PDF(1438 KB)
Guidelines for integrated traditional Chinese and Western medicine rehabilitation of heart diseases
the Drafting Group of the “Guidelines for Integrated Traditional Chinese and Western Medicine Rehabilitation of Heart Diseases” by the Muscle and Skeleton, Integrated Traditional Chinese and Western Medicine Rehabilitation Professional Committee of the Shanghai Rehabilitation Medicine Association, Rehabilitation Medicine Department of Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine
Shanghai Medical & Pharmaceutical Journal ›› 2024, Vol. 45 ›› Issue (17) : 15-28.
PDF(1438 KB)
PDF(1438 KB)
Guidelines for integrated traditional Chinese and Western medicine rehabilitation of heart diseases
({{custom_author.role_en}}), {{javascript:window.custom_author_en_index++;}}Cardiovascular disease is one of the leading causes of death worldwide. The comprehensive rehabilitation intervention for patients with heart disease is a major clinical challenge. Traditional Chinese medicine has unique advantages in the rehabilitation of this disease, but currently there is no integrated rehabilitation plan for heart disease in China. The Muscle and Skeleton Integrated Traditional Chinese and Western Medicine Rehabilitation Professional Committee of the Shanghai Rehabilitation Medicine Association has organized experts in relevant fields to combine relevant clinical guidelines in recent years and developed “Guidelines for Integrated the Traditional Chinese and Western Medicine Rehabilitation of Heart Diseases” after repeated discussions with experts in related fields, aiming to guide and standardize the practice of integrated traditional Chinese and Western medicine rehabilitation of heart diseases.
heart diseases / rehabilitation / integrated traditional Chinese and Western medicine / clinical guideline {{custom_keyword}} /
表1 心脏康复的主要适应证及其运动处方禁忌证 |
| 主要适应证 | 运动处方禁忌证 |
|---|---|
| 近期心肌梗死 急性冠状动脉综合征 慢性稳定型心绞痛 充血性心力衰竭 冠状动脉搭桥手术后 经皮冠状动脉介入治 疗后 瓣膜手术后 心脏移植手术后 | 不稳定型心绞痛 急性失代偿性充血性心力衰竭 复杂性室性心律失常 严重肺动脉高压（右心室收缩压>60 mmHg） 心脏腔室内血栓 近期血栓性静脉炎（伴或不伴肺栓塞） 严重梗阻性心肌病 严重或有症状的主动脉瓣狭窄 不受控制的心肌炎症或感染性病理改变 三度房室传导阻滞 急性心力衰竭或慢性失代偿性心力衰竭 夹层动脉瘤 急性心肌炎或心包炎 有任何妨碍充分参与运动的肌肉骨骼疾病者 |
表2 心脏康复的体适能评估方法 |
| 评估 项目 | 器械法 | 徒手法 |
|---|---|---|
| 心肺 适能 | 心肺运动负荷试验、运动负荷心电图检查、运动心脏超声检查 | 2 min踏步试验、6 min步行试验、200 m快速步行试验 |
| 肌肉 适能 | 等速肌力测试 | 握力测试、起立-行走记时测试、30 s手臂屈曲试验、1 min仰卧起坐试验、爬楼梯试验 |
| 柔韧性适能 | 抓背试验、坐椅前伸试验、改良转体试验 | |
| 平衡 适能 | 平衡测量仪检测 | 功能性前伸试验、单腿站立试验 |
表3 心肺运动试验测量参数及其意义 |
| 参数 | 定义 | 参考值 | 意义 |
|---|---|---|---|
| 峰值耗氧量 | 指人体在极限运动时的最大耗氧能力，代表人体供氧能力的极限水平，实际中常以峰值摄氧量替代 | 低于预测值的84%被认为峰值摄氧量降低 | 表示患者的心肺功能储备和外周组织摄氧能力 |
| 无氧阈 | 指机体随着运动负荷的增加，有氧代谢不能满足全身组织的能量需求，组织必须通过无氧代谢提供更多能量，这时血乳酸水平开始升高、血pH开始下降，此刻的临界点被称为无氧阈 | 无氧阈的正常值>44%的峰值摄氧量 | 无氧阈以下的运动为有氧代谢，应据此制定运动处方 |
| 氧脉搏 | 由摄氧量除以同时间的心率得到，是心脏1次搏动输出血量所摄取的氧量 | 随着运动负荷增加，氧脉搏逐渐增加，并缓慢接近上限值8.5~11.0 mL/（min·W） | 反映每搏输出量随运动负荷增加氧的时相性反应，对可疑心肌缺血具有诊断价值 |
| 呼吸交换率 | 是二氧化碳排出量与摄氧量的比值。随着运动负荷逐渐增加，当二氧化碳排出量超过摄氧量时，呼吸交换率增加 | 峰值呼吸交换率>1.1提示运动量已达到相当程度，但不是停止运动试验的指标值 | 呼吸交换率反映了患者在运动中的努力程度，峰值呼吸交换率≥1.1代表已非常尽力地进行了运动 |
| 二氧化碳通气当量 | 是每分钟通气量与二氧化碳排出量的比值，常根据运动试验中所有数据由线性回归方法计算得到 | 二氧化碳通气当量的正常值为20~30，>34可作为心力衰竭患者高危的预测因子 | 二氧化碳通气当量代表肺通气与血流的匹配程度，反映肺通气效率 |
| 摄氧量与功率的关系 | 正常生理情况下，摄氧量与功率之间存在线性关系，常用摄氧量增量与功率增量的比值表示 | 摄氧量增量与功率增量比值的正常值为8.4~11.0 mL/（min·W） | 摄氧量增量与功率增量比值降低多提示氧输送功能障碍，可见于心脏、周围动脉、肺疾病和线粒体肌病患者。在心脏疾病患者中，较低的摄氧量增量与功率增量比值可能与心肌缺血相关且预示死亡风险增加 |
表4 6 min步行试验及其结果的临床意义 |
| 试验 | 内容 |
|---|---|
| 适应证 | 心力衰竭、肺动脉高压患者治疗前后比较； 心力衰竭、心血管疾病患者功能状态评估； 心力衰竭、肺动脉高压患者心血管事件发生和死亡风险预测 |
| 禁忌证 | 绝对禁忌证为不稳定型心绞痛或心肌梗死发作1个月内患者； 相对禁忌证为静息心率>120次/min、血压>180/100 mmHg患者 |
| 终止试验指标 | 胸痛； 不能耐受的呼吸困难； 下肢痉挛； 走路摇晃； 出虚汗； 面色苍白或灰白； 患者要求终止试验 |
| 结果的临床意义 | Ⅰ级：<150 m，说明心肺功能差； Ⅱ级：150~300 m，说明心肺功能一般偏差； Ⅲ级：301~450 m，说明心肺功能一般偏好； Ⅳ级：>450 m，说明心肺功能良好 |
表5 心脏焦虑问卷 |
| 序号 | 问题 | 答案（得分） | ||||
|---|---|---|---|---|---|---|
| 从不 （0分） | 很少 （1分） | 有时 （2分） | 经常 （3分） | 总是 （4分） | ||
| 1 | 我注意到我的心跳 | |||||
| 2 | 我避免体力消耗 | |||||
| 3 | 那颗跳动的心在夜里唤醒了我 | |||||
| 4 | 胸痛/不适让我醒来 | |||||
| 5 | 我尽量放松一下 | |||||
| 6 | 我检查我的脉搏 | |||||
| 7 | 我避免锻炼或做体力劳动 | |||||
| 8 | 我能感觉到我的心在我的胸口 | |||||
| 9 | 我避免做那些让我心跳得更快的活动 | |||||
| 10 | 如果检测结果正常，我仍然会担心我的心脏 | |||||
| 11 | 我觉得在医院、医生或其他医疗机构的附近工作很安全 | |||||
| 12 | 我避免做那些让我流汗的活动 | |||||
| 13 | 我担心医生不相信我的症状是真的 | |||||
| 当我有胸部不适或当我的心跳加快时： | ||||||
| 14 | 我担心我可能会有心脏病发作 | |||||
| 15 | 我一直专注于其他的事情 | |||||
| 16 | 我吓坏了 | |||||
| 17 | 我喜欢由医生去检查 | |||||
| 18 | 我告诉我的家人或朋友 | |||||
表6 AACVPR的心血管事件风险分层 |
| 风险分层 | 内容 |
|---|---|
| 低风险 | 无明显左心室功能障碍（射血分数>50%）； 无复杂性心律失常，无论是静息还是运动时； 单纯性心肌梗死、冠状动脉旁路移植术后、经皮腔内冠状动脉成形术后； 无充血性心力衰竭或体征/症状提示运动后缺血； 无复杂性心律失常、心绞痛等症状，包括运动试验中和运动后恢复期； 心脏功能容量≥7能量代谢当量 |
| 中风险 | 中度左心室功能不全（射血分数40%~49%）； 中等强度运动时有心血管事件体征/症状，包括心绞痛（5~6.9能量代谢当量），或中等强度运动后恢复期出现心血管事件体征/症状； 心脏功能容量≤5能量代谢当量 |
| 高风险 | 严重左心室功能损害（射血分数<40%）； 心脏骤停或猝死的幸存者； 静息或运动时出现复杂性室性心律失常； 心肌梗死或心脏手术并发心源性休克或充血性心力衰竭，或术后体征/症状提示缺血； 运动时血流动力学异常（尤其是随着负荷增加，出现心率变异或心跳无力现象）或收缩压下降，或运动后恢复期有反常的血流动力学反应（如严重的运动后低血压）； 心血管事件症状/体征，包括低强度运动时出现心绞痛（<5能量代谢当量）； 运动时ST段缺血性改变（压低>2 mm） |
表7 心脏运动康复分期与目标 |
| 分期 | 时间 | 训练内容 | 适用患者 | 预期目标 |
|---|---|---|---|---|
| Ⅰ期康复 | 于心血管事件或干预完成后不久，在住院环境中开始 | 首先评估患者的身体功能。治疗师和护士可从指导患者在床上或床边进行非剧烈运动开始，重点关注运动的范围和适应能力。康复治疗团队也可专注于训练患者的日常生活活动能力，并教育患者不要有过度压力。鼓励患者保持相对休息状态，直到合并症或术后并发症治疗完成 | 过去8 h内无新发或再发胸痛，心肌损伤标志物（肌酸激酶同功酶和肌钙蛋白）水平没有进一步升高，无明显心力衰竭失代偿征兆（静息时呼吸困难伴肺部湿啰音），过去8 h内无新发严重心律失常或心电图改变 | 促进患者功能恢复，改善患者心理状态，帮助患者恢复体力及日常生活活动能力，出院时达到生活基本自理，避免卧床带来的不利影响，在缩短住院时间的同时，为Ⅱ期康复做好身心两方面的准备 |
| Ⅱ期康复 | 于患者病情稳定并通过心脏病学检查后开始，通常持续3~6周，但有时可能持续达12周 | 第一步：热身运动。多采用低水平有氧运动或低强度拉伸运动，持续5~15 min。第二步：康复运动阶段，包括有氧运动、抗阻运动、柔韧性运动、平衡运动等各种运动方式的训练。其中，有氧运动是基础，抗阻运动、柔韧性运动是补充。第三步：放松运动。可是慢节奏有氧运动的延续或是柔韧性运动，根据患者病情轻重持续5~10 min | 根据心血管事件风险分层，在心电图、血压监护下进行选择性的中等强度运动，推荐3个月内运动康复次数为每周3次或以上，3个月后需再次评估，并据此调整运动处方 | 在Ⅰ期康复的基础上进一步改善患者的身心状况，全面提高患者的体适能 |
| Ⅲ期康复 | 于Ⅱ期康复结束后开始，一直持续下去 | 在Ⅱ期康复的基础上持续进行运动康复，同时控制日常生活中的危险因素，每2~6个月重新进行1次康复评估 | 受社区和家庭条件的限制，达到Ⅱ期康复目标且能脱离监护并掌握运动方法的患者才适合回到社区和家庭继续进行运动康复 | 促进生活方式改变，并在必要时进行干预，以防止复发 |
表8 有氧运动强度评判方法 |
| 方法 | 依据 | 备注 |
|---|---|---|
| 无氧阈法 | 以无氧阈前1 min的心率或功率作为运动强度，或以无氧阈时心率的80%~100%为靶心率 | 无氧阈相当于最大摄氧量的60%左右，此水平是心脏运动康复的最佳运动强度 |
| 心率储备法 | 目标心率=（最大心率－静息心率）×运动强度＋静息心率 | 临床上较为常用，不受药物因素的影响 |
| 峰值摄氧量法 | 通过心肺运动试验测得峰值摄氧量，取其40%~80%对应的心率、功率或能量代谢当量为有氧运动的合适强度 | 峰值摄氧量是心肺运动试验的首要测量指标值 |
| 自觉疲劳程度量表法 | 多采用Borg评分表，患者根据自觉疲劳程度打分，最轻6分，最重20分 | 通常建议患者在Borg评分12~16分范围内进行运动 |
表9 营养处方推荐 |
| 关键原则 | 举例 | 注意事项 |
|---|---|---|
| 充足的蛋白质对于防止肌肉流失至关重要 | 吃优质动植物蛋白，如瘦肉、鱼、乳制品和坚果等 | 老年人和肾病患者要减少蛋白质摄入量 |
| 吃高纤维食物，限制精制淀粉和糖类摄入 | 选择高纤维食物，如全麦面包和意大利面，包括非淀粉类蔬菜 | 控制份量并减少不利于改善血糖的总碳水化合物摄入 |
| 减少饱和脂肪和反式脂肪酸摄入 | 减少肥肉、肉类食品和奶油等摄入，少吃含有黄油、起酥油的糕点 | |
| 在整体饮食和健康需求的背景下考虑乳制品摄入量 | 过多摄入无益，300 g/d即可 | |
| 鸡蛋是减少饱和脂肪摄入的健康膳食模式的组成部分 | 可能需要考虑家族性高胆固醇血症患者的鸡蛋摄入量/膳食胆固醇摄入量 | |
| 吃天然的富含不饱和脂肪的食物 | 坚果、种子、油性鱼、特级初榨橄榄油是传统地中海饮食的重要组成部分 | |
| 大量食用蔬菜和水果 | 主要是根茎类蔬菜、绿叶蔬菜，如羽衣甘蓝、生菜、菠菜和十字花科蔬菜。应包括各种水果 | 理想情况下应食用新鲜或冷冻水果，除非只能获得罐头水果。注意总碳水化合物和游离糖含量，特别是对于血糖异常的患者 |
| 对于饮酒者，建议酒精摄入量为20~30 mL/d，每周1~2 d不饮酒。避免酗酒 | ||
| 采用全饮食方法，并根据患者个体的合并症和需求量身定制 | 蔬菜、水果、坚果、豆类、未精制谷物、适量海鲜和发酵乳制品是传统心脏保护膳食的主要组成部分，可辅以少量的红肉和加工肉类；以橄榄油作为主要烹饪用油 | 考虑降低总碳水化合物摄入量，特别是对于血糖异常患者，并用植物性蛋白质或脂肪替代 |
表10 心脏疾病危险因素控制目标范围 |
| 危险因素 | 控制目标范围 |
|---|---|
| 高血压 | 对于无其他疾病的高血压患者，血压<140/90 mmHg；若患者还存在肾脏疾病或糖尿病，血压应<130/80 mmHg |
| 高血脂 | ①对于心血管疾病风险高的患者，低密度脂蛋白胆固醇<2.6 mmol/L（100 mg/dL）；对于心血管疾病风险极高的患者，包括急性冠脉综合征或冠心病合并糖尿病患者，低密度脂蛋白胆固醇应<1.8 mmol/L（70 mg/dL）。 ②甘油三酯<1.7 mmol/L（150 mg/dL）。 ③对于心血管疾病风险高的患者，非高密度脂蛋白胆固醇<3.3 mmol/L（130 mg/dL）；对于心血管疾病风险极高的患者，非高密度脂蛋白胆固醇应<2.6 mmol/L（100 mg/dL） |
| 高血糖 | 年轻患者的糖化血红蛋白<7%；老年患者的糖化血红蛋白应<8% |
| 肥胖 | 体质量指数维持在18.5~23.9 kg/m²，腰围控制在男性≤90 cm、女性≤85 cm |
| 饮酒 | 每天酒精摄入量，男性不超过30 mL、女性不超过15 mL |
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杜雪翠, 李运伦, 杨传华. 心悸(室性心律失常)中医证候研究进展[J]. 中西医结合心脑血管病杂志, 2012, 10(10): 1242-1244.
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程伟, 邓悦, 陈少军, 等. 心脏神经症中医证候分布规律的研究[J]. 中国中医药现代远程教育, 2018, 16(11): 152-155.
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段锦龙, 姚魁武, 尚小立. 胸痹的中医证候及用药规律文献研究[J]. 世界中西医结合杂志, 2019, 14(6): 772-775.
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中国中西医结合学会心血管疾病专业委员会, 中国医师协会中西医结合医师分会心血管疾病专业委员会. 慢性心力衰竭中西医结合诊疗专家共识[J]. 中国中西医结合杂志, 2016, 36(2): 133-141.
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The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets.In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5-23.1%] vs. 15.7% (IQR 14.5-21.1%)}, diabetes [7.7% (IQR 7.1-10.1%) vs. 5.6% (IQR 4.8-7.0%)], and among males smoking [43.8% (IQR 37.4-48.0%) vs. 26.0% (IQR 20.9-31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0-10.8) vs. 16.7% (IQR 13.9-19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655-8115)] compared with high-income [2235 (IQR 1896-3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures.A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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The age-specific relevance of blood pressure to cause-specific mortality is best assessed by collaborative meta-analysis of individual participant data from the separate prospective studies.Information was obtained on each of one million adults with no previous vascular disease recorded at baseline in 61 prospective observational studies of blood pressure and mortality. During 12.7 million person-years at risk, there were about 56000 vascular deaths (12000 stroke, 34000 ischaemic heart disease [IHD], 10000 other vascular) and 66000 other deaths at ages 40-89 years. Meta-analyses, involving "time-dependent" correction for regression dilution, related mortality during each decade of age at death to the estimated usual blood pressure at the start of that decade.Within each decade of age at death, the proportional difference in the risk of vascular death associated with a given absolute difference in usual blood pressure is about the same down to at least 115 mm Hg usual systolic blood pressure (SBP) and 75 mm Hg usual diastolic blood pressure (DBP), below which there is little evidence. At ages 40-69 years, each difference of 20 mm Hg usual SBP (or, approximately equivalently, 10 mm Hg usual DBP) is associated with more than a twofold difference in the stroke death rate, and with twofold differences in the death rates from IHD and from other vascular causes. All of these proportional differences in vascular mortality are about half as extreme at ages 80-89 years as at ages 40-49 years, but the annual absolute differences in risk are greater in old age. The age-specific associations are similar for men and women, and for cerebral haemorrhage and cerebral ischaemia. For predicting vascular mortality from a single blood pressure measurement, the average of SBP and DBP is slightly more informative than either alone, and pulse pressure is much less informative.Throughout middle and old age, usual blood pressure is strongly and directly related to vascular (and overall) mortality, without any evidence of a threshold down to at least 115/75 mm Hg.
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Emerging Risk Factors Collaboration,
Uncertainties persist about the magnitude of associations of diabetes mellitus and fasting glucose concentration with risk of coronary heart disease and major stroke subtypes. We aimed to quantify these associations for a wide range of circumstances.We undertook a meta-analysis of individual records of diabetes, fasting blood glucose concentration, and other risk factors in people without initial vascular disease from studies in the Emerging Risk Factors Collaboration. We combined within-study regressions that were adjusted for age, sex, smoking, systolic blood pressure, and body-mass index to calculate hazard ratios (HRs) for vascular disease.Analyses included data for 698 782 people (52 765 non-fatal or fatal vascular outcomes; 8.49 million person-years at risk) from 102 prospective studies. Adjusted HRs with diabetes were: 2.00 (95% CI 1.83-2.19) for coronary heart disease; 2.27 (1.95-2.65) for ischaemic stroke; 1.56 (1.19-2.05) for haemorrhagic stroke; 1.84 (1.59-2.13) for unclassified stroke; and 1.73 (1.51-1.98) for the aggregate of other vascular deaths. HRs did not change appreciably after further adjustment for lipid, inflammatory, or renal markers. HRs for coronary heart disease were higher in women than in men, at 40-59 years than at 70 years and older, and with fatal than with non-fatal disease. At an adult population-wide prevalence of 10%, diabetes was estimated to account for 11% (10-12%) of vascular deaths. Fasting blood glucose concentration was non-linearly related to vascular risk, with no significant associations between 3.90 mmol/L and 5.59 mmol/L. Compared with fasting blood glucose concentrations of 3.90-5.59 mmol/L, HRs for coronary heart disease were: 1.07 (0.97-1.18) for lower than 3.90 mmol/L; 1.11 (1.04-1.18) for 5.60-6.09 mmol/L; and 1.17 (1.08-1.26) for 6.10-6.99 mmol/L. In people without a history of diabetes, information about fasting blood glucose concentration or impaired fasting glucose status did not significantly improve metrics of vascular disease prediction when added to information about several conventional risk factors.Diabetes confers about a two-fold excess risk for a wide range of vascular diseases, independently from other conventional risk factors. In people without diabetes, fasting blood glucose concentration is modestly and non-linearly associated with risk of vascular disease.British Heart Foundation, UK Medical Research Council, and Pfizer.Copyright 2010 Elsevier Ltd. All rights reserved.
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中华医学会心血管病学分会流行病学组,中国医师协会心血管内科医师分会, 中国老年学学会心脑血管病专业委员会. 糖代谢异常与动脉粥样硬化性心血管疾病临床诊断和治疗指南[J]. 中华心血管病杂志, 2015, 43(6): 488-506.
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With increased efforts to lower serum cholesterol levels, it is important to quantify associations between serum cholesterol level and causes of death other than coronary heart disease, for which an etiologic relationship has been established.For an average of 12 years, 350,977 men aged 35 to 57 years who had been screened for the Multiple Risk Factor Intervention Trial were followed up following a single standardized measurement of serum cholesterol level and other coronary heart disease risk factors; 21,499 deaths were identified.A strong, positive, graded relationship was evident between serum cholesterol level measured at initial screening and death from coronary heart disease. This relationship persisted over the 12-year follow-up period. No association was noted between serum cholesterol level and stroke. The absence of an association overall was due to different relationships of serum cholesterol level with intracranial hemorrhage and nonhemorrhagic stroke. For the latter, a positive, graded association with serum cholesterol level was evident. For intracranial hemorrhage, cholesterol levels less than 4.14 mmol/L (less than 160 mg/dL) were associated with a twofold increase in risk. A serum cholesterol level less than 4.14 mmol/L (less than 160 mg/dL) was also associated with a significantly increased risk of death from cancer of the liver and pancreas; digestive diseases, particularly hepatic cirrhosis; suicide; and alcohol dependence syndrome. In addition, significant inverse graded associations were found between serum cholesterol level and cancers of the lung, lymphatic, and hematopoietic systems, and chronic obstructive pulmonary disease. No significant associations were found of serum cholesterol level with death from colon cancer, with accidental deaths, or with homicides. Overall, the inverse association between serum cholesterol level and most cancers weakened with increasing follow-up but did not disappear. The association between cholesterol level and death due to cancer of the lung and liver, chronic obstructive pulmonary disease, cirrhosis, and suicide weakened little over follow-up.The association of serum cholesterol with specific causes of death varies in direction, strength, gradation, and persistence. Further research on the determinants of low serum cholesterol level in populations and long-term follow-up of participants in clinical trials are necessary to assess whether inverse associations with noncardiovascular disease causes of death are consequences of noncardiovascular disease, whether serum cholesterol level and noncardiovascular disease are both consequences of other factors, or whether these associations are causal.
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Current knowledge of the impact of cardiovascular risk factors in Latin America is limited.As part of the INTERHEART study, 1237 cases of first acute myocardial infarction and 1888 age-, sex-, and center-matched controls were enrolled from Argentina, Brazil, Colombia, Chile, Guatemala, and Mexico. History of smoking, hypertension, diabetes mellitus, diet, physical activity, alcohol consumption, psychosocial factors, anthropometry, and blood pressure were recorded. Nonfasting blood samples were analyzed for apolipoproteins A-1 and B-100. Logistic regression was used to estimate multivariate adjusted odds ratios (ORs) and their 95% confidence intervals (CIs). Persistent psychosocial stress (OR, 2.81; 95% CI, 2.07 to 3.82), history of hypertension (OR, 2.81; 95% CI, 2.39 to 3.31), diabetes mellitus (OR, 2.59; 95% CI, 2.09 to 3.22), current smoking (OR, 2.31; 95% CI, 1.97 to 2.71), increased waist-to-hip ratio (OR for first versus third tertile, 2.49; 95% CI, 1.97 to 3.14), and increased ratio of apolipoprotein B to A-1 (OR for first versus third tertile, 2.31; 95% CI, 1.83 to 2.94) were associated with higher risk of acute myocardial infarction. Daily consumption of fruits or vegetables (OR, 0.63; 95% CI, 0.51 to 0.78) and regular exercise (OR, 0.67; 95% CI, 0.55 to 0.82) reduced the risk of acute myocardial infarction. Abdominal obesity, abnormal lipids, and smoking were associated with high population-attributable risks of 48.5%, 40.8%, and 38.4%, respectively. Collectively, these risk factors accounted for 88% of the population-attributable risk.Interventions aimed at decreasing behavioral risk factors, lowering blood pressure, and modifying lipids could have a large impact on the risk of acute myocardial infarction among Latin Americans.
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Cholesterol Treatment Trialists’ Collaboration,
Lowering of LDL cholesterol with standard statin regimens reduces the risk of occlusive vascular events in a wide range of individuals. We aimed to assess the safety and efficacy of more intensive lowering of LDL cholesterol with statin therapy.We undertook meta-analyses of individual participant data from randomised trials involving at least 1000 participants and at least 2 years' treatment duration of more versus less intensive statin regimens (five trials; 39 612 individuals; median follow-up 5·1 years) and of statin versus control (21 trials; 129 526 individuals; median follow-up 4·8 years). For each type of trial, we calculated not only the average risk reduction, but also the average risk reduction per 1·0 mmol/L LDL cholesterol reduction at 1 year after randomisation.In the trials of more versus less intensive statin therapy, the weighted mean further reduction in LDL cholesterol at 1 year was 0·51 mmol/L. Compared with less intensive regimens, more intensive regimens produced a highly significant 15% (95% CI 11-18; p<0·0001) further reduction in major vascular events, consisting of separately significant reductions in coronary death or non-fatal myocardial infarction of 13% (95% CI 7-19; p<0·0001), in coronary revascularisation of 19% (95% CI 15-24; p<0·0001), and in ischaemic stroke of 16% (95% CI 5-26; p=0·005). Per 1·0 mmol/L reduction in LDL cholesterol, these further reductions in risk were similar to the proportional reductions in the trials of statin versus control. When both types of trial were combined, similar proportional reductions in major vascular events per 1·0 mmol/L LDL cholesterol reduction were found in all types of patient studied (rate ratio [RR] 0·78, 95% CI 0·76-0·80; p<0·0001), including those with LDL cholesterol lower than 2 mmol/L on the less intensive or control regimen. Across all 26 trials, all-cause mortality was reduced by 10% per 1·0 mmol/L LDL reduction (RR 0·90, 95% CI 0·87-0·93; p<0·0001), largely reflecting significant reductions in deaths due to coronary heart disease (RR 0·80, 99% CI 0·74-0·87; p<0·0001) and other cardiac causes (RR 0·89, 99% CI 0·81-0·98; p=0·002), with no significant effect on deaths due to stroke (RR 0·96, 95% CI 0·84-1·09; p=0·5) or other vascular causes (RR 0·98, 99% CI 0·81-1·18; p=0·8). No significant effects were observed on deaths due to cancer or other non-vascular causes (RR 0·97, 95% CI 0·92-1·03; p=0·3) or on cancer incidence (RR 1·00, 95% CI 0·96-1·04; p=0·9), even at low LDL cholesterol concentrations.Further reductions in LDL cholesterol safely produce definite further reductions in the incidence of heart attack, of revascularisation, and of ischaemic stroke, with each 1·0 mmol/L reduction reducing the annual rate of these major vascular events by just over a fifth. There was no evidence of any threshold within the cholesterol range studied, suggesting that reduction of LDL cholesterol by 2-3 mmol/L would reduce risk by about 40-50%.UK Medical Research Council, British Heart Foundation, European Community Biomed Programme, Australian National Health and Medical Research Council, and National Heart Foundation.Copyright © 2010 Elsevier Ltd. All rights reserved.
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Background: Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force. Methods: An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored. Results: Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention. Conclusion: When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.
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Nutrition has a central role in both primary and secondary prevention of cardiovascular disease yet only relatively recently has food been regarded as a treatment, rather than as an adjunct to established medical and pharmacotherapy. As a field of research, nutrition science is constantly evolving making it difficult for patients and practitioners to ascertain best practice. This is compounded further by the inherent difficulties in performing double-blind randomised controlled trials. This paper covers dietary patterns that are associated with improved cardiovascular outcomes, including the Mediterranean Diet but also low-carbohydrate diets and the potential issues encountered with their implementation. We suggest there must be a refocus away from macronutrients and consideration of whole foods when advising individuals. This approach is fundamental to practice, as clinical guidelines have focused on macronutrients without necessarily considering their source, and ultimately people consume foods containing multiple nutrients. The inclusion of food-based recommendations aids the practitioner to help the patient make genuine and meaningful changes in their diet. We advocate that the cardioprotective diet constructed around the traditional Mediterranean eating pattern (based around vegetables and fruits, nuts, legumes, and unrefined cereals, with modest amounts of fish and shellfish, and fermented dairy products) is still important. However, there are other approaches that can be tried, including low-carbohydrate diets. We encourage practitioners to adopt a flexible dietary approach, being mindful of patient preferences and other comorbidities that may necessitate deviations away from established advice, and advocate for more dietitians in this field to guide the multi-professional team.© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
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Electrocardiographic (ECG) exercise stress test has been a major diagnostic test in cardiology for several decades. Ongoing technological advances that have led to a wide use of imaging techniques and development of new guidelines have called for a revised and updated approach to the technique and interpretation of the ECG exercise testing. The present document outlines an expert opinion of the Polish Cardiac Society Working Group on Cardiac Rehabilitation and Exercise Physiology regarding the performance and interpretation of ECG exercise testing in adults. We discussed technical requirements and necessary equipment for the exercise testing laboratory as well as healthcare personnel competencies necessary to supervise ECG exercise testing and fully interpret test findings. Broad indications for ECG exercise testing include diagnostic assessment of coronary artery disease (CAD), including pre-test probability of CAD, evaluation of functional disease severity and risk strati- fication in patients with established CAD, assessment of response to treatment, evaluation of exercise-related symptoms and exercise capacity, patient evaluation before exercise training/cardiac rehabilitation, and risk stratification prior to non-cardiac surgery. ECG exercise testing is safe if indications and contraindications are observed, testing is appropriately monitored, and indications for test termination are clearly established. The exercise protocol should be adjusted to the expected exercise capacity of a patient so as to limit the duration of exercise to 8-12 min. Clinical, haemodynamic, and ECG response to exercise is evaluated during the test. The test report should include information about the exercise protocol used, reason for test termination, perceived exertion, presence/severity of anginal symptoms, peak exercise capacity or tolerated workload in relation to the predicted exercise capacity, heart rate response, and the presence or absence of ST-T changes. The test report should conclude with a summary including clinical and ECG assessment.
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Heart-focused anxiety (HFA) is the fear of cardiac-related stimuli and sensations because of their perceived negative consequences. Although HFA is common to a wide variety of persons who experience chest pain and distress, it often is unrecognized and misdiagnosed, particularly in cardiology and emergency room patients without and with heart disease. To address these concerns, this article reports on the development and preliminary psychometric evaluation of the Cardiac Anxiety Questionnaire (CAQ) designed to measure HFA. In Study 1, 188 cardiology patients completed the CAQ. Item and factor analyses indicated a three-factor solution pertaining to heart-related fear, avoidance, and attention. Reliability analysis of the 18-item CAQ revealed good internal consistency of the total and subscale scores. In Study 2, 42 patients completed the CAQ and several other anxiety-related questionnaires to assess its convergent and divergent properties. Although preliminary validity results are promising, further psychometric study is necessary to cross-validate the CAQ, examine its test-retest reliability, and confirm the stability of the factor structure. Taken together, the CAQ appears to assess HFA, and may therefore be a useful instrument for identifying patients with elevated HFA without and with heart disease.
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顾俊, 甘窈. 心血管神经症患者心脏焦虑问卷的临床应用[J]. 中国现代医生, 2009, 47(27): 4-5; 22.
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In stable coronary artery disease (CAD), exercise training has well-documented positive effects on arterial endothelial function. NO derived from endothelial NO synthase (eNOS) is regarded as a protective factor against atherosclerosis. The aim of the present study was to investigate the effects of exercise training on the endothelial function in relation to the expression of eNOS and Akt-dependent eNOS phosphorylation in the left internal mammary artery (LIMA) of patients with stable CAD.In 17 training patients (T) and 18 control patients (C), endothelium-dependent vasodilation and average peak flow velocity (APV) in response to acetylcholine were measured invasively at study beginning and after 4 weeks in the LIMA. In LIMA tissue sampled during bypass surgery, eNOS expression and content of pospho-eNOS-Ser1177, Akt, and phospho-Akt were determined by Western blot and quantitative reverse transcriptase-polymerase chain reaction. After exercise training, LIMA APV in response to acetylcholine was increased by 56+/-8% (from +48+/-8% at beginning to +104+/-11% after 4 weeks, P<0.001). Patients in T had a 2-fold higher eNOS protein expression (T 1.0+/-0.7 versus C 0.5+/-0.3 arbitrary units, P<0.05) and 4-fold higher eNOS Ser1177-phosphorylation levels in LIMA-endothelium (1.2+/-0.9 versus 0.3+/-0.2 arbitrary units, P<0.01). A linear correlation was confirmed between Akt phosphorylation and phospho-eNOS levels (R=0.80, P<0.05) and between phospho-eNOS and Delta APV (R=0.59, P<0.05).Exercise training in stable CAD leads to an improved agonist-mediated endothelium-dependent vasodilatory capacity. The change in acetylcholine-induced vasodilatation was closely related to a shear stress-induced/Akt-dependent phosphorylation of eNOS on Ser1177.
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Aging is associated with decreased skeletal muscle function. Increased levels of advanced glycation end products (AGEs) in skeletal muscle tissue are observed with advancing age and in diabetes. Although serum AGE level is negatively associated with grip strength in elderly people, it is unknown whether this association is present in adult males. To determine the relationship between AGE accumulation in tissue and muscle strength and power among Japanese adult men. Skin autofluorescence (AF) (a noninvasive method for measuring tissue AGEs), grip strength (n = 232), and leg extension power (n = 138) were measured in Japanese adult men [median (interquartile range) age, 46.0 (37.0, 56.0) years]. After adjustment for potential confounders, the adjusted means [95% confidence interval (CI)] for grip strength across the tertiles of skin AF were 44.5 (43.2, 45.9) kg for the lowest tertile, 42.0 (40.6, 43.3) kg for the middle tertile, and 41.7 (40.3, 43.1) kg for the highest tertile (P for trend < 0.01). Moreover, the adjusted geometric means (95% CI) of leg extension power across the tertiles of skin AF were 17.8 (16.6, 19.1) W/kg for the lowest tertile, 17.5 (16.4, 18.7) W/kg for the middle tertile, and 16.0 (14.9, 17.1) W/kg for the highest tertile (P for trend = 0.04). Among Japanese adult men, participants with higher skin AF had lower muscle strength and power, indicating a relationship between AGE accumulation and muscle strength and power. A long-term prospective study is required to clarify the causality.
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A reduction in compliance of the large-sized cardiothoracic (central) arteries is an independent risk factor for the development of cardiovascular disease with advancing age.We determined the role of habitual exercise on the age-related decrease in central arterial compliance by using both cross-sectional and interventional approaches. First, we studied 151 healthy men aged 18 to 77 years: 54 were sedentary, 45 were recreationally active, and 53 were endurance exercise-trained. Central arterial compliance (simultaneous B-mode ultrasound and arterial applanation tonometry on the common carotid artery) was lower (P:<0.05) in middle-aged and older men than in young men in all 3 groups. There were no significant differences between sedentary and recreationally active men at any age. However, arterial compliance in the endurance-trained middle-aged and older men was 20% to 35% higher than in the 2 less active groups (P:<0.01). As such, age-related differences in central arterial compliance were smaller in the endurance-trained men than in the sedentary and recreationally active men. Second, we studied 20 middle-aged and older (53+/-2 years) sedentary healthy men before and after a 3-month aerobic exercise intervention (primarily walking). Regular exercise increased central arterial compliance (P:<0.01) to levels similar to those of the middle-aged and older endurance-trained men. These effects were independent of changes in body mass, adiposity, arterial blood pressure, or maximal oxygen consumption.Regular aerobic-endurance exercise attenuates age-related reductions in central arterial compliance and restores levels in previously sedentary healthy middle-aged and older men. This may be one mechanism by which habitual exercise lowers the risk of cardiovascular disease in this population.
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Cardiac rehabilitation combines prescriptive exercise training with coronary artery disease (CAD) risk factor modification in patients with established CAD. As such, cardiac rehabilitation programs are ideally positioned to assume a pivotal role in the rendering of many components of comprehensive cardiovascular disease risk reduction in a secondary prevention setting. However, the extent to which traditional cardiac rehabilitation programs can successfully accomplish this goal is limited by low participation rates, inadequate emphasis on many of the essential aspects of secondary prevention, and lack of long-term follow-up of patients. To overcome these deficiencies, cardiac rehabilitation programs should evolve into cardiovascular risk reduction programs by implementing approaches that have been shown to be effective in randomized clinical trials. In this manuscript we describe one such approach, based on the Stanford Coronary Risk Intervention Project, which has been implemented in > 1,000 patients. Key components of this physician-supervised, nurse case-manager model include: (1) initial evaluation and risk assessment; (2) identification of specific goals for each CAD risk factor; (3) formulation and implementation of an individualized treatment plan that includes lifestyle modification and pharmacologic interventions for accomplishing specific risk reduction goals; (4) long-term follow-up to enhance compliance and revise the treatment plan as indicated; and (5) a mechanism for outcomes based long-term assessment of each patient.
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Although the DASH (Dietary Approaches to Stop Hypertension) diet has been shown to lower blood pressure (BP) in short-term feeding studies, it has not been shown to lower BP among free-living individuals, nor has it been shown to alter cardiovascular biomarkers of risk.To compare the DASH diet alone or combined with a weight management program with usual diet controls among participants with prehypertension or stage 1 hypertension (systolic BP, 130-159 mm Hg; or diastolic BP, 85-99 mm Hg).Randomized, controlled trial in a tertiary care medical center with assessments at baseline and 4 months. Enrollment began October 29, 2003, and ended July 28, 2008.Overweight or obese, unmedicated outpatients with high BP (N = 144).Usual diet controls, DASH diet alone, and DASH diet plus weight management.The main outcome measure is BP measured in the clinic and by ambulatory BP monitoring. Secondary outcomes included pulse wave velocity, flow-mediated dilation of the brachial artery, baroreflex sensitivity, and left ventricular mass.Clinic-measured BP was reduced by 16.1/9.9 mm Hg (DASH plus weight management); 11.2/7.5 mm (DASH alone); and 3.4/3.8 mm (usual diet controls) (P <.001). A similar pattern was observed for ambulatory BP (P <.05). Greater improvement was noted for DASH plus weight management compared with DASH alone for pulse wave velocity, baroreflex sensitivity, and left ventricular mass (all P <.05).For overweight or obese persons with above-normal BP, the addition of exercise and weight loss to the DASH diet resulted in even larger BP reductions, greater improvements in vascular and autonomic function, and reduced left ventricular mass.clinicaltrials.gov Identifier: NCT00571844.
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This study aimed to explore the effects of massage on the state anxiety of patients receiving percutaneous coronary intervention (PCI).In accordance with the principle of the minimum allocation of imbalance index for comparability, a total of 117 cases that were ready to receive PCI were divided into two groups (59 in the intervention group and 58 in the control group). The patients in the control group received routine care, whereas the patients in the observation group were given massage intervention. The state anxiety, heart rate, and blood pressure of the two groups were observed and compared.Massage treatments reduced the emergency response and level of anxiety of cardiovascular patients before PCI. The post-intervention blood pressure, heart rate, and pain score of the intervention group were significantly better than those of the control group (P<0.05).Health professionals should pay attention to and strengthen the exploration of the effects of reasonable care intervention mode under PCI to promote the physical and mental health of patients, as well as improve their medical care satisfaction.
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Anxiety is the most common negative emotion among the patients awaiting coronary angiography. The increased anxiety may exacerbate coronary heart disease symptoms and possibly contribute to complications during the procedure. Chinese hand massage is a nonpharmaceutical intervention that has been used in several clinical situations in China and might have beneficial effects on reducing anxiety before coronary angiography.The aim of this study was to evaluate the effectiveness and safety of Chinese hand massage care on anxiety among patients awaiting coronary angiography.One hundred eighty-five subjects awaiting coronary angiography in a single hospital in Fuzhou, China, between May 2012 and September 2012 were screened. One hundred eligible participants were recruited and randomly assigned into the control or Chinese hand massage group. The control group received the conventional therapies and care according to the guidelines, and those in the Chinese hand massage group received additional Chinese hand massage care in conjunction with the same conventional therapies and care as the control group. The anxiety scores (evaluated by using the Hamilton Anxiety Rating Scale), heart rate, blood pressure, quality of life (Short-Form Health Survey), and the adverse events were recorded at the baseline and after coronary angiography, respectively.The scores of Hamilton Anxiety Rating Scale in the Chinese hand massage group (11.78 [SD, 2.9]) had a statistically significant decrease compared with those in the control group (15.96 [SD, 3.4]) at post-procedure (P <.01). There was no statistically significant difference on blood pressure, heart rate, and Short-Form Health Survey at postangiography between the Chinese hand massage group and the control group. No adverse event was reported during the intervention period.Chinese hand massage effectively alleviated anxiety without any adverse effects among patients awaiting coronary angiography. Therefore, it might be recommended as a nonpharmacological nursing intervention. However, future study with a larger sample size is needed to further confirm the efficacy of Chinese hand massage intervention.
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PDF(1438 KB)
表1 心脏康复的主要适应证及其运动处方禁忌证表2 心脏康复的体适能评估方法表3 心肺运动试验测量参数及其意义表4 6 min步行试验及其结果的临床意义表5 心脏焦虑问卷表6 AACVPR的心血管事件风险分层表7 心脏运动康复分期与目标表8 有氧运动强度评判方法表9 营养处方推荐表10 心脏疾病危险因素控制目标范围/
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