心肺运动试验在慢性心力衰竭患者高强度个体化运动康复处方制定和运动康复效果评估中的作用研究

摘要

目的：采用心肺运动试验（CPET）客观定量评估慢性心力衰竭（ CHF）患者整体心肺功能变化，精准制定高强度个体化运动康复处方进行运动康复，评估运动康复对 CHF 患者心肺功能、运动耐力和生活质量（ QoL）的影响，探讨 CPET 在 CHF 患者高强度个体化运动康复处方制定和运动康复效果评估中的作用。方法选择2014年8月—2016年1月首都医科大学附属北京康复医院临床诊断为 CHF 的患者20例，按照随机原则和患者参与意愿将患者分为两组：对照组（n ＝10）患者给予不包括运动处方的康复治疗；康复组（n ＝10）患者给予包括运动处方的康复治疗，根据 CPET 检查结果精准制定高强度个体化运动康复处方进行运动康复，功率自行车运动强度为无氧阈以上Δ50％功率，30 min/ d，5 d/周，共12周。记录两组患者一般资料，治疗前后 CPET 指标、血浆 B 型脑钠肽（BNP）水平、超声心动图、6分钟步行距离（6MWD）、QoL 评分。结果康复组患者均安全无并发症完成症状限制性最大极限运动CPET 检查和全程运动康复12周。治疗前，对照组与康复组患者静息及峰值心率、收缩压、舒张压，无氧阈（L/ min、ml·min -1·kg -1、％ pred）、峰值摄氧量（L/ min、ml·min -1·kg -1、％ pred）、峰值氧脉搏（ ml/次、％ pred）、BNP 水平、左心室舒张末期内径（LVEDD）、左心室射血分数（LVEF）、6MWD、QoL 评分比较，差异均无统计学意义（P ＞0.05）；治疗后，康复组患者无氧阈（L/ min、ml·min -1·kg -1）、峰值摄氧量（L/ min、ml·min -1·kg -1）、峰值氧脉搏（ml/次）、LVEF、6MWD 较对照组升高，BNP 水平、QoL 评分较对照组降低（P ＜0.05）。对照组患者治疗前与治疗后静息及峰值心率、收缩压、舒张压，无氧阈（ L/ min、ml·min -1·kg -1、％ pred）、峰值摄氧量（ L/ min、ml· min -1·kg -1、％ pred）、峰值氧脉搏（ml/次、％ pred）、BNP 水平、LVEDD、LVEF、6MWD、QoL 评分比较，差异均无统计学意义（P ＞0.05）；康复组患者治疗后无氧阈（L/ min、ml·min -1·kg -1、％ pred）、峰值摄氧量（L/ min、ml· min -1·kg -1、％ pred）、峰值氧脉搏（ ml/次、％ pred）、LVEF、6MWD 较治疗前升高，QoL 评分较治疗前降低（ P ＜0.05）。结论 CPET 可以客观定量评估 CHF 患者病情，精准制定高强度个体化运动康复处方，运动康复12周可显著改善 CHF 患者心肺功能、运动耐力和 QoL，是 CHF 二级预防的重要组成部分，值得大力推广。%Objective To evaluate the holistic cardiopulmonary function by using cardiopulmonary exercise testing (CPET) among patients with chronic heart failure ( CHF) objectively and quantitatively, to formulate high - intensity individualized rehabilitation exercise prescription precisely,to evaluate the effects of exercise rehabilitation on cardiopulmonary function,exercise tolerance and quality of life( QoL)among patients with CHF,to investigate the role of CPET in the formulation of individualized rehabilitation exercise prescription and rehabilitation effects evaluation among patients with CHF. Methods 20 patients who were diagnosed with CHF in Beijing Rehabilitation Hospital Affiliated to Capital Medical University from August 2014 to January 2016,were randomly divided into two groups:control group(n = 10)and exercise rehabilitation group(ER group,n = 10). Patients in control group were treated with conventional therapy without exercise and patients in ER group were treated with conventional therapy and exercise rehabilitation according to high - intensity individualized rehabilitation exercise prescription based on CPET results,exercise intensity of cycle ergometer was Δ50% power,30 min/ d,5 d/ week,for 12 weeks. General information,CPET results,plasma brain natriuretic peptide( BNP)level,echocardiogram,6 minute walking distance(6MWD)and QoL score of two groups of patients before and after treatment were recorded. Results All patients in ER group finished symptom limited maximum CPET and 12 weeks - exexcise rehabilitation safely without complications. Before rehabilitation,There were no significant difference in resting and peak HR,SBP,DBP,AT(L/ min,ml ·min - 1 ·kg - 1 ,% pred),peak VO2 ( L/ min,ml·min - 1 ·kg - 1 ,% pred),peak oxygen pulse( ml/ beat,% pred),BNP level,left ventricular end diastolic dimension(LVEDD),left ventricular ejection fraction(LVEF),6MWD,and QoL score between control group and ER group( P > 0. 05 ). After rehabilitation,AT( L/ min,ml · min - 1 · kg - 1 ),peak VO2 (L/ min,ml·min - 1 ·kg - 1 ),peak oxygen pulse(ml/ beat),LVEF,and 6MWD of patients in ER group were significantly higher than those of patients in control group,respectively,BNP level and QoL score of patients in ER group were significantly lower than those of patients in control group,respectively(P < 0. 05). For patients in control group,there were no significant difference in resting and peak HR,SBP,DBP,AT(L/ min,ml·min - 1 ·kg - 1 ,% pred),peak VO2 (L/ min,ml·min - 1 ·kg - 1 ,% pred),peak oxygen pulse( ml/ beat,% pred),BNP level,LVEDD,LVEF,6MWD,and QoL score before and after treatment(P > 0. 05). For patients in ER group,AT(L/ min,ml·min - 1 ·kg - 1 ,% pred),peak VO2 (L/ min,ml· min - 1 ·kg - 1 ,% pred),peak oxygen pulse( ml/ beat,% pred),LVEF,and 6MWD after treatment were significantly higher than those before treatment,respectively,and QoL score after treatment were significantly lower than those before treatment(P< 0. 05). Conclusion CPET is an objective,quantitative,safe and effective method to evaluate the patient's condition,and help to formulate high - intensity individualized rehabilitation exercise prescription precisely. Exercise rehabilitation for 12 weeks can improve the cardiopulmonary function,exercise tolerance and QoL of CHF patients and is an important part of CHF secondary prevention,so it is deserved to be applied widely.