2011 년대한임상건강증진학회추계통합학술대회 Exercise for Cardiac Rehabilitation 김명화우송대학교스포츠건강관리학부 Cardiac rehabilitation The process by the person with the cardiovascula

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1 Exercise for Cardiac Rehabilitation 김명화우송대학교스포츠건강관리학부 Cardiac rehabilitation The process by the person with the cardiovascular disease including limited to patients with coronary heart disease, is restored to and maintained optimal physiological, psychological, social, vocational and emotional status. Epidemiology Majority of United States is Physically inactive -American adults Completely sedentary : 25% Activity<30minutes/day : 60% - American age 12 to 21 No recent exercise : 14% Not vigorously active : 50% - Americans over age 65 years Sedentary : 75% Cardiac rehabilitation services Medical care Patient and family education Physical and occupational therapy Supervised telemetry exercise Rehabilitation nursing Psychology and neuropsychology Vocational rehabilitation Work conditioning Orthotics and prosthetics Specific Objects Physiological and psychological effects of cardiac illness. Reduction of risk for sudden death Behavior modification -Nutrition counseling -Smoking cessation -Relaxation skills -Stress reduction Vocational rehabilitation Psychological counseling 104

2 세미나 Ⅱ 재활을위한운동처방 Rehabilitation program Intervention Education and counselling Home visits program Low intensity Exercise Effects - Reduced rehospitalization (First 3months : 13% vs. 29%) (First year : 32% vs. 47%) -ER visit reduce Phase-I : Inpatient period Acute MI, CABG :6 to 14 days Phase-II : Hospital discharge Up to 4 to 6 months Phase-III and IV : Supervised outpatient program Maintained period(indefinite length) Ref : Bondestam(1995) Am. J. Cardiol. 75: Phase-I Education Counselling : Physician & nurse ROM ex, Intermittent sitting & standing, Walking Reduce the deconditioning that normally accompanies prolonged bed rest Phase-II Immediate exercise intervention Order : Physician/cardiac rehabilitation staff. Within 3wks hospital discharge. Medical history : low, moderate, high risks determined. GXT results : Arrhythmias, LV function, concurrent disease Risk factor education - Psychological & vocational needs Exercise : Continuous ECG monitoring Risks stratifications Phase-III and IV Low risk : Uncomplicate dx. VO2max. >7mets & EF > 50% Moderate risk : Stseg dep.>2mm flat, downsloping, Reversible thallium defects. EF > 35-49% High risk : Infarct involving >35%(LV). Rest EF <35, SBP(ex) Fall 10mmHg, VO2max. <5mets, STseg dep.>1mm CHF >2mm, Peak HR <135, Post hospital/extened outpatient and exercise maintenance. Exercise maintenance stage - Stabilized cardiovascular disease and physiological responses to exercise. - Desired outcome from exercise therapy achieved or no additional process. 105

3 Exercise prescription Benefits of Aerobic Exercise Duration minutes mild to moderates Intensity - Metabolic Energy Equivalents:3-6 mets - Heart Rate<55% of peak Heart Rate - Borg rating of perceived exertion <11 - Caloric expenditure : 150 to 200Cals per day Modes - Walk the dog, Yard work, Golf without a cart Biking, Hiking, Cross Country Skiing, Aquarobics Brisk walking for 60 minutes per day Reduces Cardiovascular Risks(x2) Improves Lipid profile Enhances Fibrinolysis and alters platelet function Lowers Blood Pressure Improves Glucose Tolerance and Insulin Sensitivity Increase in maximal cardiac output Oxygen consumption Lowering heart rate at systolic submaximal work levels Increase peak heart rate Contraindications Graded exercise test Change in resting ECG Myocardial infarction Unstable angina Uncontrolled ventricular dysrhythmia Uncontrolled atrial dysrhythmia Chronotropic capacity VO2 peak, RPE RPP Symptom(Dyspnea, Chest pain, Dizziness) ECG (ST-T-wave change, arrythmias, LBBB, LVH) Drug response Third-degree A-V block Thallium scan 201, Technetium 99m, Acute congestive heart failure Drugs PTCA Anti-ischemic drugs : beta blockers, Ca-channel blocker Nitrogen(longer duration) Platelet inhibitors Anticoagulants Digitalis Diuretics Angiotensin-converting enzyme inhibitors Vasodilators Anti-arrhythmic drugs Lipid-altering drugs Aspirin(baby) 관상동맥죽상경화증 : 관상동맥내지질및섬유조직의국부적축적 혈관내강이점차좁아 혈관내강의 75% 이상이폐쇄 막힌관상동맥의혈류량향상및허혈심근에산소공급향상 심혈관관련이환율및사망률의잠재적감소 혈관의팽창ㆍ혈소판응집및재분해ㆍ혈관벽의신전및혈관직경의증가 허혈성심장질환자의과반수이상이 PTCA( 연간 60만명이상 ) 심기능상실잔존 : PTCA의최대제한요인 PTCA시술환자중 30~40% 정도 (6개월이내 ) -재협착발생 106

4 세미나 Ⅱ 재활을위한운동처방 Effects of PTCA CABG T-파의전위 - 심전도상의변화를감소, 제거 약한운동시자각증세 : 운동능력향상 심실수축및심근활동의향상 운동시혈역학반응의향상 최대산소섭취량 : 20% 증가 최대하운동시심박수와혈압의감소 사망률의감소 : 20~25% 재협착유병율의감소 관상동맥의동맥경화방지 약물요법에불응성인협심증경감 PTCA가불가능한경우 좌측주관상동맥질환자 삼중관상동맥질환자 이중관상동맥질환자및좌심실기능장애자 근위좌전관상동맥질환자의수명연장 평균좌심실구출율 38% CABG시술 -5년이내에70% 는협심증이완전히제거 - 10년이내 50% 정도는자각증상 Angina pectoris Angina Scale Lack of Oxygen demand Acute Chest pain (Shoulder, Lt. arm, Neck, Jaw radiation) Dyspnea, diaphoretic Symptom : 10-20secs. ( 30mins longer) Stable Angina pectoris, Unstable Angina pectoris (GI, skeletal muscle, respiratory dx.) PVO2max : 50~70% Lack of Peripheral extraction of oxygen -CO(SV, HR) decrease.) No symptom ST seg dep. : mild 1 단계에서 4 단계 1단계 = 가볍고, 거의두드러지지않는다. 2단계 = 보통, 불편하다 ; 3단계 = 심함, 매우불편하다 ; 4단계 = 가장심함 운동중 : 단지 50% 만이최대운동검사 운동검사중 ST 분절하강은검사중협심증유무 : - 차후심장질환의가능성증가 Myocardial infarction Cardiac Transplantation 150만이상의미국인, 약 1/3인 50만명이사망 / 년 Sign & symptom 팔, 등, 목등으로퍼져나가는심하고지속적인흉통. 발한, 메스꺼움, 구토등혈청농도의증가 Aspartate transaminase Serum glutamic oxaloacetic transaminase Creatine phosphokinase Creatine kinase; Lactic dehydrogenase ST분절의하강과 T-wave reverse(ischemic injury) Q-wave : myocardial necrosis, permanant change 심장이식수술 : 말기심부전 성인의생존율 : 83%(1년 ), 77%(3년 ) 동소이식 - Recipient 심방에 Doner 심장심방의연결. 운동의적응이어려운이유 - 운동부족, 심장기능의약화, 근력의저하자율신경분포의부재 Cardiac Rehabilitation programme - Decrease : RHR (4bs/min), Sensitivity of beta receptor, Resting nor-epinephrine. -Increase: max Ex. HR - No change : Rest Stroke Volume 107

5 Exercise prescription Congestive Heart Failure 등척성운동은금기심실빈맥, 심장정지 ( 급사 ), 저혈압등의병력 : 심전도 (ECG) 노에피네프린의감소혈관확장물질의순환증가고혈당증의개선신장기능의변화를포함운동강도 : 최대심박수의 50-65% 범위운동지속시간 : 15분 - 60분 / 회운동빈도 : 유산소운동 4-6회 / 주저항성트레이닝 : 2회 / 주 심근수축능력의감소 ( 좌심실의수축기능저하 ) 이완기혈압의기능장애 심박출량감소 좌심실압의증가 심실의과부하 골격근대사에서의심각한장애 혈관확장장애 염분과물을정체시키는신장기능부전 증상 : 피로, 호흡곤란, 운동지구력감소등 운동효과 : 운동능력증가 - 관상동맥의개선보다는말초혈관에서효과 Artificial pacemaker 안정시, 운동시정상적인심장기능을거의모방 운동시 DDD와 VVIR 조율기는상한심박수가제한 환자의허혈역치아래로설정. 운동시심박수와설정된심박수사이의 10% 안전범위 -부정맥, 심실부정맥을유발 - 운동전환자의 ICD 프로그램에대해완전한지식은근본적으로필요 적용의예 3도방실 (A-V) 차단, 병적인동서맥의증상 비적용의예심근비대, 낮은심박출량 Training effects and Education 운동능력증진 -심박출량증가 : 교감신경자극, 신경전달물질, 호르몬분비 ( 심박수증가 ) 위험요인감소 : 콜레스테롤의조절, 고혈압의감소등 정신적문제의개선 영구적사용 : 생존율증가, 증상감소 상체운동주의 : 삽입된리드제거처음부터고려되지말아야함 교육 - 기본적인충분한지식 - 환자와전기생리학자와의면밀한상의 - 상한선의운동강도 : 허혈역치이하로설정 - ICD를촉진하는심박수의원인제공은삼가 Mitral valve stenosis 류마치스성열 ( 대략 60%) 선천적인원인 승모판의석회화 - 승모판역류 : 경한협착 좌심방압력, 폐혈관압력증가 - 호흡부전의발생 호흡곤란 : 초기에고강도운동시발생 - 승모판막질환이악화됨 - 저강도활동에서도점차발생 : 기좌호흡과진성폐부종등 객혈, 흉통, 혈전, 심내막염증, 쉰소리 Intensity : maximal heart rate reserve : 40-85% RPE; 9-11 Frequency : 3days/wk Duration : 20-40mins intermittently ex. 108

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untitled Case Report : Asan Medical Center Cardiac Rehabilitation AACVPR (http://www.aacvpr.org/) KACVPR (http://www.kacvpr.com/) Backgrounds PCI 2,395 consecutive patients in Minnesota (Mayo Clinic) Between1994