解读与评论2010年欧洲心血管预防和康复协会心脏康复分会关于二级预防中心脏康复的意见(以下简称《意见》)

Interpretation and comment on secondary prevention through cardiac rehabilitation:from knowledge to implementation.A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation in 2010

《意见》充分肯定了心脏康复(CR)在心血管病人及伴发病糖尿病,慢性阻塞性肺疾病等的作用,承袭了2004年美国心肺康复学会的心脏康复和二级预防指南第4版[以下简称《美国心脏康复指南》]的传统,首先论述了所有心血管病人CR的要素(核心成份)和通常目标(很全面),继而介绍了特定病情和人群的心脏康复,并有新的发展,比如制定了PCI后康复程序,经常提到抗阻力运动,有新的血脂调整的目标等。不同点:(1)是《美国心脏康复指南》是一本书,正文205页,而《意见》是一文件,正文仅16页,这就决定了二者结构的不同:《美国心脏康复指南》的CR程序,主要的用表格显示,辅以正文叙述,特定病情和人群的心脏康复程序大都是用正文表达,辅以简短表格,有的甚至没有表格,而《意见》几乎都是用表格显示,所以《意见》的优点是扼要、集中,便于掌握,而且有不少新内容;(2)美中不足是1《意见》中CR程序,缺乏日程,不如《美国心脏康复指南》,和中国康复医学会心血管病专业委员会制定的急性心肌梗塞康复程序,2006年制定的冠心病介入手术后的康复程序有日程程序,易于实施;2有些指标因为人种,国情的不同,我们要参考我国的数据,比如《意见》中肥胖的标准是BMI≥30,而我国肥胖汇总分析报告肥胖的标准是≥28;3《意见》认为,在老年患者谨慎治疗高血压是强制性的,老年人目标血压为≤130/89mmHg,事实上老年人常见的单纯收缩期高血压,很难达到此标准,强制性的降压虽然可降低收缩压,但是同时舒张压要降低,舒张压过低就会影响到脑循环的灌注压,所以我国专家认为老年人收缩压≤150mmHg是允许的;4《意见》在慢性心力衰竭康复中提到:改善期:逐渐增加运动强度(50,60,70%~80%O2max,如果可耐受的话),虽然有如果可耐受的附注,但实际上要达到70%~80%O2max(相当于80%~90%HR max)几乎是不可能的,追求不切实际的目标容易产生副作用,而安全是心脏康复的首要目标。只要注意到这些,《意见》是很值得借鉴的。

Summary of comments： The （（position paper）） fully affirms the role of cardiac rehabilitation （CR） in patients with cardiovascular diseases and complicated with diabetes mellitus and COPD, inherits the tradition of guidelines for car- diac rehabilitation and secondary prevention programs formulated by American Association of Cardiovascular and Pulmonary Rehabilitation （Fourth edition） in 2004 [abbreviated as （（American cardiac rehabilitation guidelines）） be- low~. Firstly, it discusses CR core components and goals of CR intervention in different cardiovascular conditions, then introduces CR of special patients conditions and population and makes new developments, such as formulation of rehabilitation programs post PCI, resistance exercise is often mentioned, new target for lipid adjustment etc. Differences： （1） （（American cardiac rehabilitation guidelines）） is a book of 205 pages of normal text, while the （（position paper）） is a paper with only 16 pages of normal text, which determines the difference of structure between them： CR programs in （（American cardiac rehabilitation guidelines）） arc mainly presented as tables assisted by de- scription of normal text, CR programs of special patient＇s conditions and population are mainly expressed by normal text assisted by simple tables, even some have no table; but CR content almost presented as table in （（position paper））; therefore, advantages of the （（position paper）） is brief, concentrated, easy to grasp, and there are quite a few new contents; （2） Some flaws in perfection are ~ CR programs in （（position paper）） are lack of schedule, which is inferior to （（American cardiac rehabilitation guidelines））, and （（Rehabilitation program for acute myocardial infarc- tion））, （（Rehabilitation program for coronary heart disease after intervention in 2006）} formulated by Cardiovascular Committee of Chinese Association of Rehabilitation Medicine, which have schedule and are easy to perform; （~） Be- cause of different races and national conditions, some indexes should refer to our Chinese data. For example, crite- rion for obesity is BMI^30 in （（position paper））, while it＇s 928 in China standard; O The （（position paper）） thinks that should mandatory to carefully treat hypertension in aged patients, and target blood pressure for the aged is 130/89 mmHg, in fact, this target is hard to achieve for isolated systolic hypertension, which is frequent in the aged. Though mandatory lowering blood pressure can decrease systolic blood pressure, diastolic blood pressure also decreases, and too low diastolic blood pressure can affect perfusion pressure in cerebral circulation, so Chinese ex- perts think that it＇s permissive that systolic blood pressure -~150 mmHg in the aged; @ The （（position paper）） men- tions that gradually increase exercise intensity （50, 60, 70% -80%O2 as tolerated） during rehabilitation impro- ving period of chronic heart failure, though there is note of ＂as tolerated＂, in fact, it＇s almost impossible to achieve 70% - 80%02 , （equivalent to 80 - 90%HRmax）, Seeking an impractical goal is easy to produce side effects, and safety is the chief goal of CR. The （（position paper）） is worth reference and learning if above issues are noticed.