Method for rehabilitation of patietns with ischemic heart disease

FIELD: medicine.

SUBSTANCE: stress test is administered by performing a physical load accompanied by recording cardiac parameters followed by performing a training load. The training load is preceded by administering a repeated stress test 30-60 minutes following the first one. The cardiac parameter consists in recording ST segment displacement and calculating ST index. The ST indices subsequent to the results of the first and second stress tests are compared. If the second index tends to decrease as compared to the first one by at least 10%, the training load is performed. A third stress test is administered 30-60 minutes later to evaluate a third ST index. The training load is performed for 24-48 hours on completion of the second stress test. The training load represents alternative clamping and blood flow recovery in the peripheral vessels. One cycle is expected to consist of at least 4 cycles of clamping and recovery procedures in the peripheral blood vessels. Besides, each clamping and recovery within the training load cycle alternates for 3-5 minutes.

EFFECT: method enables reducing the rehabilitation time of the IHD patients and reducing a risk of complications by providing a sparing load pattern.

2 cl

 

The invention relates to medicine, namely to cardiology, rehabilitation medicine, and can be used in the rehabilitation of patients with coronary heart disease (CHD) in a short period of time, including after acute coronary syndrome and/or procedure percutaneous coronary intervention (PCI).

The known method of physical rehabilitation of patients with coronary heart disease (see RF patent №2154460, IPC AS 1/00, AV 5/02, pub. 20.08.2000), based on training of patients with continuous monitoring of heart rate (HR). Starting with the third week after the occurrence of a myocardial infarction, patients underwent a four-month course of physical exercise every day 5 times a week, including warm-up in the hall in the form of physical therapy, then training on the Ergometer.

However, this method provides for rehabilitation, only starting from the third week since the onset of the disease. In patients with limited activity, especially after PCI procedure, this method may cause the risk of development of cardiovascular complications.

Also known method of rehabilitation treatment of patients after coronary artery bypass surgery at the hospital stage (see RF patent №2371161, CL. AN 1/00, pub. 27.10.2009), which consists in carrying out gymnastic, breathing pack�of agnani, as well as massage of biologically active points which have a reflex connection with the circulatory system, and segmental massage of the areas that regulate motor and respiratory functions that perform 5 motional modes: intensive care, bed, nonstrict bed, ward, adaptation. This movement modes differ by the content of the exercises, and they run. Breathing exercises performed within 1-2 minutes every hour. The method can be used from the first hours after the operation.

However, the method does not lead to the formation of adaptation to ischemia, there are no criteria for evaluating the effectiveness of the recovery process.

The closest to the claimed is a method of rehabilitation of patients with coronary heart disease (see RF patent №2440085, IPC AS 1/00, pub. 20.01.2012), which consists in conducting the stress test by performing physical activity with simultaneous registration of parameters of cardiac activity and the implementation of the additional training load by walking with a load. The method involves determining a threshold power of the load, the choice of a coaching power of the load, dispensing the coaching power of the load, calculation of the individual walking speed.

However, the method is time-consuming, because it includes the physical tre�of irewoc walking with load for 3 months at least 1 hour per day and, as a result, fails to achieve long-lasting therapeutic effect in the shortest possible time.

The invention is aimed at solving the problem of creating an effective and inexpensive method of rehabilitation of patients with coronary artery disease for patients undergoing intracoronary intervention, myocardial infarction and other forms of ischemia by creating a gentle treatment of loads while reducing recovery time and reducing the risk of developing cardiovascular complications.

To solve the problem in the method of rehabilitation of patients with coronary heart disease, consisting in conducting the stress test by performing physical activity with simultaneous registration of parameters of cardiac activity and the implementation of the additional training load according to the invention before training load additionally, a second stress test, as a parameter of cardiac activity register change of ST segment displacement and calculate the index ST, carried out a comparison of indexes of ischemia on the results of the first and second stress tests, while reducing the second value of the index relative to the first not less than 10% conduct training load followed by the third stress test with the assessment of third ST index and reduction of the third index ST is not less than 10% compared to the first Zn�rising index is judged on the effectiveness of rehabilitation, this training load is carried out in the form of successive cycle periti rebounds and blood flow in peripheral vessels of not less than 4 times per cycle.

To achieve the most optimal mode of rehabilitation repeated the stress test is conducted at intervals of 30-60 minutes from the first, the training load is performed in the interval of 24-48 hours after the second stress test, and the third stress test carried out in 30-60 minutes after training load, and each clamping and recovery in cycle training load is carried out alternately in 3-5 minutes.

To improve and reinforce the regenerative effect of this method after the end of the third diagnostic stress test carried out for the second day additional cycles of training loads in an amount of not less than 3 cycles with intervals of 1-2 days, and after 30-60 minutes after the last training load performed fourth diagnostic stress test with the evaluation of the ST index.

The value of the last index, ST is compared with a third index value ST to assess the effectiveness of rehabilitation measures.

In the known authors of the sources of patent and scientific and technical information not described method of rehabilitation of patients with coronary heart disease, effectively, �Egorova, without use of special equipment, in the shortest possible time and without complications conduct the restoration activities as in postoperative patients not subjected to surgical intervention of patients with coronary heart disease through the use of a gentle type of training load by clamping and restoration of blood flow in peripheral vessels and, consequently, create the effect of remote preconditioning.

The essence of remote ischemic preconditioning is that short episodes of ischemia of one organ (kidney, mesentery, lower extremities) increase the resistance of other bodies to severe ischemic damage. In this case, the resistance of tissues to ischemia may increase as a result of preconditioning by short episodes of ischemia - reperfusion (Lim SY, Yellon DM, Hausenloy DJ: The neural and humoral pathways in remote limb ischemic preconditioning. Basic Res Cardiol 2010;105:651-655). In experiments on dogs Murry in 1986, first described the phenomenon of local ischemic preconditioning of the myocardium (see, e.g., Murry CE. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium // Circulation, 1986, Vol.74, No. 5, P. 1124-1136), which is to increase the resistance of the heart to ischemic damage after transient episodes of ischemia / reperfusion. It was noticed that several episodes of ischemia and reper�usii, which was carried out by clamping the left anterior descending artery ligature, with subsequent relaxation prior to a prolonged ischemic episode, has contributed to a drastic decrease in the area of myocardial necrosis, in contrast to the control group, in which such episodes have not been conducted. Further research it was discovered that four short episode of coronariography alternating five-minute periods of reperfusion before the forty-minute coronariography, reduced the size of myocardial infarction by almost 2 times.

It is known to use in cardiac surgery method of preconditioning of the myocardium during operations (see, for example, patent RF №2504336, IPC AV 17/00, pub. 20.01.2014), including clamping of the aorta and the creation of two episodes of ischemia and reperfusion given duration.

The known method of correction of ischemia in experimental cardiovascular surgery (see, for example, patent RF №2438192, IPC G09B 23/28, pub. 27.12.2011), which consists in the simulation of ischemia in the hind limb of rats by conducting distant preconditioning 10-minute compression of the femoral artery contralateral limb with subsequent 30-min reperfusion.

In the claimed authors of the method first proposed to use the phenomenon of remote preconditioning for the rehabilitation of patients with ischemia myoko�Yes, which indicates the novelty of the proposed solution.

The authors proposed to create short episodes of ischemia in peripheral vessels by occlusion and restoration of blood flow by applying the cuff on the shoulder for 3-5 minutes.

The unknown use of the training load in the form of a 4-fold cross-clamping of the peripheral vessels with subsequent reperfusion in certain time intervals and the estimation of the index ST at a particular, selected by the authors, the criterion on the background of the control that the training load by conducting stress tests allows us to conclude about the presence of the claimed invention, the criterion of "inventive step".

The method is as follows.

Conduct a diagnostic stress test Protocol Bruce R. by performing exercise on a treadmill to identify the initial level of myocardial ischemia: measure the displacement of the ST segment and calculate the index ST as the ratio of the magnitude of ST segment displacement to the heart rate at which this change happened, is measured in mV/min.

After 30-60 minutes after the first by a second diagnostic stress test Protocol R. Bruce on the treadmill, re-measure the displacement of the ST segment below the contours are in mm and calculate the index ST.

When you decrease the second value of the index ST with respect to the first not less than 10% spend trenirovok�ing the load after 24 to 48 hours after the end of the second stress test.

Training load is carried out by creating ischemia in the hand due to the clamping (overlay cuff on the shoulder) and restore blood flow in peripheral vessels, each clamping and restoration is carried out alternately in 3-5 minutes, and the interruption and restoration of blood flow is carried out not less than 4 times in the training cycle.

After the training load through spend 30-60 minutes a third stress test with the assessment of third ST index and reduction of the third index ST is not less than 10% compared to the first index value is judged on the effectiveness of rehabilitation.

The evaluation criterion of the second and third indices ST in relation to the first index with a decrease of 10% or more is crucial and sufficient condition necessary physical activity to assess the possibility of conducting training loads. In addition, this decrease of the ST index is statistically significant and proven positive change in this indicator.

The second stress test in 30-60 minutes after the first due to the need to restore the patient to baseline physiological state. Similar considerations form the basis of the timing of the third stress test (30-60 minutes after training load).

Carrying out training load� after 24-48 hours after the second stress test is due to at this period resumes protective effect against ischemia, representing the second phase of perconditioning.

The implementation of compression and recovery (reperfusion) within 3-5 minutes due to the effect of distant perconditioning, since the first protective phase is already apparent after 5 minutes of reperfusion and lasts up to 2 hours. Then the effect disappears and resumes in the period from 24 to 72 hours. This is the second protective phase from ischemia.

Conducting training load in the form of a series of 4-fold clamping and restore blood flow for 3-5 minutes due to the need for consistent repetition of cycles of ischemia-reperfusion to generate a robust cardioprotective effect, based on the adaptation to ischemia and used for rehabilitation activities.

For the proof of reachability of the effect of ischemia of the training load in the form of occlusion and restoration of blood flow can be performed under the control of oximetry, confirming the occurrence of local ischemia.

Example 1. Patient N., 53 were in the hospital with myocardial infarction.

Underwent a clinical and instrumental examination revealed:

according to ECHOCG - hypokinesia front middle, prednamerennoe, septal-apical segments of the left ventricle, the mind�nisene the thickness of the front wall of the middle segment of the left ventricle;

- according to Holter ECG monitoring - 1 long episode of depression of ST segment duration 8 min 17 sec, the maximum depression was 2 mm;

- according to multislice computed tomography of long stenosis of the right coronary artery and 80%.

From medications the patient refused.

Patient was performed paired diagnostic stress test Bruce Protocol on the treadmill.

The results of the first stress test: maximum ST-segment depression of 2.20 mm, the ST index is 1.32 mV/min.

After 30 minutes the patient was performed a second stress test on the treadmill. Results: maximum ST-segment depression 1.75 mm, index ST - 1,10 µv/min.

These results indicate that the reduction of depression of segment ST on the results of the second stress test by 20.5%, the reduction of the ST index by 17%.

After 28 hours after the second stress test, the patient underwent training load creating ischemia in the hand due to the termination and restoration of blood flow. Cessation of blood flow was performed for 4 minutes by applying the cuff on the shoulder and blow air in it to 200-220 mm Hg.CT., recovery by completely letting off the air from the cuff for 3 minutes. Termination and restoration of blood flow was repeated 4 times, after 30-60 minutes after the last restoration of the blood flow and realized�and conducted the third stress test on the treadmill with the assessment of third ST index.

Using an oximeter measured the amount of oxygen in the tissues throughout the cycle. During ischemia (clamping) the amount of oxygen in the tissues averaged 37%, and during reperfusion (restoration of blood flow) - 79%.

Initial blood pressure was 120 and 80 mm Hg.CT., pulse 74 beats per minute and at the end of cycle training load has not changed.

After 30 minutes of training load the patient held the third stress test on the treadmill. Results: maximum ST-segment depression of 1.35 mm, index ST for 1.08 µv/min.

These results indicate that the reduction of depression of segment ST at 39% and the reduction of the ST index by 19% compared to the initial index value of ST obtained from the first stress test (1,32 µv/min).

The patient underwent additional cycles of the training loads in the amount of 3 cycles with intervals of 1 day, and 30 to 60 minutes after the last training load held fourth diagnostic stress test with evaluation of the index ischemia and ST-segment depression. Maximum ST-segment depression of 1.20 mm, ST index of 0.93 mV/min the Obtained data, the fourth stress test, compared with the third, show a reduction of depression of segment ST at 11%, the reduction of the ST index is 14% and show high efficiency of Prov�exercise rehabilitation.

A month later the patient was performed another stress test, the results of which compared with the third stress test reducing the ST index was 11%, indicating preservation of the effect of training loads.

Example 2. Patient M. 60 years old with myocardial infarction after undergoing PCI was admitted to the hospital with complaints of discomfort in the chest that occurs during physical activity (walking at a distance of 350 m).

Underwent a clinical instrumental study:

according to ECHOCG - hypokinesia of the basal posterior segment of the left ventricle;

- according to coronary angiography detected the defeat of the three coronary arteries: stenosis of the anterior interventricular branch (PMA) in the proximal segment 90% stenosis of the envelope branch (S) 70% in the middle segment, stenosis of the right coronary artery (RCA) 60% in the proximal segment, 70% in the distal segment; diffuse atheromatosis in the proximal segment of pmsa.

The patient was taking b-blockers, antiplatelet agents, statins, and angiotensin-converting enzyme.

Was performed percutaneous balloon coronary angioplasty of the RCA, S, pmsa.

The results of coronary angiography after percutaneous coronary balloon angioplasty: stenosis of PMA 80% proximal to the stent previously implanted stent pass: stenosis S 50% on average segment�E.

Was performed the first diagnostic stress test on a treadmill according to the Bruce Protocol. The results of the first stress test: maximum ST-segment depression of 2.20 mm, ST index of 1.74 mV/min.

After 30 minutes, the patient underwent a second stress test on the treadmill. Results: maximum ST-segment depression of 1.90 mm, ST index of 1.48 mV/min.

The obtained data of the second stress test show compared to the first (initial) value on the reduction of depression of segment ST on 14% and the reduction of the ST index by 15%.

After 28 hours after the second stress test, the patient underwent training load creating ischemia in the hand due to the termination and restoration of blood flow. Cessation of blood flow was performed for 4 minutes by applying the cuff on the shoulder and blow air in it to 200-220 mm Hg.CT., and recovery by completely letting off the air from the cuff for 3 minutes. Termination and restoration of blood flow was repeated 4 times.

Using an oximeter measured the amount of oxygen in the tissues throughout the cycle, during ischemia (clamping) the amount of oxygen in the tissues averaged 40%, and during reperfusion (restoration of blood flow) - 75%.

Initial blood pressure was 115 and 75 mm Hg.PT. and heart rate 60 beats per minute and did not change significantly at the end of cycle training load.

after 30 minutes of training load and recovery of the patient was performed the third stress test on the treadmill. Results: maximum ST-segment depression of 1.40 mm, index ST - 1,03 µv/min. the Obtained data of the third stress test compared with baseline (first index value ST) have shown a reduction of depression of segment ST on 37%, lower ST index by 41% and show a high effectiveness of rehabilitation measures.

The inventive method physiological and safe for the patient, as provides for gentle load and continuous monitoring of hemodynamic parameters.

A method of rehabilitation of patients with coronary artery disease effective for patients undergoing intracoronary intervention, myocardial infarction and other forms of ischemia by creating a gentle treatment of loads while reducing recovery time and reducing the risk of developing cardiovascular complications. The method is inexpensive and requires no special additional equipment for its implementation.

1. Method of rehabilitation of patients with coronary heart disease, consisting in conducting the stress test by performing physical activity with simultaneous registration of parameters of cardiac activity with the subsequent performance of the training load, characterized in that, before training load is further carried every 30-60 minutes from the first re-stress test, as a parameter of cardiac deyatelnosti.seychas change in ST segment displacement and calculate the index ST, conduct a comparison of the ST indices according to the results of the first and second stress tests, while reducing the second value of the index relative to the first not less than 10% conduct training load, then after 30-60 minutes spend a third stress test with the assessment of third ST index, training load is performed in the interval of 24-48 hours after the second stress test in the form of successive cycle periti rebounds and blood flow in peripheral vessels of not less than 4 times per cycle, with each clamping and recovery in cycle training load is carried out alternately in 3-5 minutes.

2. Method of rehabilitation of patients with coronary heart disease according to claim 1, characterized in that after the end of the stress test carried out for the second day additional cycles of training loads in an amount of not less than 3 cycles with intervals of 1-2 days.



 

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