目前心肺运动功能评估最精确的检查指标心肺运动试验心功能评估标准BRUCE方案下VO2和METs的相对关系Circulation, 2013指南推荐运动强度为12-13级。如患者对运动耐受较好且无并发症，可进行强度14-16级的运动中等强度的运动频率为每周5-7次，每次30min（2000-3500千卡/周）康复运动期间需要严密监测患者血压、心率、自觉症状及心电图变化Circulation, 20126. 疗，维持患者良好的精神和生理状态，降低冠心病危险因素及指导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疗介入或非介入治疗重症监护治疗重症监护治疗无并发症心梗无并发症心梗有并发症心梗有并发症心梗院内院内2-3天天院内院内4-7天天院内院内5-7天天院内院内10-14天天阶段I开始 运动试验 风险评估门诊随访门诊随访住院患者住院