不同心脏康复模式在急性心肌梗死经皮冠状动脉介入治疗术后早期的临床价值研究

Clinical Value of Different Cardiac Rehabilitation Programs Applied to Patients with Acute Myocardial Infarction Early after Percutaneous Coronary Intervention

目的明确早期心脏康复训练对急性心肌梗死(AMI)经皮冠状动脉介入治疗(PCI)术后患者的临床价值,进一步探索不同心脏康复模式对AMI患者预后的效果。方法选取2014年1月—2016年5月绍兴市人民医院接受PCI的AMI患者90例,采用随机数字表法分为3组,传统常规组(30例)、传统强化组(30例)和新型优化组(30例)。传统常规组根据2006年颁布的中国PCI术后心脏康复程序中急症PCI术后1周康复程序制定,以步行等简单的方式作为主要运动形式;传统强化组根据2006年颁布的中国PCI术后心脏康复程序中择期PCI术后康复程序制定,基础活动量和总活动量强于传统常规组;新型优化组在传统常规康复模式基础上,综合荷兰Avans大学、UMC St RAdboud医学院及香港伊利沙伯医院接受的最新心脏康复理念,为患者提供早期、个体化和精确定量的新型心脏康复方案。3组均为期6个月。各组患者分别于PCI术后即刻(康复前)和心脏康复干预6个月后(康复后)行心脏彩色多普勒检查,测量左心室射血分数(LVEF)、左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV)、室壁运动积分指数(WMSI)。测定血清中肿瘤坏死因子α(TNF-α)、一氧化氮(NO)、内皮素1(ET-1)、可溶性血管细胞黏附分子1(sVCAM-1)水平。观察患者心脏康复干预期间恶性心律失常、心绞痛、心力衰竭、猝死发生情况。结果康复前3组患者LVEF、LVESV、LVEDV、WMSI、TNF-α、NO、ET-1、sVCAM-1水平比较,差异均无统计学意义(P>0.05)。康复后传统强化组WMSI低于传统常规组,新型优化组LVEF高于传统常规组和传统强化组、WMSI低于传统常规组和传统强化组(P<0.05)。3组康复后LVEF较康复前升高(P<0.05)。康复后传统强化组TNF-α、ET-1、sVCAM-1水平低于传统常规组,NO水平高于传统常规组;新型优化组TNF-α、ET-1、sVCAM-1水平低于传统常规组和传统强化组、NO水平高于传统常规组和传统强化组(P<0.05)。3组康复后TNF-α、ET-1、sVCAM-1水平较康复前降低,NO水平较康复前升高(P<0.05)。3组患者心脏康复干预期间恶性心律失常发生率比较,差异有统计学意义(P<0.05);心绞痛、心力衰竭发生率比较,差异无统计学意义(P>0.05)。3组患者均无猝死发生。结论早期心脏康复训练对AMI PCI术后患者的心功能及预后有明显改善,新型康复模式有效实现康复模式的个体化、人性化,最大限度地保护AMI患者的心功能,切实改善AMI患者的预后。

Objective To investigate the clinical value and impact of cardiac rehabilitation programs applied to patients with acute myocardial infarction（ AMI） early after percutaneous coronary intervention（ PCI）. Methods The enrolled participants were 90 cases of AMI who received PCI in Shaoxing People＇ s Hospital from January 2014 to May 2016. They were randomized into traditional routine group,traditional strengthening group and new optimization group with 30 cases in each. The cardiac rehabilitation program for traditional routine group was developed based on the rehabilitation program applied to patients one week after emergency PCI included in 2006 Chinese Cardiac Rehabilitation Programs after PCI,mainly consisting of simple forms of exercise such like walking. Both the traditional strengthening group and new optimization group received the cardiac rehabilitation program developed based on the rehabilitation program applied to patients after selective PCI included in 2006 Chinese Cardiac Rehabilitation Programs after PCI. In addition, the new optimization group received the early-applied,personalized and accurate cardiac rehabilitation program developed in accordance with the latest concepts in cardiac rehabilitation received by Avans University,UMC St RAdboud,Queen Elizabeth Hospital and other hospitals in Hong Kong. The traditional strengthening group and new optimization group had greater basal activities and total activities than the traditional routine group.The intervention period for all the groups was six months. Color Doppler echocardiography was performed in the groups immediately after PCI（ before the cardiac rehabilitation intervention） and six months after the starting of cardiac rehabilitation program（ after the cardiac rehabilitation intervention）,respectively for measuring the left ventricular ejection fraction（ LVEF）,left ventricular end-systolic volume（ LVESV）,left ventricular end-diastolic volume（ LVEDV） and wall motion score index（ WMSI）. Levels of serum tumor necrosis factor-alpha（ TNF-α）,nitric oxide（ NO）,endothelin 1（ ET-1） and soluble vascular cell adhesion molecule 1（ sVCAM-1） were measured before and after the cardiac rehabilitation intervention. The incidences of malignant arrhythmia, angina pectoris, heart failure and sudden death during the cardiac rehabilitation were observed. Results No significant differences in LVEF,LVESV,LVEDV,WMSI,TNF-α,NO,ET-1 and sVCAM-1 levels were found among the three groups before the cardiac rehabilitation（ P〈0. 05）. After the cardiac rehabilitation intervention,the WMSI was lower in the traditional strengthening group than that in the routine traditional group,LVEF was higher in the new optimization group than that in the routine traditional group and traditional strengthening group, WMSI was lower in the new optimization group than that in the routine traditional group and traditional strengthening group（ P〈0. 05）. LVEF was higher after the cardiac rehabilitation intervention than that before the cardiac rehabilitation intervention in the three groups（ P〈0. 05）.After the cardiac rehabilitation intervention,the levels of TNF-α,ET-1 and sVCAM-1 were lower in the traditional strengthening group than those in the routine traditional group,the level of NO was higher in the traditional strengthening group than that in the routine traditional group,the levels of TNF-α,ET-1 and sVCAM-1 were lower in the new optimization group than those in the routine traditional group and traditional strengthening group,the level of NO was higher in the new optimization group than that in the routine traditional group and traditional strengthening group（ P〈0. 05）. The levels of TNF-α,ET-1 and sVCAM-1 were lower,but the level of NO was higher after the cardiac rehabilitation intervention than that before the cardiac rehabilitation intervention in the three groups（ P〈0. 05）. During the cardiac rehabilitation intervention, the incidence of malignant arrhythmia differed significantly among the three groups（ P〈0. 05）; three groups had similar incidences of angina pectoris and heart failure（ P〈0. 05）; no sudden death occurred in all groups. Conclusion Cardiac rehabilitation training applied to patients with AMI early after PCI can obviously improve the cardiac function and prognosis. The humanitarian cardiac rehabilitation program based on personal conditions used in the new optimization group can achieve the optimal effect of rehabilitation,which can also protect the cardiac function to the utmost and improve the prognosis tangibly.