RU2746296C1 - Method for determining rehabilitation potential in patients after coronary artery bypass graft - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and namely to cardiac rehabilitation. The invention can be used in the rehabilitation of patients with various cardiac pathologies after open heart surgery. First, the presence of a complicated or uncomplicated postoperative course and myocardial ischemia is determined. Next, a treadmill test or a 6-minute walk test is performed to determine the level of exercise tolerance (METs) and the FIT index. Echocardiography is performed to determine the left ventricular ejection fraction (LVEF). The blood levels of alanine aminotransferase (ALT) and hemoglobin are then determined. Holter ECG monitoring is performed based on the results of which the gradation of ventricular arrhythmias is determined according to Lown. If there is an uncomplicated postoperative course, exercise tolerance of more or equal to 7 METs, no myocardial ischemia, the LVEF of more than 50%, absence of high-grade ventricular arrhythmias according to Lown, the FIT index level of 1-100, the blood ALT level of more than or equal to 17 U / L, the hemoglobin level of more than or equal to 100 g / l, a high level of rehabilitation potential and a low risk of adverse events are determined, which indicates a high level of readiness of the patient's condition for aerobic cardiorespiratory training (CRT). If there is angina pain in the postoperative period, exercise tolerance of 5-7 METs, reversible deviations according to the results of a stress test on a treadmill or a 6-minute walk test, the LVEF of 45-50%, high-grade ventricular arrhythmias according to Lown, the FIT index level varying from -56.9 to -30.9, the blood ALT level of less than or equal to 17 U / L, the hemoglobin level in blood of less than or equal to 100 g / L, a low level of rehabilitation potential and an average risk of adverse events are determined, which indicates a low level of readiness of the patient's condition for aerobic CRT.

EFFECT: method provides accurate determination of the physical readiness of patients after CABG to perform aerobic cardiorespiratory training.

1 cl, 3 tbl, 2 ex

Description

The invention relates to medicine, namely to cardiac rehabilitation, and can be used in the rehabilitation of patients with various cardiac pathologies after open heart surgery.

Improvement of rehabilitation measures after heart surgery due to the increase in the number of patients with cardiovascular diseases with severe concomitant pathology necessitates the search and development of new criteria for the effectiveness of the most individualized and safe rehabilitation and more accurate methods of their objective assessment.

Before embarking on a particular program of physical cardiac rehabilitation, a thorough assessment of the clinical and functional status of the patient is required, which should allow creating a protocol for selection and risk stratification: to calculate the level of physical readiness for choosing the intensity of physical training, further planning the rehabilitation program; to assess the possible risks of various adverse events, cardiovascular morbidity and mortality in the long term after such operations. On the basis of clinical, instrumental and laboratory criteria, patients should be classified according to levels - with low, medium or high levels of readiness for physical cardiac rehabilitation.

There is a spectrum of risk in this patient population. It is necessary to differentiate between patients with complete and incomplete myocardial revascularization, preserved or reduced left ventricular ejection fraction (LVEF) of the heart, with or without disturbances in the heart rhythm. It is important to identify patients at high risk from the above spectrum in order to anticipate the development of adverse events. Despite the increased relative risk of developing acute cardiac and other events with unusual intense exercise, it is important to understand and know that the absolute risk of developing sudden cardiac death (SCD) or myocardial infarction (MI) during exercise is negligible. Increasingly, SCD or MI develop in individuals without a previous history of coronary artery disease (CAD), angina pectoris, or acute myocardial infarction. Major adverse events rarely occur in high-risk patients.

According to the definition contained in the Russian clinical guidelines for the rehabilitation and secondary prevention of patients after coronary artery bypass grafting (CABG), the "rehabilitation potential" takes into account: the clinical course of coronary heart disease, the volume and severity of myocardial damage, the degree of obstruction of the coronary arteries; other functional disorders - complications that developed in acute myocardial infarction or CABG; the psychological state of the patient; individual resources and compensatory capabilities of the cardiovascular system; the presence of comorbidity; state of cognitive function; environmental factors affecting the viability and social activity of the patient [Bokeria L.A., Aronov D.M. Russian clinical guidelines. Coronary artery bypass grafting in patients with ischemic heart disease. Rehabilitation and secondary prevention. CardioSomatics. 2016; 7 (3-4): 5-71].

The allocated levels of rehabilitation potential - high, medium, low and extremely low, are differentiated only according to the functional classes (FC) of chronic heart failure (CHF) according to the NYHA (New York Heart Association) classification, proposed in 1964 and received worldwide recognition [Criteria Committee, New York Heart Association // In: Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis. 6th ed. Boston: Little, Brown and Co .; 1964: 114]. A high level of rehabilitation potential corresponds to FC I CHF, medium - FC II CHF, low - FC III CHF and extremely low - FC IV CHF according to NYHA. This method is the closest analogue of the developed method.

The disadvantage of this classification method is that it only takes into account the general physical activity of patients and complaints such as shortness of breath, fatigue, weakness and palpitations. Based on this classification, it is impossible to accurately determine the physical readiness of patients to perform aerobic cardiorespiratory training after CABG and evaluate such significant indicators as exercise tolerance, FIT-treadmill index, the nature of rhythm disturbances (ventricular or supraventricular rhythm disturbances) and laboratory data. research. It is of little use in patients after CABG, which prompted us to create a new method and approach to assessing the physical readiness of patients after such operations.

The technical problem solved in the present invention was the development of a method without the disadvantages of the prototype.

The achieved technical result is an accurate determination of the physical readiness of patients after CABG to perform aerobic cardiorespiratory training.

The technical result is achieved due to the following set of essential features: determine the presence of a complicated or uncomplicated postoperative course and myocardial ischemia; a treadmill test or 6-minute walk test is performed to determine the level of exercise tolerance (METs) and the FIT index; perform echocardiography (EchoCG) with the definition of LVEF; determine the levels of alanine aminotransferase ALT (U / l) and hemoglobin (g / l) in the blood; Holter monitoring of the electrocardiogram (ECG) is performed, based on the results of which the gradation of ventricular arrhythmias is determined according to Lown.

With uncomplicated postoperative course, exercise tolerance ≥ 7 METs, absence of myocardial ischemia, LVEF> 50%, absence of high-grade ventricular arrhythmias according to Lown, FIT index 1-100, blood ALT level ≥ 17 U / L, hemoglobin level ≥ 100 g / L determines a high level of rehabilitation potential and a low risk of adverse events in the patient, which indicates a high level of readiness of the patient's condition for aerobic cardiorespiratory training (CRT).

In the presence of angina pectoris pain in the postoperative period, exercise tolerance of 5-7 METs, reversible deviations according to the results of a stress test on a treadmill or a 6-minute walk test, LVEF 45-50%, high-grade ventricular arrhythmias according to Lown, level FIT index from -56.9 to -30.9, blood ALT level ≤ 17 U / L, hemoglobin level in blood ≤ 100 g / L determine a low level of rehabilitation potential and an average risk of adverse events in a patient, which indicates a low the level of readiness of the patient's condition for aerobic CRT.

To determine the risk of developing SCD in patients after CABG, the classification of ventricular arrhythmias according to Lown is used, which plays a significant role in the comprehensive assessment of the readiness of such patients for aerobic KPT [Lown V., Wolf M. Approach to sudden death from coronary heart disease. Circulation. 1971; 44: 130-42; Lown B., Calvert A.F., Armington R., Ryan M. Monitoring for serious arrhythmias and high risk of sudden death. Circulation. 1975; 51-52 (suppl III): 189-198].

Lown classification of ventricular arrhythmias:

Grade 0 - there are no ventricular arrhythmias.

Grade 1 - rare (no more than 30 per hour) monotopic ventricular premature beats (PVCs).

Grade 2 - frequent (more than 30 per hour) monotopic PVC.

Grade 3 - polytopic PVC.

Grade 4A - two consecutive (paired) PVCs.

Grade 4B - several in a row (three or more) ventricular ectopic contractions - "jogging" of ventricular tachycardia.

Grade 5 - early PVC type R / T.

Grades 3-5 refer to high Lown grade ventricular arrhythmias.

When developing the proposed method, 105 patients with coronary artery disease (70 men, 35 women) were examined, the median age is 67 years, after CABG surgery at the N.M. A.N. Bakulev ", which underwent cardiac rehabilitation at the Research Institute of Cardiac Surgery. IN AND. Burakovsky.

Postinfarction cardiosclerosis was diagnosed in 94% of patients. The average duration of the history of ischemic heart disease was 6.5 years. The vast majority of patients (88%) were classified as FC II by NYHA. The diagnosis of ischemic heart disease was verified on the basis of anamnesis, complaints and confirmed by objective examination methods.

Patients with an ALT level of more than 40 U / L, hepatitis, liver dysfunction, liver cirrhosis, Gilbert's disease were excluded from the study, and patients with neurological disorders (who had suffered neurological deficits), orthopedic disorders and severe stenosing atherosclerosis of the arteries of the lower extremities were excluded from the study. , which limited their ability to participate in training programs.

We analyzed 29 indicators, which included demographic, clinical instrumental and laboratory data. When performing univariate regression analysis, taking into account the inclusion of data with a normal distribution and an abnormal distribution (parametric and nonparametric data), the 95% confidence interval (CI) for the χ ² test varied from 2.7 to 27.5.

Significantly significant indicators based on univariate regression analysis were: complicated / uncomplicated postoperative course, METs according to the stress test on treadmill, presence / absence of myocardial ischemia, FIT index, LVEF, presence / absence of ventricular arrhythmias according to Lown, ALT and hemoglobin levels ...

Further, the most significant indicators were entered into multivariate regression analysis. Based on the results obtained, we developed our own approach to the selection of patients for effective participation in rehabilitation programs after CABG.

When determining the role of laboratory parameters for the selection of groups after CABG with low, medium and high levels of readiness for aerobic CRT, attention was focused on two indicators - ALT and hemoglobin levels.

After analyzing the possibilities of a simple biochemical indicator of ALT, an indicator of liver function, but, as it turned out, not only in predicting the survival of patients with coronary artery disease in large-scale studies, which included 15 524 patients, and associated with the level of "decrepitude" of patients, reduced weight, it was decided to analyze it in patients after CABG and to identify how much it can help in determining the physical readiness of patients in this category for cardiac rehabilitation.

According to large studies to assess and identify the prognostic role of ALT [Peltz-Sinvani N., Klempfher R. et al. Low ALT levels independently associated with 22-year all-cause mortality among coronary heart disease patients. Gen. Intern. Med. 2015; 31 (2): 209-14], the study patients were divided into groups depending on the level of serum ALT. It has been proven and known that the threshold ALT level associated with an increased likelihood of long-term mortality in patients with coronary artery disease is ≤ 17 U / L. It turned out that in the group of patients with ALT level ≤ 17 U / L exercise tolerance, measured in METs, and the duration of physical activity were significantly lower, the heart rate (HR) at rest was significantly higher, the reserve heart rate was significantly lower (Table . one).

The threshold level of ALT is more than 10 U / L, but ≤ 17 U / L was observed significantly more often in women than in men, in the older age group (67.3 ± 5.2 years); also statistically significantly associated with a reduced body mass index, current smoking, a history of smoking and COPD, lower blood triglycerides and total creatine phosphokinase (CPK) levels. LV systolic function, determined by LV ejection fraction, as well as HF FC according to NYHA did not differ significantly in the groups with ALT levels less than and more than 17 U / L. In the group of patients with ALT levels ≤ 17 U / L, exercise tolerance, measured in METs, and the duration of exercise were significantly lower, resting heart rate was significantly higher, reserve heart rate was significantly lower. The statistically most significant factors associated with ALT ≤ 17 U / L were older age (over 67 years old), body mass index (≤25.8), female sex, and total CPK level.

From our point of view, the severity of postoperative anemia is extremely important in assessing the physical readiness of patients after CABG. Therefore, hemoglobin levels were also included in the analysis. According to the recommendations of the European Society of Cardiothoracic Surgeons, the hemoglobin level ≤ 100 g / l after CABG is considered the threshold for entering cardiac rehabilitation programs, patients are advised to refrain from starting aerobic CRT [Ranucci M., La Rovere MT, Castelvecchio S. et al. Postoperative anemia and exercise tolerance after cardiac operations in patients without transfusion: what hemoglobin level is acceptable? Ann. Thorac. Surg; 2011; 92: 25-31]. At a hemoglobin level of 100 g / l and below, exercise tolerance, determined by the test with a 6-minute walk, is significantly lower. In our study, a hemoglobin level of 100 g / L was detected in 42 (40%) of 105 patients before the start of cardiorespiratory training. The study did not include patients with hemoglobin levels below 95 g / L. In 63 patients, the hemoglobin level was above 100 g / l and varied from 100 to 130 g / l. Before the start of aerobic cardiorespiratory training in the subgroup of patients with hemoglobin levels of 95-100 g / l, the average distance during the 6-minute walking test was 258 ± 106 m, while in the subgroup of patients with hemoglobin levels above 100 g / l - 306 ± 101 meters (p = 0.007). Maximum METs on the treadmill, maximum heart rate and threshold heart rate were significantly lower in the group of patients with hemoglobin levels of 95-100 g / l. Non-ischemic ST segment depression, as well as T-wave inversion and single PVCs during exercise, also significantly more frequently occurred in patients with hemoglobin levels of 95-100 g / l.

There was a cubic curve of the relationship between the hemoglobin value before the start of cardiorespiratory training and the distance traveled according to the 6-minute walk test (r ² = 0.59, p <0.001). At a hemoglobin level of 100 g / L and below, the distance traveled in meters according to the 6-minute walk test was significantly lower, and these patients showed a significant increase in the distance traveled 6 minutes after the end of the CRT cycle. In general, in all patients, the average distance in meters within 6 minutes increased from 298 ± 100 m (before the start of CRT) to 431 ± 90 m at the end of the 3-week course of CRT (p = 0.001). Thus, even if exercise tolerance is reduced with hemoglobin levels less than 100 g / L, the absolute values of the 6-minute walk test are acceptable (> 200 m). Moreover, this decrease in exercise tolerance is fully restored after the course of CRT, when physical fitness no longer depends on the values of the hemoglobin level.

When included in multivariate regression analysis, hemoglobin levels of 100 g / L and below and ALT levels of 17 U / L and below, independently of each other and of other indicators, were associated with reduced exercise tolerance and, therefore, with reduced cardiorespiratory fitness in patients after CABG operations for cardiac rehabilitation programs.

In our study, in addition to simple and financially inexpensive laboratory parameters such as ALT and hemoglobin levels, we used the FIT index, which was developed at Johns Hopkins Hospital in the USA in 2015 based on data from a standard stress test, which allowed the clinician to predict 10 -year risk of mortality from all causes [Ahmed NM, Al-Mallah MN, McEvoy JW et al. Maximal exercise testing variables and 10-year survival: fitness risk score derivation from the FIT Project. Mayo Clin. Proc. 2015; 90 (3): 346-55. DOI: 10.1016 / j.mayocp.2014.12.013]. The developers used the standard BRUCE treadmill stress test protocol. Some followers decided to use the Naughton Protocol. To calculate the formula, the following indicators are used - age, gender, level of exercise tolerance, expressed in METs, achieved during the test, and maximum heart rate during exercise. Grades of the FIT index: the spread of the FIT-treadmill index varies from -200 to +200. FIT treadmill index ≥ +100 means very low risk of mortality, range 1-100 - low risk, ≤0 to -100 - intermediate risk, ≤-100 to -200 - high risk [Mayo Clin. Proc. 2015; 90 (3): 346-55. DOI: 10.1016 / j.mayocp.2014.12.013]

To calculate the FIT index in our study, we used the mode-BRUCE protocol (modified protocol) in patients after CABG 16 days after surgery. The formula for calculating the FIT treadmill index is as follows:

Max. Heart rate + 12 × METs - 4 × Age (+43 if female patient).

The FIT treadmill index is a quantitative expression of cardiorespiratory fitness for participation in training programs. It's easy to calculate. It does not depend on symptoms and is not limited to electrocardiographic changes, but includes age and gender when calculating risk. Moreover, in addition to determining the risk during training programs and predicting stenosing atherosclerosis of the coronary arteries, it makes it possible to predict long-term survival. By risk categories, before the start of cardiac rehabilitation programs using aerobic CRT, 70% of our patients had a low probable mortality risk (correspondingly, a high estimated survival rate), and 30% of patients had an intermediate probable mortality risk. After a 3-week course of aerobic CRT, the average FIT-treadmill index was -30.9 ± 63.3. The FIT-treadmill index from -59.9 to -30.9 was diagnostically significant in the selection of patients to assess the readiness for aerobic CRT after CABG.

The METs index is the determining and universal in the selection of patients for cardiac rehabilitation, and the FIT index, in the calculation of which METs are used, can serve as an additional factor for determining the cardiorespiratory fitness. Aerobic physical training programs were started in patients after surgery only with a high predictive level of METs from 6.3 ± 0.3 to 8.5 ± 1.1. 90 patients with uncomplicated course after CABG took part in cardiac rehabilitation. Physical rehabilitation was carried out for 3 weeks, 3 times a week using aerobic physical training. Patients underwent cardiac rehabilitation courses lasting 150 minutes per week, once every 3 months. And for the period from 2013 to 2018, we were able to track long-term results in 90 patients after CABG.

FIT-treadmill index increased on average by 38.1 ± 10.2 points (p≤0.05). After a 3-week course of aerobic CRT using constant loads of moderate intensity, 30% of patients who had an initially probable intermediate risk of mortality according to the FIT-treadmill index moved to the group with a low probable risk of mortality.

When conducting a comparative analysis of the sensitivity, specificity and predictive reliability of METs indicators, percent of the maximum predictive heart rate and FIT-treadmill index, the FIT-treadmill-index turned out to be statistically the most reliable. the threshold value of an increase in the FIT-treadmill index by 18.2 points with a specificity of 76% (CI 68.1-80.49%) and a sensitivity of 68% (CI 52.9-79.7%). Estimated survival rates were given for 1 year. Thus, the FIT-treadmill index provides a quantitative measure of cardiorespiratory fitness and predicts long-term survival. It is obvious that participation in the cardiac rehabilitation program significantly improves the value of the FIT-treadmill index.

The FIT-treadmill index was used, due to certain limitations, in isolation of METs as a way to characterize or describe the intensity of physical activity and energy expenditure during physical activity. It is generally known that METs correspond to a peak oxygen consumption (VO ₂ ) of 3.5 ml / kg / min. But there is a certain limitation, which is that a patient with a higher body weight at rest will have a higher oxygen consumption than a patient with a lower weight. Patients with the same weight, but differing from each other in the percentage of fat mass and lean body mass (that is, the lean component), will have different metabolic equivalents at rest with an energy expenditure proportional to the amount of muscle mass available (lean body mass is the difference between total body weight and fat mass).

For low, medium and high risk groups, we offer patients appropriate light, moderate and high intensity training programs: light intensity training, which achieves 40% of peak oxygen consumption; Moderate intensity training, where 75% of peak oxygen consumption or 75% of maximum training heart rate is reached; High-intensity interval training, when 80% of peak oxygen consumption or 80% of maximum training heart rate is reached.

Patients with a high level of cardiac rehabilitation ability can be offered a protocol for switching from moderate-intensity aerobic physical training lasting 15 minutes for 2 days to high-intensity interval aerobic physical training lasting 25-30 minutes 3 times a week for 3 weeks postoperative period. Patients with a low level of cardiac rehabilitation ability may be offered light intensity training with a transition to continuous moderate intensity aerobic training. Workouts should be done 4 to 6 days a week, one workout per day with a duration of ≥ 30 minutes and a course duration of ≥ 7 weeks.

The set of diagnostic indicators developed by us significantly correlates with the physical readiness of patients after CABG to perform aerobic CRT, and also allows us to analyze long-term survival in actively exercising and non-exercising patients.

In accordance with our method, patients with a high level of readiness for aerobic CRT can receive high-intensity interval physical training, while patients with a low level of readiness for aerobic CRT can receive continuous training of medium or moderate intensity.

Patients with a high level of readiness for aerobic CRT and a low risk of adverse events are offered a transition from medium-intensity aerobic cardiorespiratory training for 2 days to high-intensity interval aerobic cardiorespiratory training (HIIFT). Patients with a low level of fitness for exercise and an average risk of adverse events are offered only continuous moderate to moderate intensity aerobic cardiorespiratory training (PTSI).

We did aerobic cardiorespiratory training for 3 weeks. Over time, significantly changed parameters VO _2, heart rate, load capacity, and oxygen pulse (p <0.001). VO _2, heart rate and increased load capacity in the group VIIFT significantly higher than in PTSI group. In both groups, after aerobic CRT of high and medium intensity, there was a significant decrease in weight, BMI, heart rate at rest, a decrease in systolic and diastolic blood pressure (BP), to a greater extent in diastolic blood pressure, an improvement in high-density lipoprotein and a significant decrease in triglyceride levels, but the coefficient atherogenicity did not change as a result of aerobic CRT. From the baseline echocardiography over a 3-week period of aerobic CRT, we observed a statistically significant decrease in LV end-diastolic pressure (p = 0.025670) and an increase in ejection fraction (p = 0.003683), mostly in the HIIT group. These effects reflect the positive effect of aerobic CRT on the physiology and hemodynamics of the cardiovascular system, metabolism, lipid, carbohydrate metabolism, etc.

Based on such postoperative data as pericarditis, pneumothorax, hydrothorax, bleeding, rhythm disturbances, complete or incomplete myocardial revascularization (according to the results of intraoperative shuntography), a conclusion was made about the severity of the postoperative course.

16 days after CABG, Holter ECG monitoring was performed to determine cardiac arrhythmias - ventricular arrhythmias (including ventricular premature beats according to the Lown classification), supraventricular arrhythmias, and conduction disorders.

16 days after CABG, according to the stress-treadmill test using the mod-BRUCE protocol, exercise tolerance in METs, the presence or absence of ischemia based on ST segment changes, and the presence or absence of cardiac arrhythmias combined with subjective data were assessed. The FIT-treadmill index was calculated using the formula:

FIT Treadmill Index = 85% Max. predictive heart rate + 12 × (METs) - 4 × (age) + 43 (if the patient is female).

If the treadmill test could not be performed, a 6-minute walk test was performed. Within 6 minutes, fixed by the doctor, the distance that the patient can walk along the hospital corridor is determined.

Using transthoracic echocardiography 16 days after CABG, LVEF was assessed using the Simpson and Teichholz methods.

When taking blood using laboratory methods of research 16 days after CABG, ALT and hemoglobin levels were determined.

The results of multivariate regression analysis of indicators after CABG to assess physical readiness for aerobic CRT are presented in Table 2.

Multivariate regression analysis for assessing physical readiness for aerobic CRT after CABG showed the following results:

- in the presence of an uncomplicated postoperative course, exercise tolerance ≥ 7 METs, absence of myocardial ischemia, LVEF> 50%, absence of high-grade ventricular arrhythmias according to Lown, FIT index level 1-100, blood ALT level ≥ 17 U / L, a hemoglobin level ≥ 100 g / l determines a high level of rehabilitation potential and a low risk of adverse events in a patient;

- in the presence of angina pain in the postoperative period, exercise tolerance of 5-7 METs, reversible deviations according to the results of a stress test on a treadmill or a 6-minute walk test, LVEF 45-50%, high-grade ventricular arrhythmias according to Lown, The level of FIT-treadmill index from -56.9 to -30.9, blood ALT level ≤ 17 U / L, hemoglobin level in the blood ≤ 100 g / L determine the low level of rehabilitation potential and the average risk of adverse events in the patient.

A high level of readiness for aerobic CRT and a low risk of adverse events after CABG indicate that myocardial blood supply is compensated, moderate or high exercise tolerance, and that there is no risk of sudden cardiac death or myocardial infarction. Such patients with high aerobic capacity 16 days after CABG can be offered high and medium intensity interval aerobic cardiorespiratory training, and they have a good prognosis for long-term survival and quality of life.

A low level of readiness for aerobic CRT and an average risk of adverse events after CABG indicate incomplete myocardial revascularization, cicatricial changes in the myocardium, reduced exercise tolerance and an average risk of developing large (SCD and MI) and small (hypotension, tachycardia, ventricular extrasystoles, atrial fibrillation) adverse events resulting from exercise. Such patients, 16 days after CABG, can be offered aerobic CRT of moderate and low intensity in a continuous mode, or training can be delayed until the performance improves.

Clinical examples:

1. Patient K., born in 1948, female, on the 16th day after CABG-2 - mammary-coronary bypass grafting of the anterior interventricular branch (MCSh PAD), venous shunt - VTK. Postinfarction cardiosclerosis from 2014 along the posterior-inferior wall of the LV. The right coronary artery is occluded, not shuntable. LVEF 48% as a result of hypokinesis of the postero-lateral wall of the LV, mitral valve insufficiency, stage 2. Body mass index (BMI) 26. According to laboratory research methods, the ALT level is 6 U / l, the hemoglobin level is 98 g / l. The postoperative course is uncomplicated. Asthenization and postoperative non-ferrous deficiency anemia persisted. In a 6-minute walk test, the patient was able to walk 200 m along the hospital corridor.

Given the low tolerance to physical activity, moderately reduced contractility of the left ventricular myocardium, low levels of ALT and hemoglobin, the patient did not find it possible to undergo aerobic CRT, she was discharged for outpatient treatment and observation until her indicators improved.

2. Patient M., born in 1961, male, on the 16th day after MCS LAD. History without myocardial infarction. The postoperative course is not complicated. LVEF 58%. BMI 28. Data of laboratory research methods - hemoglobin 120 g / l, ALT 22 U / l. According to the data of the treadmill stress test, exercise tolerance was 10 METs, the FIT treadmill index was 7, 85% of the maximum predictive heart rate was 119 bpm.

Thus, the patient after single-vessel CABG has high aerobic capacity to perform high-intensity interval CRT, and therefore he was offered a training course according to the 4 × 4 program - 4 minutes of high-intensity exercises according to the Ramp protocol (HIIFT), followed by 3-minute pauses. with sets of 4 times - "Scandinavian model". In this training program, heart rate and ergometer load are also interrelated quantities. The load in this program changes in two levels, which replace each other. The load at which the training heart rate is first reached serves as the reference load to determine the lower return point, which is calculated by subtracting the specified value from the upper load level. As soon as the training heart rate is reached (if this frequency is not reached, then the maximum upper load), the load will continuously decrease over a period of time to the lower point of return.

Initial load 50 W.

Phase A1: 5 min (phase 1); increase in load 5 W / min.

Phase A2: 10 min (phase 2); load reduction by 15%.

Training heart rate 140 bpm; the duration of the workout is 25-30 minutes; recovery duration 2 min.

This patient may be offered a continuous exercise program.

Initial load 50 W.

Phase A1: 1 min (phase 1); increase in load 10 W / min.

Phase A2: 5 min (phase 2); training heart rate 130 beats / min.

Duration of training 10 minutes; recovery duration 2 min.

In a program with a constant pulse (pulse steady state), heart rate training and the ergometer load are interrelated quantities, while the ergometer load is an adjustable parameter. The ergometer load is adjusted to maintain a constant “training heart rate”. The peculiarity of this program is that, in addition to the actual training, it is very suitable as a reference program for comparing the work done during other training sessions.

Initially, in order to adapt to physical training, a weekly course of aerobic CRT was carried out according to a program with a constant load. Then a 2-week training course was performed according to the 4 × 4 program - 4 minutes of high-intensity exercises according to the Ramp protocol, followed by 3-minute pauses, with sets of 4 times - the "Scandinavian model". A three-week course of training contributed to an objective improvement in the level of exercise tolerance (METs), physical activity (W), distance traveled in meters according to the 6-minute walking test, systolic and diastolic blood pressure, resting heart rate, and a decrease in end-diastolic volume (EDV) ) LV (Table 3). Thus, exercise tolerance and hemodynamic parameters of the cardiovascular system (heart rate, systolic-diastolic blood pressure) significantly improved.

Claims (1)

A method for determining the rehabilitation potential in patients after coronary artery bypass grafting, including determining a complicated or uncomplicated postoperative course and myocardial ischemia, performing a treadmill test or a 6-minute walk test with an assessment of the level of exercise tolerance (METs) and FIT index, performing echocardiography with determination of the ejection fraction of the left ventricle of the heart (LVEF), determination of blood levels of alanine aminotransferase (ALT) and hemoglobin; performing Holter monitoring of the electrocardiogram, based on the results of which the gradation of ventricular arrhythmias according to Lown is determined, and in the presence of an uncomplicated postoperative course, exercise tolerance ≥ 7 METs, absence of myocardial ischemia, LVEF> 50%, absence of high-grade ventricular arrhythmias according to Lown, level FIT index 1-100, blood ALT level ≥ 17 U / L, hemoglobin level ≥ 100 g / L determine a high level of rehabilitation potential and a low risk of adverse events in the patient; in the presence of angina pain in the postoperative period, exercise tolerance of 5-7 METs, reversible deviations according to the results of a stress test on a treadmill or a 6-minute walk test, LVEF 45-50%, high-grade ventricular arrhythmias according to Lown, level FIT index from -56.9 to -30.9, blood ALT level ≤ 17 U / L, hemoglobin level in blood ≤ 100 g / L determine the low level of rehabilitation potential and the average risk of adverse events in the patient.