心梗后心康复治疗

1、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不运动动的不利影响的不利影响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/wk)

2、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 baseline

3、202171199174197190200188tgmenwomen3956415540503747hdl-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=h

4、igh density lipoprotein cholesterol, ldl-c=low density lipoprotein cholesterol, tg=triglycerideexercise evidence:运运动对动对血脂的影响血脂的影响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:运运动对动对肥胖和糖尿病的影响肥胖和糖尿病的影响manson je et al. nejm 2002;347:716-25quintiles of activity (me

5、t-hour/week*)walkingrelative 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

6、heart diseaseexercise evidence:运运动对动对冠心病的影响冠心病的影响 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:运运动对动对冠心病患者冠心病患者预预后的影响后的影响 * effect

7、 of cardiac rehabilitation in randomized controlled trials following a mioldridge nb et al. jama 1988;260:945-950 *p0.0125心心脏脏康复康复:运运动对动对心梗后患者的影响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分析提示心脏康复治疗使心梗后死亡率降低降低20%circulation, 1989左图为未参加康复患者，右图为参加康复患者，图中虚线表示预左图为未参加康复患者，右图为参

8、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 intern med 2005;143:659-72meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without exercise pro

9、grams心心脏脏康复康复:二二级预级预防的益防的益处处降低降低cv事事件件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。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低落的患者比例出抑郁和低落的患者比例the american journal of medicine, 2007the american journal of medicine,

10、 2007接受康复治疗抑郁改善的患者死亡率明显降低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前的全面评估心梗患者进行康复治疗的危险分层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心肺运动试验标准标准bruce方案下方案下vo2和和mets的相对关系的相对关系circulation, 2013指南推荐运动强度为指南推荐运动强度为12-13级。级。如患者对运动耐受较好且无并发如患者对运动耐受较好且无并发症，可进行强度症，可进行强度14-16级的运动级的运动circulation, 2012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