心脏康复对年纪较大的心力衰竭患者有益

罗马——据比利时根特大学的研究者Sofie Pardaens医生及其合作者在欧洲心血管病预防与康复学会(EACPR)年会上报告的一项研究，多周的心脏康复计划对年纪较大的慢性心力衰竭患者与对较年轻患者一样有益；其另外一项分析显示，较长期的心脏康复计划对近期刚出院的心力衰竭患者与对心脏手术后或发生急性冠脉综合征(ACS)事件后的患者同等有效。


Sofie Pardaens医生

与患者年龄有关的这项心脏康复评估共包括243例参与根特大学心脏康复计划的患者，这些患者均患有慢性心力衰竭，并且氨基末端B型利尿钠肽前体值≥400 pg/ml(心力衰竭的征象)(Circulation 2011;123:2015-9)，其中43例(18%)年龄≥75岁(平均年龄，78岁)，68例年龄＜60岁，其余132例年龄介于60~74岁。所有的受试者均刚因ACS事件、心脏外科手术或心力衰竭住院。这项以医院为基础的康复计划将有氧与力量训练相结合，旨在在每个训练阶段，将患者的心率调整到无氧阈值。每周训练2~3次，整个计划包括45次训练，为期4~5个月。每位受试者平均进行34次训练；年龄≥75岁的患者每例平均进行32次训练，而年龄<60岁的患者每例平均进行35次训练。

研究者在基线及各个康复训练阶段结束时运用心肺运动试验测量峰值运动耐量，发现年龄≥75岁的患者平均提高26%，与后两个年龄段的患者几乎不相上下(年龄>60岁的患者平均提高19%，余者平均提高17%)。所有的年龄段患者在平均通气当量比以及平均6分钟步行距离上也显示出相似程度的改善，但60岁以下的患者在该指标上平均增加29%，明显超过年龄≥75岁者的19%。

该研究小组的另一项分析的对象是371例于2010年1月~2012年5月间在根特大学进行心脏康复的患者，这部分患者是从1,253例在此时间段内因急性冠脉综合征事件、心脏外科手术或心力衰竭住院的患者中挑选出的。该心脏康复计划也是每周训练2~3次，给患者设定的目标也是5个月内完成45次训练。在428例来自较大组的因心力衰竭住院的患者中，康复签到率较低，实际上有37例急性心力衰竭患者(9%)进行了康复训练，早358例因心脏外科手术住院的患者中康复训练参与率最高，为56%，而在467例发生ACS事件的患者中参与率为28%。尽管在心力衰竭患者中只有9%的参与率，但他们从参与康复训练中的受益与手术患者和ACS患者的受益旗鼓相当。在康复训练结束时，心力衰竭患者峰值运动耐量相对于基线平均提高19%，而ACS患者平均提高17%，手术患者平均提高24%，差异无统计学意义。这3个亚组患者在6分钟步行距离上获得的平均改善幅度也相近，心力衰竭患者平均增加21%，其余两组分别平均增加27%和28%。

研究者表示，今后还应进行相关研究，探讨提高心力衰竭患者心脏康复训练应用率的方法。

Pardaens医生及其合作者称无相关的经济内容披露。

专家点评：朝正确的方向迈进

心脏康复毋庸置疑是当今治疗冠状动脉疾病及心力衰竭的基本疗法。

运动训练有望在推动康复训练的其他方面起到催化剂的作用，其中包括通过治疗性的生活方式改变及社会心理支持的优化来调整危险因素。在上了年纪的患者中，这类结局指标可以包括获得功能独立、预防过早伤残以及减少监护需要。

尽管目前数据有限，但年纪较大的患者在运动耐量方面显示出的改善幅度与参与等当运动训练计划的较年轻患者相当。另外，心脏康复计划中的运动安全性接受度良好并且也获得证实。

点评专家Jun Chiong医生是加州罗玛琳达大学医疗中心的医学副教授，并且是CHEST医生顾问委员会的成员。

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By: MITCHEL L. ZOLER, Cardiology News Digital Network

ROME – A multiweek program of cardiac rehabilitation is as beneficial in elderly patients with chronic heart failure as it is in younger heart failure patients, according to a review of 243 patients at one Belgium center.

"Although they have lower exercise capacity at baseline, older patients have at least as much benefit from an exercise program as younger patients with chronic heart failure," Dr. Sofie Pardaens reported in a poster at the annual meeting of the European Association for Cardiovascular Prevention and Rehabilitation.

A second analysis by Dr. Pardaens, a researcher at Ghent (Belgium) University, and her associates, reported in a separate poster, showed that a prolonged cardiac rehabilitation program was as effective in patients recently discharged from a heart failure hospitalization as it was in patients following cardiac surgery or after an acute coronary syndrome (ACS) event.
 
Their assessment of cardiac rehabilitation relative to a patient’s age included 243 patients who participated in a rehabilitation program at the University of Ghent, who had chronic heart failure, and who had an amino-terminal pro-B-type natriuretic peptide value of at least 400 pg/mL, a level very suggestive of heart failure (Circulation 2011;123:2015-9). The group included 43 patients (18%) who were at least 75 years old (average, 78 years) and 68 patients younger than 60 (average, 51 years), with the remaining 132 patients evenly distributed across the range of 60-74 years old.

All participants had just been hospitalized, for an ACS event, cardiac surgery, or heart failure.

The hospital-based rehabilitation program combined aerobic and strength training, and was designed to bring a patient’s heart rate to his anaerobic threshold during each session. Sessions occurred two or three times a week, and the full program included 45 sessions over a period of 4-5 months. The patients studied averaged 34 sessions each; patients aged 75 or older averaged 32 sessions each, while those younger than 60 averaged 35 sessions each.

The researchers measured peak exercise capacity using cardiopulmonary exercise testing at baseline and at the end of the rehabilitation session sequence, and found that the 16% average level of improvement among patients at least 75 years old closely matched the average 19% improvement among the patients younger than 60, and the 17% average improvement among everyone else, Dr. Pardaens and her associates reported. All age groups also showed similar improvements in their average ventilatory equivalence ratio, as well as their average 6-minute walk distance; however, the 29% average increased distance among patients younger than 60 years significantly exceeded the 19% average increase among those aged 75 or older.

The group’s second analysis focused on the 371 patients who underwent cardiac rehabilitation at the University of Ghent during January 2010 through May 2012 from among the 1,253 patients hospitalized during this period for an acute coronary syndrome event, cardiac surgery, or heart failure. In this pool of more than 1,000 patients who were potentially eligible to participate, only 30% actually enrolled in the rehabilitation program. The cardiac rehabilitation program again involved two to three sessions per week, with a goal for patients to complete 45 sessions within 5 months.

The sign-up rate for rehabilitation lagged even more among the 428 patients from the larger group whose index hospitalization had been for heart failure, with 37 of the acute heart failure patients (9%) actually engaging in rehabilitation. Rehabilitation participation was highest, a 56% rate, among the 358 patients who had been hospitalized for cardiac surgery, with a 28% uptake rate among 467 patients who had an ACS event.

Despite the low, 9% uptake of cardiac rehabilitation in heart failure patients, their benefit from participation closely tracked the benefit seen in surgery and ACS patients. Improvement in peak exercise capacity over baseline at the end of rehabilitation averaged 19% in the heart failure patients, 17% in the ACS patients, and 24% in the surgery patients, differences that were not statistically significant, reported Dr. Pardaens. All three subgroups also had similar average improvements in their 6-minute walk distance, which rose by an average of 21% in the heart failure patients and by averages of 27% and 28% in the other two subgroups.

Based on the efficacy but low usage of cardiac rehabilitation, future research should examine ways to boost its use by heart failure patients, concluded Dr. Pardaens.

Dr. Pardaens and her associates said they had no relevant financial disclosures.

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Steps in the right direction

Cardiac rehabilitation is undoubtedly an essential component of the contemporary treatment of patients with coronary disease and heart failure.

Exercise training has the potential to act as a catalyst for promoting other aspects of rehabilitation, including risk factor modification through therapeutic lifestyle changes and optimization of psychosocial support. Similarly, among patients who are elderly, such outcome measures may include the achievement of functional independence, the prevention of premature disability, and a reduction in the need for custodial care.

Despite limited data, older patients have shown improvement in their exercise tolerance comparable to that of younger patients participating in equivalent exercise programs. In addition, the safety of exercise within cardiac rehabilitation programs is well accepted and established.

Dr. Jun Chiong is associate professor of medicine at Loma Linda (Calif.) University Medical Center. He is on the on the advisory board of CHEST Physician.