急性心肌梗死患者早期运动康复干预的临床研究
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摘要
目的探讨早期个体化运动康复对早期血管开通的ST段抬高型心肌梗死(ST segment elevation myocardial infarction,STEMI)患者左室重构及左室功能的影响,随访其心血管不良事件发生情况。方法选取2016年1月至2016年12月在本院急诊内科住院并于12 h内开通血管的STEMI患者63例为研究对象,按照梗死部位均一化将其分为康复组(33例)和对照组(30例)。康复组患者根据运动处方,利用功率自行车进行有氧康复训练;对照组患者不予运动处方,自行控制活动量。观察两组患者治疗前及治疗后1个月、3个月B型脑钠肽前体(pro-B-type natriuretic peptide,pro-BNP)、超敏C反应蛋白(hypersensitive C-reactiveprotein,hs-CRP)、醛固酮(aldosterone,ALD)、血管紧张素Ⅱ(angiotensinⅡ,AngⅡ)、射血分数(ejection fraction,EF)、左室舒张末期内径(left ventricular end-diastolic diameter,LVEDD)变化。随访6个月,比较两组患者心血管不良事件发生情况。结果治疗前两组患者hs-CRP、ALD、AngⅡ、pro-BNP水平均高于正常值,但差异均无显著性(P_均> 0.05)。治疗后1个月,两组患者hs-CRP、AngⅡ、pro-BNP水平比较差异均无显著性(P_均> 0.05),康复组患者ALD水平显著低于对照组(Z=-1.992,P=0.046)。治疗后3个月,康复组患者hs-CRP、ALD、AngⅡ、pro-BNP水平显著低于对照组(P_均<0.05)。治疗前、治疗后1个月,两组患者EF、LVEDD比较差异均无显著性(P_均> 0.05);治疗后3个月,康复组患者EF显著高于对照组(t=2.836,P=0.007),但两组患者LVEDD比较差异无显著性(P> 0.05)。随访6个月,对照组有1例患者因心力衰竭再住院,两组均无再梗死及死亡患者。结论 STEMI患者采取早期个体化康复运动训练可以降低肾素-血管紧张素-醛固酮系统活性,抑制心肌重塑,改善心功能,且不增加心血管不良事件,安全可行。
Objective To investigate the effects of early individualized exercise rehabilitation on left ventricular remodeling and left ventricular function in patients with ST-segment elevation myocardial infarction(STEMI) with early vascular access, and followup of cardiovascular adverse events. Method 63 patients with STEMI who underwent vascular access within 12 hours from January 2016 to December 2016 were enrolled in the emergency department of our hospital. They were divided into rehabilitation group(33 cases) and control group(30 cases) according to infarct site homogenization. Patients in rehabilitation group received aerobic rehabilitation training with power bicycle according to the exercise prescription. Patients in control group controlled the amount of activity by themselves. Pro-B-type natriuretic peptide(pro-BNP), hypersensitive C-reactive protein(hs-CRP), aldosterone(ALD), angiotensin Ⅱ(AngⅡ), ejection fraction(EF), and left ventricular end-diastolic diameter(LVEDD) were observed before treatment, 1 month, and 3 months after treatment. The patients were followed up for 6 months to compare the incidence of cardiovascular adverse events between the two groups. Result Before treatment, hs-CRP, ALD, Ang Ⅱ, pro-BNP levels of the two groups were higher than normal, but there were no significant differences(P_(all)> 0.05). At 1 month after treatment, there were no significant differences in hsCRP, Ang Ⅱ, and pro-BNP levels between the two groups(P_(all)> 0.05), but ALD level in rehabilitation group was significantly lower than that in control group(Z =-1.992, P = 0.046). The levels of hs-CRP, ALD, AngⅡ and pro-BNP in rehabilitation group were significantly lower than those in control group at 3 months after treatment(P_(all)< 0.05). There were no significant differences in EF and LVEDD between the two groups before and 1 month after treatment(P_(all)> 0.05). The EF of rehabilitation group was significantly higher than that of control group at 3 months after treatment(t = 2.836, P = 0.007), but the difference of LVEDD between the two groups was not significant(P > 0.05). After 6 months of follow-up, 1 patient in control group was re-hospitalized due to heart failure. There were no reinfarction patients and death patients in the two groups. Conclusion Early individualized rehabilitation exercise program in patients with STEMI can reduce the activity of renin-angiotensin-aldosterone system, inhibit myocardial remodeling, improve cardiac function, and not increase cardiovascular adverse events.
Objective To investigate the effects of early individualized exercise rehabilitation on left ventricular remodeling and left ventricular function in patients with ST-segment elevation myocardial infarction(STEMI) with early vascular access, and followup of cardiovascular adverse events. Method 63 patients with STEMI who underwent vascular access within 12 hours from January 2016 to December 2016 were enrolled in the emergency department of our hospital. They were divided into rehabilitation group(33 cases) and control group(30 cases) according to infarct site homogenization. Patients in rehabilitation group received aerobic rehabilitation training with power bicycle according to the exercise prescription. Patients in control group controlled the amount of activity by themselves. Pro-B-type natriuretic peptide(pro-BNP), hypersensitive C-reactive protein(hs-CRP), aldosterone(ALD), angiotensin Ⅱ(AngⅡ), ejection fraction(EF), and left ventricular end-diastolic diameter(LVEDD) were observed before treatment, 1 month, and 3 months after treatment. The patients were followed up for 6 months to compare the incidence of cardiovascular adverse events between the two groups. Result Before treatment, hs-CRP, ALD, Ang Ⅱ, pro-BNP levels of the two groups were higher than normal, but there were no significant differences(P_(all)> 0.05). At 1 month after treatment, there were no significant differences in hsCRP, Ang Ⅱ, and pro-BNP levels between the two groups(P_(all)> 0.05), but ALD level in rehabilitation group was significantly lower than that in control group(Z =-1.992, P = 0.046). The levels of hs-CRP, ALD, AngⅡ and pro-BNP in rehabilitation group were significantly lower than those in control group at 3 months after treatment(P_(all)< 0.05). There were no significant differences in EF and LVEDD between the two groups before and 1 month after treatment(P_(all)> 0.05). The EF of rehabilitation group was significantly higher than that of control group at 3 months after treatment(t = 2.836, P = 0.007), but the difference of LVEDD between the two groups was not significant(P > 0.05). After 6 months of follow-up, 1 patient in control group was re-hospitalized due to heart failure. There were no reinfarction patients and death patients in the two groups. Conclusion Early individualized rehabilitation exercise program in patients with STEMI can reduce the activity of renin-angiotensin-aldosterone system, inhibit myocardial remodeling, improve cardiac function, and not increase cardiovascular adverse events.
引文
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[10]D'Andrea A,Formisano T,Riegler L,et al.Acute and chronic resp onse to exercise in athletes:the"supernormal heart"[J].Adv Exp Med Biol,2017,999:21-41.
[11]杨絮飞,张抒扬.从临床治疗到心脏康复:全程化关注[J].中国医刊,2015,50(12):5-6.
[12]Kones R.The Jupiter study,CRP screening,and aggressive statin therapy-implications for the primary prevention of cardiovascular disease[J].Ther Adv Cardiovasc Dis,2009,3(4):309-315.
[13]Kim C,Kim DY,Moon CJ.Prognostic influences of cardiac rehabilitation in korean acute myocardial infarction patients[J].Ann Rehabil Med,2011,35(3):375-380.
[14]Frangogiannis NG.Pathophysiology of myocardial infarction[J].Compr Physiol,2015,5(4):1841-1875.
[15]Husain K,Hernandez W,Ansari RA,et al.Inflammation,oxidative stress and renin angiotensin system in atherosclerosis[J].World J Biol Chem,2015,6(3):209-217.
[16]Van Belle E,Susen S,Mouquet F,et al.Aldosterone a major deter minant of long term mortality in elective PCI[J].Circul ation,2007,116(5):701-703.
[17]Higaki J,Aoki M,Morishita R,et al.In vivo evidence of the impor tance of cardiac angiotensin-converting enzyme in the patho genesis of cardiac hypertrophy[J].Arterioscler Thromb Vasc Biol,2000,20(2):428-434.
[18]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 SPECTimaging study[J].Eur J Prev Cardiol,2012,19(6):1410-1419.
[19]Perkiomaki JS,Hamekoski S,Junttila MJ,et al.Predictors of long-term risk for heart failure hospitalization after acute myocardial infarction[J].Ann Noninvasive Electrocradiol,2010,15(3):250-258.
[20]Gravning J,Smedsrud MK,Omland T,et al.Sensitive troponin assays and N-terminal pro-B-type natriuretic peptide in acute coronary syndrome:prediction of significant coronary lesions and long-term prognosis[J].Am Heart J,2013,165(5):716-724.
[2]Ribeiro PAB,Boidin M,Juneau M,et al.High-intensity interval training in patients with coronary heart disease:Prescription models and perspectives[J].Ann Phys Rehabil Med,2017,60(1):50-57.
[3]Gayda M,Ribeiro PA,Juneau M,et al.Comparison of different forms of exercise training in patients with cardiac disease:where does high-intensity interval training fit?[J].Can JCardiol,2016,32(4):485-494.
[4]白瑾,张永珍.心肌梗死心脏康复的循证医学证据[J].中国医学前沿杂志(电子版),2013,5(9):8-10.
[5]程文飞,董少红.心脏康复运动对梗死后心室重构的影响[J].中国医学前沿杂志(电子版),2016,8(8):3-6.
[6]Rivas-Estany E,Sixto-Fernández S,Barrera-Sarduy J,et al.Effects of long-term exercise training on left ventricular function and remodeling in patients with anterior wall myocardial infarction[J].Arch Cardiol Mex,2013,83(3):167-173.
[7]Hedb?ck B,Perk J,Wodlin P.Long-term reduction of cardiac mortality after myocadial infarction:10-year results of a comprehensive rehabilitation programme[J].Eur Heart J,1993,14(6):831-835.
[8]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.
[9]Taylor RS,Brown A,Ebrahim S,et al.Exercise-based rehabilitation for patients with coronary heart disease:system atic review and meta-analysis of randomized controlled trials[J].Am J Med,2004,116(10):682-692.
[10]D'Andrea A,Formisano T,Riegler L,et al.Acute and chronic resp onse to exercise in athletes:the"supernormal heart"[J].Adv Exp Med Biol,2017,999:21-41.
[11]杨絮飞,张抒扬.从临床治疗到心脏康复:全程化关注[J].中国医刊,2015,50(12):5-6.
[12]Kones R.The Jupiter study,CRP screening,and aggressive statin therapy-implications for the primary prevention of cardiovascular disease[J].Ther Adv Cardiovasc Dis,2009,3(4):309-315.
[13]Kim C,Kim DY,Moon CJ.Prognostic influences of cardiac rehabilitation in korean acute myocardial infarction patients[J].Ann Rehabil Med,2011,35(3):375-380.
[14]Frangogiannis NG.Pathophysiology of myocardial infarction[J].Compr Physiol,2015,5(4):1841-1875.
[15]Husain K,Hernandez W,Ansari RA,et al.Inflammation,oxidative stress and renin angiotensin system in atherosclerosis[J].World J Biol Chem,2015,6(3):209-217.
[16]Van Belle E,Susen S,Mouquet F,et al.Aldosterone a major deter minant of long term mortality in elective PCI[J].Circul ation,2007,116(5):701-703.
[17]Higaki J,Aoki M,Morishita R,et al.In vivo evidence of the impor tance of cardiac angiotensin-converting enzyme in the patho genesis of cardiac hypertrophy[J].Arterioscler Thromb Vasc Biol,2000,20(2):428-434.
[18]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 SPECTimaging study[J].Eur J Prev Cardiol,2012,19(6):1410-1419.
[19]Perkiomaki JS,Hamekoski S,Junttila MJ,et al.Predictors of long-term risk for heart failure hospitalization after acute myocardial infarction[J].Ann Noninvasive Electrocradiol,2010,15(3):250-258.
[20]Gravning J,Smedsrud MK,Omland T,et al.Sensitive troponin assays and N-terminal pro-B-type natriuretic peptide in acute coronary syndrome:prediction of significant coronary lesions and long-term prognosis[J].Am Heart J,2013,165(5):716-724.