RU2405608C2 - Method of rehabilitation of patients with acute myocardial infarction and accompanying chronic cardiac failure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to cardiology. The rehabilitation of the patients with acute myocardial infarction and accompanying chronic cardiac failure is ensured by a standard medical therapy that involves prolonged release nitrates, calcium antagonists, beta-blockers, direct anticoagulants to be prescribed. On the 3-5^th day, the therapy is supplemented with respiratory muscle training with the use of Threshold IMT and Threshold PEP trainers that create respective inhale and exhale resistive load. The start inhale resistive load is specified at 9 cm WC, while exhale resistive load - at 5 cm WC. Every third-fifth training, resistive loads of both trainers are increased by 2 cm WC. The trainings are daily, 2 times a day. The training involve 4 cycles consisting of fourfold repeated sequence of inhale for 4-5 seconds and exhale for 5-6 seconds, and a pause. The cycles are separated by 2 minutes of rest.

EFFECT: method improves rehabilitation effectiveness in the patients with acute myocardial infarction and accompanying chronic cardiac failure.

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Description

The invention relates to medicine, namely cardiology, and can be used for the rehabilitation of patients with acute myocardial infarction and concomitant heart failure.

The concept of cardiac or cardiac rehabilitation has firmly entered into the cardiology practice of most countries of the world. In this case, the term cardiac rehabilitation should be understood as a set of measures aimed at the most complete restoration and maintenance of the physiological, psychological, medical, social, and professional status of patients with myocardial infarction (MI) (Komissarenko I.A. Tactics of management of patients of older age groups who had a heart attack myocardium. Handbook of a polyclinic physician, 2006, volume 04, No. 6). In accordance with the recommendations of the WHO, rehabilitation for myocardial infarction is divided into three phases: inpatient, sanatorium (recovery) and supportive; in this case, the purpose of the stationary phase of rehabilitation is the relief of acute MI, prevention of complications and stabilization of the state, restoration of the physical and psychological state of the patient; the purpose of the sanatorium (second) stage of rehabilitation is to prepare the patient for an active life - to adapt to return to the domestic and industrial environment; the purpose of the supporting (third) stage of rehabilitation is to maintain the level of physical performance achieved in the sanatorium or a possible increase in this level.

Despite the fact that the use of physical exercises as an integral stage of cardiorehabilitation for patients after myocardial infarction began in the late seventies, there is still no consensus on the optimal timing and rate of expansion of the motor regime during physical rehabilitation. In some cases, physical exercises begin at the inpatient rehabilitation stage, and, in most cases, after it, at the sanatorium, rehabilitation treatment department, or coronary club. The positive effects of the use of physical exercises can be divided into several components: reduced mortality, improved lipid profile, decreased adverse remodeling of the left ventricle, positive effect on hemodynamic parameters and endothelial dysfunction, increased exercise tolerance.

At the same time, the question of the possibility of physical rehabilitation of patients with severe concomitant pathology, in particular with chronic heart failure, is very difficult. A patient suffering from chronic heart failure has the peculiarities of respiration biomechanics, the most important feature of which is the constantly high respiration rate. A short respiratory cycle leads to an increase in the functional residual capacity of the lungs and its gradual prevalence over the volume of relaxation of the lungs (the volume of the lungs at which the elastic recoil pressure is zero). In other words, insufficient (short) expiratory time excludes the process of lung decompression to the level of the natural volume of relaxation before the start of the next inhalation. The most adverse effect of the described process is the effect on the respiratory muscles through the development of its fatigue and, in some cases, exhaustion (Korsunskaya MI et al. Respiratory striated muscle dysfunction in patients with chronic heart failure and reduced body weight. Heart failure. 2001, Volume 2, No. 3). An increase in functional residual capacity changes intrathoracic pressure and affects venous return, closing the pathological circle triggered by systolic dysfunction of the left ventricle. The recommendations for the treatment of patients with chronic heart failure of III-IV functional classes (FC) according to the classification of the New York Heart Association (NYHA), as well as those with severe body mass deficiency, cachexia, generally accepted physical activity are not shown (according to at least initially).

At the same time, information is known from the prior art that it is possible to use respiratory training as such in the rehabilitation of patients with chronic heart failure (CHF) of FC I-II according to NYHA classification (see, for example, RU 2271235 C1, 03/10/2006; Kurtaev O.Sh. et al. Selected Sanatorium Rehabilitation Techniques for Patients with Coronary Heart Disease. St. Petersburg, 2002, pp. 11-16; Gianfranco Parati et al., Device-Guided Paced Breathing in the Home Setting, Effects on Exercise Capacity, Pulmonary and Ventricular Function in Patients With Chronic Heart Failure: A Pilot Study, Circulation: Heart Failure, 2008, No. 1, p. 178-183). The proven effect of respiratory training on reducing systolic pressure, reducing the severity of dyspnea, improving hemodynamic parameters, increasing exercise tolerance, improving quality of life (based on the results of using the Minnesota Questionnaire).

The foregoing has led us to the idea of the possibility of using breathing training in those patients who are contraindicated in active physical activity, but the inclusion of which (along with the use of standard therapy) could help accelerate rehabilitation. In particular, we were tasked with developing a method for the rehabilitation of patients with acute myocardial infarction (AMI) and concomitant heart failure, including chronic heart failure III-IV FC according to the NYHA classification.

The analysis of the prior art showed that the closest way to the proposed one is the method of the same purpose, which consists in carrying out the so-called standard therapy for acute myocardial infarction, including the use of prolonged nitrates, calcium antagonists, beta-blockers, direct anticoagulants (heparin), antiplatelet agents, statins, diuretics, angiotensin converting enzyme inhibitors (see the description to RU 2168993 C1, 06/20/2001 or Chazov EI Diseases of the heart and blood vessels. M: Medicine, vol. II, p. 5-178). The known method can improve coronary blood flow, reduce blood coagulation, improve the course of energy processes in the myocardium.

The disadvantages of this method are the lack of pathogenetically substantiated effects on the vicious cycle described in p.2 of the present description.

The technical result of the proposed method is to increase the efficiency of rehabilitation of patients with acute myocardial infarction and concomitant heart failure through the use of respiratory training according to our developed method, leading to changes in the biomechanics of breathing of a patient with AMI and CHF, which, in turn, reduce the functional residual capacity lungs, decreased intrathoracic pressure and venous return, normalization of contractile function of the left ventricle, decreased sys pressure, reducing the severity of dyspnea, improving hemodynamic parameters, increasing exercise tolerance. Moreover, as a result of our studies, we reliably established the fact that the most favorable early start of respiratory training, namely 3-5 days after myocardial infarction, since respiratory training, begun precisely at the indicated time, will contribute to the prevention of adverse post-infarction remodeling of the left ventricle against the background of heart failure.

Before starting respiratory training according to the proposed method, it is necessary to assess the presence of contraindications to the patient. The list of contraindications is standard and is taken into account when prescribing any respiratory training in patients with cardiovascular and bronchopulmonary diseases:

- blood pressure less than 90/60 mm Hg and more than 160/110 mm Hg;

- the use of iv inotropic drugs;

- glomerular filtration rate less than 40 ml / min;

- potassium of blood less than 3.5 or more than 5.5 mmol / l;

- acute cerebrovascular accident during the previous 3 months;

- any concomitant disease in art. decompensation;

- hemodynamically significant valvular defects.

Our proposed method of rehabilitation is as follows.

For 3-5 days of hospitalization of a patient with acute myocardial infarction and concomitant chronic heart failure, in the absence of contraindications (see above), against the background of standard (traditional) AMI therapy, breathing muscles are trained according to the proposed method. For training, breathing simulators are used with the creation of additional resistance on inhalation and exhalation - Threshold IMT ^® and Threshold PEP ^®, respectively (Healthscan Products Inc., New Jersey, USA). The simulator consists of a spring valve attached to the mouthpiece, through which the inhale or exhale. Using compression or decompression of the spring, you can change the valve opening pressure in the simulator. The simulator has a pressure scale in cm of water column. The starting resistance to inspiration is set at 9 cm of water, exhalation is at 5 cm of water.

The patient takes a comfortable sitting position, puts a clip on his nose. After a normal inhalation, the Threshold IMT ^® mouthpiece is taken into the mouth and a slow inhalation is performed for 4-5 seconds, so as to feel the passage of an air stream through the device body. After that, without exhaling air, a Threshold PEP ^® mouthpiece is placed in the mouth and a slow exhalation through Threshold PEP ^® is performed for 5-6 seconds. Then a pause of about 3 seconds follows. After that, the sequence of inhalation, exhalation and pause is repeated 3 more times. After this, the nose clip must be removed and breathed normally (calm breathing) for 2 minutes to prevent hyperventilation. Then the whole cycle, consisting of four times repeated sequence of inspiration, expiration and pause, is repeated 3 more times. Before the start of the next cycle (at the end of the previous one), 2 minutes of rest are followed. Thus, the duration of one workout is about twenty minutes. It is necessary to conduct 2 workouts a day in the morning and in the evening at least five times a week. At the same time, every third to fifth workout should increase the resistance by 2 cm of water. After 30, 90, 180, 360 days, an assessment is made of the patient's condition, exercise tolerance, quality of life, the results of which decide on the feasibility of further respiratory training according to the proposed method or their termination.

The proposed method is illustrated by the following clinical examples.

Example 1. Patient G., 63 years old, was admitted to the hospital with a diagnosis of Acute myocardial infarction. The diagnosis was made on the basis of patient complaints, clinical presentation, instrumental and laboratory research methods. When examining a patient's condition of moderate severity. Integuments of usual color, acrocyanosis. On palpation of the lower extremities, swelling of the legs was determined. Rigid breathing was heard in the lungs, moist finely bubbly inaccurate rales in the lower sections on both sides. With auscultation of the heart, tones are muffled, the rhythm is correct. Heart rate 78 per minute. HELL 130/80 mm Hg On palpation, the abdomen is soft, painless, the liver protrudes 5 cm from under the edge of the costal arch; on palpation, its edge is smooth, moderately painful. The symptom of striking is negative on both sides. In a general clinical blood test without features, in a biochemical blood test, an increase in MV-CPK, LDH, total cholesterol and LDL. General urine analysis without features.

3 days after admission against the background of standard AMI therapy, including injections of low molecular weight heparin, followed by cancellation and replacement with antiplatelet agents, angiotensin converting enzyme inhibitors, beta-blockers, statins, diuretics, prolonged nitrates, as well as physical rehabilitation carried out according to approved standards for physical rehabilitation of patients with AMI, given concomitant heart failure and the absence of contraindications, the patient is recommended to conduct respiratory training on the proposal ennomu method using Threshold IMT ^® simulators (inhalation) and Threshold PEP ^® (exhalation). Starting resistance to inspiration is set at 9 cm water column, exhalation is at 5 cm water column.

The patient, in a sitting position, placed a clip on his nose. After a normal inhalation, he took the mouthpiece Threshold IMT ^® into his mouth and inhaled slowly for 4-5 seconds. After that, without exhaling air, a Threshold PEP ^® mouthpiece was placed in the mouth and a slow expiration was made through Threshold PEP ^® for 5-6 seconds. Then he paused for about 3 seconds. Then he repeated the procedure of inhaling and exhaling 3 more times. After that, he removed the clip from the nose and breathed calmly for 2 minutes. Then the entire cycle, consisting of four times repeated sequence of inspiration, expiration and pause, is repeated 3 more times. The cycles are separated by a 2-minute rest. The patient performed 2 workouts a day in the morning and evening at least five times a week. At the same time, every third to fifth workout produced an increase in resistance by 2 cm of water column.

The patient was discharged from the hospital on the 17th day. Recommendations for further treatment are given and a handbook on the implementation of breathing exercises is issued on hand. After 30, 90, 180, 360 days, an assessment was made of the patient's condition, exercise tolerance, quality of life, the results of which are given below. Initially, the indicators of the 6-minute test were 180 m, after 30 days - 187 m, after 60 days - 191 m, after 90 days - 205 m, after 180 days 220 m, after 360 days - 245 m. The initial total QL score (for The Minnesota Quality of Life Questionnaire) amounted to 56 initially, after 30 days - 55 points, after 60 days - 50 points, after 90 days - 43 points, after 180 days - 40 points.

Example 2. Patient K., 65 years old, was admitted to the hospital with a diagnosis of Acute myocardial infarction. The diagnosis was made on the basis of patient complaints, clinical presentation, instrumental and laboratory research methods. When examining the patient's condition of moderate severity. Integuments of usual color, acrocyanosis. On palpation of the lower extremities, swelling of the legs was determined. Rigid breathing was heard in the lungs, moist finely bubbly inaccurate rales in the lower sections on both sides. With auscultation of the heart, tones are muffled, the rhythm is correct. Heart rate 64 min. HELL 140/80 mm Hg On palpation, the abdomen is soft, painless, the liver protrudes 4 cm from under the edge of the costal arch; on palpation, its edge is smooth, moderately painful. The symptom of striking is negative on both sides. In a general clinical blood test without features, in a biochemical blood test, an increase in MV-CPK, LDH, total cholesterol and LDL. General urine analysis without features.

On the 5th day after admission against the background of standard AMI therapy, including injections of low molecular weight heparin, followed by cancellation and replacement with antiplatelet agents, administration of angiotensin converting enzyme inhibitors, beta-blockers, statins, diuretics, prolonged nitrates, as well as physical rehabilitation carried out by approved standards for physical rehabilitation of patients with AMI, taking into account concomitant heart failure and the absence of contraindications, the patient is recommended to conduct respiratory training on the proposal Nome method using Threshold IMT ^® simulators (inhalation) and Threshold PEP ^® (exhalation). Starting resistance to inspiration is set at 9 cm water column, exhalation is at 5 cm water column.

The patient, in a sitting position, placed a clip on her nose. After a normal breath, I took the Threshold IMT ^® mouthpiece into my mouth and took a slow breath for 4-5 seconds. After that, without exhaling air, she placed a Threshold PEP ^® mouthpiece in her mouth and exhaled slowly through Threshold PEP ^® for 5-6 seconds. Then she paused for about 3 seconds. Then she repeated the procedure of inhalation and exhalation and pause 3 more times. After that, she removed the clip from her nose and breathed calmly for 2 minutes. Then the whole cycle, consisting of four times repeated sequence of inhalation, exhalation, pause, was repeated 3 more times. The cycles were separated by a 2-minute rest. The patient performed 2 workouts a day in the morning and evening at least five times a week. At the same time, every third to fifth workout produced an increase in resistance by 2 cm of water column.

The patient was discharged from the hospital on the 18th day. Recommendations for further treatment are given and a handbook on the implementation of breathing exercises is issued on hand. After 30, 90, 180, 360 days, an assessment was made of the patient's condition, exercise tolerance, quality of life, the results of which are given below. Initially, the indicators of the 6-minute test were 178 m, after 30 days - 188 m, after 60 days - 193 m, after 90 days - 207 m, after 180 days - 218 m, after 360 days - 247 m. The initial total QL score ( according to the Minnesota Quality of Life Questionnaire) it was 57 initially, after 30 days - 55 points, after 60 days - 49 points, after 90 days - 43 points, after 180 days - 41 points.

Below are examples that confirm the need for strict implementation of the entire set of techniques of the claimed method for implementing the claimed purpose and achieving the technical result of the method (that is, examples that reflect the fact of the negative impact of non-compliance with the entire set of methods of the method on achieving its technical and clinical result).

Example 3. Patient N., 59 years old, was admitted to the hospital with a diagnosis of Acute myocardial infarction. The diagnosis was made on the basis of patient complaints, clinical presentation, instrumental and laboratory research methods. When examining a patient's condition of moderate severity. Integuments of usual color, acrocyanosis. On palpation of the lower extremities, swelling of the legs was determined. Rigid breathing was heard in the lungs, moist finely bubbly inaccurate rales in the lower sections on both sides. With auscultation of the heart, tones are muffled, the rhythm is correct. Heart rate 82 min. HELL 140/85 mm Hg On palpation, the abdomen is soft, painless, the liver protrudes 5 cm from under the edge of the costal arch; on palpation, its edge is smooth, moderately painful. The symptom of striking is negative on both sides. In a general clinical blood test without features, in a biochemical blood test, an increase in MV-CPK, LDH, total cholesterol and LDL. General urine analysis without features.

On the 12th day after admission against the background of standard AMI therapy, including injections of low molecular weight heparin, followed by cancellation and replacement with antiplatelet agents, administration of angiotensin converting enzyme inhibitors, beta-blockers, statins, prolonged nitrates, as well as physical rehabilitation carried out according to the approved standards of physical rehabilitation of patients with AMI, given concomitant heart failure and the absence of contraindications, the patient is recommended to conduct respiratory training according to the proposed method using Threshold IMT ^® (breath) and Threshold PEP ^® (breath) simulators. Starting resistance to inspiration is set at 9 cm water column, exhalation is at 5 cm water column.

The patient, in a sitting position, placed a clip on his nose. After a normal inhalation, he took the mouthpiece Threshold IMT ^® into his mouth and inhaled slowly for 4-5 seconds. After that, without exhaling air, a Threshold PEP ^® mouthpiece was placed in the mouth and a slow expiration was made through Threshold PEP ^® for 5-6 seconds. Then he paused for about 3 seconds. Then he repeated the procedure of inhalation-exhalation-pause 3 more times. After that, he removed the clip from the nose and breathed calmly for 2 minutes. Then the whole cycle, consisting of a four-fold repeated sequence of inhalation-exhalation-pause, was repeated 3 more times, the cycles were separated by a 2-minute rest. The patient performed 2 workouts a day in the morning and evening 5 times a week. At the same time, every third to fifth workout produced an increase in resistance by 2 cm of water column.

The patient was discharged from the hospital on the 17th day. Recommendations for further treatment are given and a handbook on the implementation of breathing exercises is issued on hand. After 30, 90, 180, 360 days, an assessment was made of the patient's condition, exercise tolerance, quality of life, the results of which are given below. Initially, the 6-minute test indicators were 187 m, after 30 days - 189 m, after 60 days - 190 m. The initial total QOL score (according to the Minnesota quality of life questionnaire) was 56 initially, after 30 days - 55 points, after 60 days - 55 points. At the same time, the patient showed low motivation to perform training. After 60 days, the patient stopped training, continuing to take drug therapy.

Example 4. Patient N., 59 years old, was admitted to the hospital with a diagnosis of Acute myocardial infarction. The diagnosis was made on the basis of patient complaints, clinical presentation, instrumental and laboratory research methods. When examining a patient's condition of moderate severity. Integuments of usual color, acrocyanosis. On palpation of the lower extremities, swelling of the legs was determined. Rigid breathing was heard in the lungs, moist finely bubbly inaccurate rales in the lower sections on both sides. With auscultation of the heart, tones are muffled, the rhythm is correct. Heart rate 82 min. HELL 140/85 mm Hg On palpation, the abdomen is soft, painless, the liver protrudes 5 cm from under the edge of the costal arch; on palpation, its edge is smooth, moderately painful. The symptom of striking is negative on both sides. In a general clinical blood test without features, in a biochemical blood test, an increase in MV-CPK, LDH, total cholesterol and LDL. General urine analysis without features.

3 days after admission against the background of standard AMI therapy, including injections of low molecular weight heparin, followed by cancellation and replacement with antiplatelet agents, angiotensin converting enzyme inhibitors, beta-blockers, statins, prolonged nitrates, and physical rehabilitation carried out according to approved standards physical rehabilitation of patients with AMI, given concomitant heart failure and the absence of contraindications, the patient is recommended to conduct respiratory training according to the proposed method using Threshold IMT ^® (breath) and Threshold PEP ^® (breath) simulators. Starting resistance to inspiration is set at 9 cm water column, exhalation is at 5 cm water column.

The patient, in a sitting position, placed a clip on his nose. After a normal inhalation, he took the mouthpiece Threshold IMT ^® into his mouth and inhaled slowly for 4-5 seconds. After that, without exhaling air, a Threshold PEP ^® mouthpiece was placed in the mouth and a slow expiration was made through Threshold PEP ^® for 5-6 seconds. Then he paused for about 3 seconds. Then he repeated the procedure of inhalation, exhalation and pause 3 more times. After that, he removed the clip from the nose and breathed calmly for 2 minutes. Then the whole cycle, consisting of a four-fold repeated sequence of inhalation-exhalation-pause, was repeated 3 more times, the cycles were separated by a 2-minute rest. The patient performed 1 workout a day in the evening 3-4 times a week. At the same time, every third to fifth workout produced an increase in resistance by 2 cm of water column.

The patient was discharged from the hospital on the 17th day. Recommendations for further treatment are given and a handbook on the implementation of breathing exercises is issued on hand. After 30, 90, 180, 360 days, an assessment was made of the patient's condition, exercise tolerance, quality of life, the results of which are given below. Initially, the 6-minute test indicators were 185 m, after 30 days - 190 m, after 60 days - 189 m, after 90 days - 195 m, after 180 days - 201 m, after 360 days - 205 m. The initial total QL score ( according to the Minnesota Quality of Life Questionnaire) it was 56 initially, after 30 days - 55 points, after 60 days - 55 points, after 90 days - 55 points, after 180 days - 53 points.

Thus, our proposed set of methods provides an increase in the efficiency of rehabilitation of patients with acute myocardial infarction and concomitant chronic heart failure.

Claims (1)

A method for the rehabilitation of patients with acute myocardial infarction and concomitant chronic heart failure, including the appointment of standard therapy using prolonged nitrates, calcium antagonists, beta-blockers, direct anticoagulants, characterized in that on 3-5 days of the treatment they additionally begin respiratory muscular training with using the Threshold IMT and Threshold PEP simulators, which allow creating resistance on inhalation and exhalation, respectively; while the starting resistance to inspiration is set at 9 cm water column, exhalation is set at 5 cm water column; every third to fifth workout increase the resistance of both simulators by 2 cm of water; training on simulators is carried out daily 2 times a day and consists of 4 cycles consisting of a four-fold repeated sequence of inhalation lasting 4-5 seconds, exhalation lasting 5-6 seconds and pause; cycles are separated by a 2-minute rest.