RU2757965C1 - Method for the prevention of recurrent myocardial infarction in patients with coronary heart disease (chd) after acute coronary syndrome and cardiovascular surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, spa treatment, cardiology, medical rehabilitation, balneology, can be used in the treatment and medical rehabilitation of cardiovascular patients after acute coronary syndromes (ACS, myocardial infarction) and various cardiovascular surgical interventions. A therapeutic course of complex effects from drug therapy of current cardiovascular disorders and a complex of metabolic procedures and physiotherapeutic methods is carried out in the form of taking procedures of "dry" carbon dioxide baths (DCDB), infrared laser therapy (ILT), enhanced external counterpulsation (EEC) and interval cyclic physical training (ICPT). Repeated courses of secondary prevention are carried out within 6 months. after suffering an acute coronary syndrome or cardiovascular surgery. The DCDB is received at a gas flow rate of 15 l/min, under a pressure of 2.3 atm until its concentration is 1.5 g/l, at a bath temperature of 26-28°С for 10-15 minutes, followed by rest. ILT is carried out according to a stable method, continuous mode, wavelength 0.85 mcm, frequency 50 Hz, radiation power 5-6 W, to the apex region, middle 1/3 of the sternum, left subscapularis for 1 min for each region. Immediately after the ILT, EEC is carried out for 20-30 minutes, followed by a rest of at least 40 minutes. The whole complex of metabolic adaptation is carried out in a course of 7 daily procedures. From day 3 from the beginning of the course, daily at the end of all sequentially metabolic adaptations, a physical adaptation procedure is added in the form of ICPT on a treadmill - treadmill, 5 daily sessions, with obligatory rest for 20 minutes after each session, daily with increasing duration from session to session and increasing intensity - from 10% of the maximum heart rate on the first day of training. The course is repeated every 5-6 months.

EFFECT: method provides prolongation of the effect of secondary prevention, long-term preservation of positive metabolic effects in the affected myocardium.

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Description

The invention relates to medicine, spa treatment, cardiology, medical rehabilitation, balneology, can be used in the treatment and medical rehabilitation of cardiovascular patients, for effective secondary prevention after acute coronary syndromes (ACS, myocardial infarction) and various cardiovascular surgical interventions ... The method can be applied in the centers and departments of rehabilitation of multidisciplinary hospitals, as well as in specialized sanatoriums.

As you know, cardiovascular diseases, primarily coronary heart disease (CHD), remain the world leaders in morbidity and mortality. Methods of medical rehabilitation, secondary prevention of ACS are constantly being improved, however, the search for new complex methods of influence to improve the health of patients from these groups is still relevant.

The treatment of cardiovascular patients with the help of medications and various methods of cardiac surgical revascularization of ischemic myocardium is widely known: coronary artery bypass grafting, mammary-coronary bypass grafting, endovascular interventions with stenting of the coronary arteries. However, the number of patients for whom it is impossible to perform such interventions due to various contraindications is quite large. The ineffectiveness of the provision of high-tech medical care is also associated with the fact that the myocardium of such patients is deeply ischemic. Ischemia prevents oxygen utilization by reperfusion cardiomyocytes, neutralizes the effect of increasing oxygen delivery to them and does not allow achieving significant effects in cardiac rehabilitation and preventive measures. To combat the factors that interfere with the full-fledged rehabilitation of cardiovascular patients, the prevention of repeated acute cardiac events, a search is underway for new, more effective modes of treatment.

A known method of treating patients with cardiovascular diseases using acupuncture (IRT), massage, herbal treatment, general sodium chloride, contrast baths, dry radon and general iodine-bromine baths in combination with laser therapy, underwater shower massage on the collar area and lower extremities (Lebedeva OD Optimization of restorative correction by methods of reflexotherapy and physiological balneotherapy of structural and functional cardiac disorders in patients with essential hypertension and ischemic heart disease. Abstract of the thesis ... Doctor of Medical Sciences M. 2004. S. 44). As a result, such a complex of effects reduces the pharmacological load on the body, allows the use of the listed methods in patients with coronary artery disease with concomitant arterial hypertension, but mainly only in the early stages of the disease. At the same time, a psychotropic effect appears, the state of health, activity improves, the level of neurotization and blood pressure decreases, adequate ratios of indicators of central and peripheral hemodynamics are restored, with prolonged (at least six months of treatment), the hypertrophy of the left ventricular myocardium regresses, the geometry of the myocardium is normalized, and its further remodeling is prevented. The functional reactivity of the cardiovascular system decreases, the tolerance to stress increases. The vegetative supply of the circulatory function improves. All this is achieved by increasing the power of the central and peripheral stress-limiting systems and limiting excess adrenergic influences on the heart. The cardioprotective effect develops, the coronary, aerobic and myocardial reserves of the heart increase.

However, IRT is an invasive method, it requires a narrow specialization of the doctor, there is a wide range of contraindications for IRT (liver disease, skin diseases, including infections, a labile nervous system, pregnancy, etc.).

A known method of treatment and secondary prevention in patients with coronary artery disease after acute myocardial infarction (AMI) and cardiac surgery using physical training (Aronov D.M., Barbarash O.L., Bubnova M.G. and others. Rehabilitation and secondary prevention in patients with acute ST-segment elevation myocardial infarction. Russian clinical guidelines. Moscow 2014. S. 88.). At the same time, rehabilitation of patients after AMI with therapeutic exercises begins from the first days. Gymnastics is carried out lying down, using breathing exercises, active movements for small joints of the arms and legs, passive movements for large joints, using an incomplete range of motion alternating with static breathing exercises, light superficial stroking of the legs, turning to the right side, lifting the pelvis repeat 3- Five times. The duration of the procedure is from 5-8 to 12 minutes. Breathing exercises are carried out together with general developmental exercises in a ratio of 1: 2 or 1: 1, lasting 12-15 minutes. Independent exercises for 5-6 minutes, morning hygienic exercises and dosed walking are also prescribed. They also carry out exercises for the joints of the arms and legs with full amplitude in the lying and sitting positions, for the body - with incomplete amplitude, the pace is slow or medium, repeated 5-6 times, the duration of the sessions is 15-20 minutes. At the same time, the moment the patient gets out of bed and his very first steps are carefully controlled, after which the exercises are performed mainly in a standing position, the pace is slow or medium, and for the small joints of the arms and legs - fast. Repeat 6-8 times, lasting 20-25 minutes. Exercises with moderate effort and with objects (gymnastic sticks, balls, dumbbells 0.5-1 kg), dosed walking 1-2 r / d up to 400 m, as well as climbing stairs are used.

The program of physical training in patients with AMI, according to D.M. Aronov consists of 3 stages:

- preparatory (10-12 lessons),

- basic (25 lessons),

- supportive (the number of classes is not limited).

At the same time, the structure of each lesson includes an introductory part (10-12 minutes), which consists of simple developmental exercises for the upper and lower extremities, relaxation exercises, marching and breathing exercises. The main part (28-30 minutes) includes exercises on a stationary bike at a slow and medium pace (40-60 rpm), with a power of 50-75% of the maximum. The final part (5 min) includes general developmental exercises for small and medium muscle groups of the upper and lower extremities, corrective exercises while standing and sitting on a chair, and static breathing exercises. Classes are held in the gym 3 r / week, physical training in a mode of moderate intensity - at the rate of 50-60% of the maximum.

Physical training in AMI patients reduces the risk of re-infarction by about 7 times, mortality by 6 times. Adequate training improves the general condition by expanding the coronary vessels, activating metabolic processes, and reducing the likelihood of thrombosis. At the same time, blood pressure, sleep, mood are normalized, there is a tendency to weight loss and the risk of osteoporosis, diabetes is prevented, and stress tolerance improves.

However, excessively intense physical training in patients after AMI and cardiovascular surgery is risky, can lead to new attacks of angina pectoris and re-infarction. At the same time, moderate exercise is safer but less effective. Periodic exercise no more than 40 minutes 5 r / week helps to increase the level of "good" cholesterol, prevent the progression of atherosclerosis and the development of heart failure, training the cardiovascular system. Regular aerobic exercise helps to normalize the functioning of collateral blood flow, an inter-arterial connection that redistributes blood flow, which helps to increase the amount of oxygen-rich blood reaching the myocardium.

However, moderate physical training, similar to medical and cardiac surgery methods, does not sufficiently correct metabolic disorders of the heart muscle that arose during its ischemia after AMI and cardiac surgery.

Therefore, for the secondary prevention of ACS, myocardial infarction, it is important to study the effect of the relationship between physical and metabolic adaptation of the myocardium to ischemia and stress. In this regard, the development and substantiation of improved modes of physical therapeutic effects, including methods of physiotherapy and physical exercise, to improve the results of long-term secondary prevention due to the correct distribution of modes of metabolic and physical adaptation, is of particular interest.

A known method of treating cardiovascular patients after acute coronary syndrome and cardiac surgery (RU 2715209 C1, publ. 02/25/2020, authors Knyazeva T.A., Nikiforova T.I., Eremushkin M.A., Styazhkina E.M. , FSBI "NMITs RK" of the Ministry of Health of Russia). Patients, against the background of adequately selected drug therapy for cardiovascular disorders, undergo a complex of effects of the following regime: in the first half of the day - therapeutic gymnastics in the gym and interval cyclic training on treadmill - and sensory - C-Mill - tracks according to a certain scheme: 4 workouts per treadmill, 3 on the sensory track, 2 treadmill workouts in combination with the sensory track, at the end of the lesson 4-5 treadmill workouts.

Then, not earlier than an hour after physical training, metabolic adaptation procedures are sequentially carried out:

- enhanced external counterpulsation for 30-40 minutes, followed by rest for at least 30 minutes,

- "dry" carbon dioxide bath with a gas flow rate of 15 l / min under a pressure of 2.3 atm until an optimal carbon dioxide concentration of 1.2 hl is obtained, at a temperature in the bath of 28 ° C for 10-15 minutes, followed by a rest of at least 20 minutes,

-infrared laser therapy from the device "Mustang 2000+" according to a stable method, continuous mode, wavelength 0.85 microns, frequency 50 Hz, radiation power 5-6 W, affect the apex of the heart, middle third of the sternum, left subscapularis 2 -3 min.

The whole complex of influences is carried out daily 5 times a week with 2 days of rest, for a course of treatment 10 procedures.

This known method is recommended to be carried out from 5-7 days after acute coronary syndrome, in the early postoperative periods - from 5-6 days after X-ray surgical revascularization of the myocardium (angioplasty of the coronary arteries with stenting) and from 14-15 days after cardiac surgery (CABG, MKSh). At the same time, such a broad combination of methods of physical treatment provides effective cardiac rehabilitation by improving metabolic processes in the ischemic myocardium with the achievement of anti-ischemic, antianginal, antiarrhythmic, antihypoxic and cardioprotective action, potentiating the effect of metabolic adaptation to ischemia and cardioprotection of ischemic myocardium. Thus, in patients there is a marked decrease in the severity of angina pectoris, physical performance and exercise tolerance increase, the power of the threshold load (an increase in coronary, myocardial and aerobic reserves of the body), the blood lipid profile and hemostasis indicators improve, and anxiety indicators decrease.

This complex method of rehabilitation is also described in our publication, where it is said that the mentioned positive effects of such complex rehabilitation reduce the risk of recurrent myocardial infarction, i.e. including represent secondary prevention (T.A. Knyazeva, V.A. balneology, physiotherapy and physical therapy, 2020, T.97, No. 5, pp. 5-12, see p.10 right column).

However, the publication lacks data on the effectiveness of such secondary prevention, the duration of the relapse-free period in terms of manifestations of angina pectoris, which is a clinical manifestation of myocardial ischemia.

It is known (Lyamina N.P., Karpova E.S., Kotelnikova E.V., Bizyaeva E.A. Physical training in cardiac rehabilitation and prevention in patients with coronary artery disease after percutaneous coronary interventions: limits of effectiveness and safety. Russian Journal of Cardiology. 2014; 6 (110): 93-98) that the following are considered as the main mechanisms of the influence of regular moderate physical training (FT) on reducing the frequency of cardiac disorders and the development of a cardioprotective effect:

• improving the function of the endothelium (the inner surface of the vessels);

• slowing the progression of coronary damage;

• reduction of thrombogenic risk (blood clots);

• increased collateralization of microvessels (development of a network of parallel microvessels);

• activation of intracellular and metabolic processes.

When using moderate loads, the incidence of adverse events is very low, both during and after training. Therefore, moderate loads with high safety and clinical efficacy do not require complex methods of ongoing monitoring of patients, which makes them more in demand at the stage of long-term rehabilitation. Clinical experience shows that patients with coronary artery disease after PCI with limited coronary and myocardial reserves, clinical manifestations of the syndrome of reduced tolerance and symptoms of heart failure are preferable to prescribe interval PT, in which the period of intense loads alternates with loads of low intensity. The limitation of the coronary and myocardial reserves does not allow the use of loads during training of this category of patients, causing a significant effect on myocardial contractility, since it has been proven that in patients with reduced reserves of the left heart during PT, rhythm disturbances of high gradations often occur and an increase in the degree of ischemia can be observed. myocardium during exercise. Low exercise tolerance in this category of patients is often determined not by the depletion of reserves of energetically important substances, but by 90% depends on the state of the cardiorespiratory system, peripheral circulatory disorders, pulmonary ventilation disorders, changes in the structure and metabolism of skeletal muscles.

Insufficient perfusion of skeletal muscles and reduced oxygen extraction in patients with chronic heart failure (CHF) at rest and during exercise are based on vasoconstriction caused by activation of the sympathoadrenal and renin-angiotensin systems, and endothelial dysfunction. In recent years, there have been reports that indicate a connection between low physical activity in patients with CHF not only with structural changes in muscle fibers, but also with an increase in the amount of interstitial tissue in skeletal muscles. With the growth of the functional class of CHF, the degree of collagen accumulation in skeletal muscles increases, which makes them less elastic and elastic; the thickness of the collagen layer between the muscle fiber and the capillary increases, which impairs the blood supply to the muscle fibers. Similar changes develop in the respiratory muscles, which leads to a deterioration in ventilation of the lungs, reducing the strength of inhalation and exhalation, and the progression of shortness of breath. When patients in this category are prescribed FT with interval load in terms of intensity, the main mechanism and implementation of the training effect of FT is carried out, mainly due to peripheral adaptation mechanisms: an increase in the arteriovenous difference in oxygen and an improvement in its utilization, a decrease in the blood pressure response to physical activity, optimization of microcirculation processes, blood rheology, etc.

It seems that the effectiveness of secondary prevention could be enhanced by conducting rehabilitation courses using a certain - a modified sequence of targeted therapeutic effects - first on metabolic adaptation (to improve the metabolism of internal tissues, mainly the heart muscle, lungs, blood vessels), and only then - on the physical adaptation of the previously damaged myocardium, already metabolically "prepared" to the loads, as well as the entire vascular system and lungs.

As noted in the publication: Aronov D.M., Barbarash O.L., Bubnova M.G. Rehabilitation and secondary prevention in patients with acute ST-segment elevation myocardial infarction. Russian clinical guidelines. M. 2014, p. 31-32, the active period of patient management in an outpatient setting ends in 3-4 months, in some cases up to 5-6 months. Further, the patient is prescribed uncontrolled FT, which is performed without fear at home under self-control. The program of modification of physical rehabilitation is ongoing. Medical therapy is carefully performed, selected in the hospital and includes drugs for secondary prevention (antiplatelet agents, statins, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, drugs necessary for the treatment of arterial hypertension, CHF, rhythm / conduction disorders and concomitant diseases). Medication therapy is supervised by a cardiologist who is part of the multidisciplinary cardiac rehabilitation team. It is mandatory to visit the cardiac rehabilitation polyclinic department of the polyclinic or the Rehabilitation Center every 3 months. The patient is also given the right to visit the clinic unscheduled as needed. Polyclinic cardiac rehabilitation and secondary prevention are the best form of management of patients after myocardial infarction (the third stage, the longest, is multidisciplinary). At the same time, the patient has a real opportunity to really engage with anti-smoking specialists, with a nutritionist and other specialists. The first two stages of rehabilitation with a total duration of at least a month (for patients with high and medium risk according to GRACE) allow the pathological process to be completed more quickly and to stabilize the patient's condition. This process can also occur spontaneously, but it is very unreliable and, as the results of the ACS / AMI registers show, is fraught with high mortality (up to 50% of patients discharged from the hospital die within 3 years). At the same time, complex long-term controlled cardiac rehabilitation gives a reliable and stable effect, which is noticeable already in the first 2 years in the form of a decrease in overall and cardiovascular mortality, a decrease in the number of hospitalizations, a significantly greater return of patients to work and a good quality of life.

Thus, the modification of the courses of treatment and rehabilitation effects seems to be necessary for this category of patients.

As the closest analogue , a method of complex rehabilitation after AMI and cardiovascular interventions is considered, aimed, among other things, at secondary prevention of AMI, disclosed in the above-mentioned publication (T.A. Knyazeva, V.A. Badtieva, T.I. with physiotherapeutic methods of restoring myocardial metabolism in the rehabilitation of patients after acute coronary syndrome and cardiosurgical revascularization of the myocardium. early periods after AMI and cardiovascular interventions: physical training in the form of therapeutic exercises, interval cyclic exercises, enhanced external counterpulsation procedures, "dry" carbon dioxide baths and infrared laser therapy.

The technical result of our proposed method is the prevention for a longer period, compared with the prototype, of repeated acute cardiac syndromes (ACS) after AMI and cardiovascular interventions, as well as the prevention of angina attacks, due to systemically repeated support of metabolic processes in the ischemic myocardium, anti-ischemic, antianginal, antiarrhythmic, antihypoxic and cardioprotective effect of metabolic adaptation, potentiating the effect of subsequent physical adaptation - physical training. In turn, physical training improves the basic functional indicators of the cardiovascular system by mobilizing its reserve capabilities, improving the contractility of the heart muscle and peripheral circulation by training non-cardiac factors of blood circulation and the development of compensatory-adaptive reactions to physical exertion.

The specified technical result is achieved by the fact that a method of secondary prevention is proposed, in which the sequence of adaptation methods used is improved in comparison with the prototype method: first, metabolic adaptation procedures are carried out and only then - physical adaptation methods in the form of physical exertion. At the same time, in order to prolong prophylaxis, it is proposed to repeat such courses several times.

For the prevention of recurrent myocardial infarction in patients with coronary artery disease after acute coronary syndrome and cardiovascular surgical interventions, a therapeutic course of complex effects from drug therapy of current cardiovascular disorders and a complex of metabolic procedures and physiotherapeutic methods, in the form of taking procedures of "dry" carbon dioxide baths (SUV ), infrared laser therapy (ILT), enhanced external counterpulsation (EAC) and interval cyclic physical training (ICFT).

Repeated courses of secondary prevention are carried out within 6 months after acute coronary syndrome or cardiovascular surgery. Moreover, each course is carried out in the following sequence, regimen and dosages.

From the first day of the course of preventive treatment, daily in the first half of the day, at the beginning, sequential procedures of metabolic adaptation are carried out in the form of:

1) SUV with a gas flow rate of 15 l / min, under a pressure of 2.3 atm until its concentration is 1.5 g / l, at a bath temperature of 26-28 ° C for 10-15 minutes, followed by a rest of at least 30 minutes.

2) ILT from the device "Mustang 2000+" according to a stable method, continuous mode, wavelength 0.85 microns, frequency 50 Hz, radiation power 5-6 W, affect the region of the apex of the heart, middle third of the sternum, left subscapularis region by 1 min for each of the specified areas.

3) Immediately after the ILT, UNK is carried out for 20-30 minutes, followed by a rest of at least 40 minutes.

The whole complex of metabolic adaptation is carried out in a course of 7 daily procedures.

From day 3 from the beginning of the course, every day at the end of all sequential metabolic adaptation procedures, a physical adaptation procedure is added in the form of ICFT on a treadmill - treadmill, 5 daily sessions, with obligatory rest for 20 minutes after each session, daily with an increasing duration from session to session: 5 minutes, 10 minutes, 15 minutes, 20 minutes, 25 minutes, and increasing training intensity - from 10% of the maximum heart rate on the first day of training, adding 10% for each next day of training - up to 60% of the maximum heart rate to 5th day of training.

The course is proposed to be repeated every 5-6 months.

While taking SUV, the human body is exposed to carbon dioxide, while the patient is placed in a special reservoir so that only the head is fixed on the surface, the body is in a "capsule". A minimum of clothing remains on the body, gas is pumped into the tank in the mode described above. Bath temperature 26-28 ° C.

This procedure is completely painless, sometimes the patient feels a slight coolness or tickling, tingling sensation. The sealed collar reliably fixes the medical "capsule" around the neck - CO2 does not go out, and the person breathes in the usual atmospheric air of the treatment room. The cuff is soft, which completely eliminates damage to the neck. At the end of the session, the person leaves the bath on their own and rests in the ward.

In the course of SUV procedures, carbon dioxide in a neurohumoral way affects the capacitive and resistance vessels with a decrease in pre- and afterload on the heart muscle, blood oxygen capacity, blood supply to the heart and brain. The most striking manifestations of the effects of WTS are vagotonia and vasodilation (decrease in heart rate, moderate decrease in blood pressure, etc.). Thermoasymmetry disappears, the skin temperature rises by 0.2-1.4 ° C, which persists even after SUV for another 30-40 minutes. An important role in the mechanism of the therapeutic action of this physical factor is played by its ability to increase the partial tension of oxygen in the arterial blood, which persists throughout the entire aftereffect of the bath (more than an hour). This is due not only to an increase in the supply of oxygen from the external environment, but also to the ability of CO2 to accelerate the dissociation of oxyhemoglobin and the release of oxygen into the blood. The increase in blood oxygenation and vasodilation complement the improvement in the microcirculation rate and the decrease in the increased platelet aggregation. Therefore, after a course of treatment in patients with coronary artery disease, there is a clear increase in the stroke volume of the heart and myocardial reserve with a decrease in the clinical signs of heart failure. This leads to an increase in exercise tolerance, relief of angina attacks. In addition, SUV usually helps to relax the body. In connection with the listed effects, it is most optimal to use SUV as the first procedure of the complex.

At the end of the SUV procedure, ILT is performed on the Mustang 2000+ apparatus, guided by the above regimen and dosage.

Infrared radiation is the least of all other wavelengths absorbed by melanin, hemoglobin, oxyhemoglobin, water, skin. The concentration of absorbed energy in the blood is several times higher than that in the muscle tissue. With close contact of the laser emitter with the skin and slight compression of soft tissues, the laser radiation reaches all dermal and subdermal vascular plexuses and structures, including muscle layers. When infrared radiation is absorbed, heat is generated, which leads to a local increase in the temperature of the irradiated skin by 1-2 ° C and causes local thermoregulatory reactions of the superficial vascular network. The vascular reaction develops in phases. Initially, there is a short-term (up to 30 s) minor spasm of the superficial vessels of the skin, which is replaced by an increase in local blood flow and an increase in the volume of blood circulating in the tissues. There is hyperemia of the irradiated parts of the body, due to an increase in blood flow in the tissues. The heat energy released in this case significantly accelerates metabolic processes in the skin and subcutaneous tissue. Some of the liquid is released in sweat and evaporates, which leads to dehydration and increased skin turgor.

Infrared laser radiation is selectively absorbed by nucleic acid and oxygen molecules, induces reparative tissue regeneration and enhances their metabolism. With infrared laser glow of the tissues or edges of the wound bordering with the focus of inflammation, fibroblasts are stimulated, and granulation tissue matures. Penetrating deep into tissues by 6-7 cm, infrared laser radiation activates the endocrine glands, hematopoiesis, enhances the activity of immunocompetent organs and systems, leads to an increase in cellular and humoral immunity. In connection with these effects of infrared laser radiation, it is most optimal to prescribe its procedures after SSV, since ILT will facilitate the elimination of metabolic products, including the working heart muscle, while improving blood flow caused by the preliminary SSV procedure, as well as supporting the current reparative processes in the myocardium.

After ILT, UNC procedures are performed on the Enhanced External Counter Pulsation System ECP - MC3 (manufactured by Foshan Wamed Medical Instrument Co. Ltd., China). The patient is lying on the couch; pneumatic cuffs are placed on the thighs and lower legs, sometimes on the arms. Disposable electrodes are placed on the chest to continuously record an ECG during the procedure, which is displayed on a monitor. A sensor is placed on the finger to record a pulse curve that displays blood flow in the arteries and blood oxygen saturation. During the procedure, pneumatic cuffs on the limbs are sequentially inflated and deflated in sync with the heart rate.

While the heart muscle is relaxed and filled with blood, the coronary arteries are filled, the cuffs are sequentially (bottom-up) inflated, which leads to the formation of a wave of blood directed towards the heart. This improves blood flow in the coronary arteries. At the moment when the heart contracts and throws blood into the aorta, the cuffs are sharply deflated, which facilitates the work of the heart and accelerates blood flow in other vessels. This procedure, in fact, already represents a certain physical preparation of the heart muscle (preliminarily metabolically "prepared" by the procedures of UWS and ILT) to transfer more difficult physical loads for it on the treadmill. Thus, the proposed sequence of procedures is the most physiologically justified and at the same time the most gentle preparation of the heart muscle for a gradual increase in physical exertion on the patient.

In the proposed method, from day 3 from the beginning of the course, every day at the end of all sequentially carried out metabolic adaptation procedures, a physical adaptation procedure is added in the form of ICFT on a treadmill - treadmill (TRAC series "CARDIO LAIN", manufactured by "ERGOFIT GmbH & Co.KG", Germany), 5 daily sessions, with mandatory rest for 20 minutes after each session, daily with increasing duration from session to session: 5 minutes, 10 minutes, 15 minutes, 20 minutes, 25 minutes, and increasing training intensity - from 10% of the maximum heart rate in the first day of training, adding 10% for each next day of training - up to 60% of the maximum heart rate by the 5th day of training.

It is advisable to repeat the entire course every 5-6 months.

During the introductory and final part of the training, the load is 10% of the threshold. The heart rate is controlled by a heart rate monitor (Heart Rate Monitor), which is worn on the arm like a watch. Before training, always warm up (exercises for the lower extremities and practicing rolling from heel to toe for 5 minutes, then training on the track, daily).

In the course of our research, we found that the mentioned sequence of procedures has a longer prophylactic effect in patients of this group. According to our data, this is due to the fact that the change, modification of the sequence of carrying out the known procedures, which took place in the prototype method, leads to a more physiological and sparing training of the myocardium, first improving its metabolic adaptation to stress (consistent improvement of the "nutrition" of the heart muscle ), and then - to its physical adaptation (increasing exercise tolerance).

Examples of implementation of the method

Example 1.

Patient A.R., 35 years old. The main diagnosis : ischemic heart disease. Postinfarction cardiosclerosis. Myocardial infarction of the lower wall of the LV with the transition to the pancreas from 19.10.2017. Atherosclerosis of the coronary arteries. Condition after stenting of RCA from 19.10.2017. Stenting of PNA and DV-1 from 16.01.2018. Background. Hypertension 3 tbsp., 2 tbsp., OVRSSO. Obesity 1 tbsp. Dyslipidemia. Complication. NK IIA Art., 2 FC by NYHA. Violation of the rhythm of the heart by the type of ventricular extrasystole.
Concomitant diagnosis. Atherosclerosis of the brachiocephalic arteries, arteries of the lower extremities. Severe sleep apnea.

At the beginning of 2018, the patient underwent medical rehabilitation according to the prototype method. However, 7-8 months after the end of rehabilitation, despite adherence to a diet, regular moderate physical activity, the implementation of recommendations for taking appropriate cardiovascular medications, smoking cessation after cardiac surgery, the patient began to notice the appearance of periodic attacks of angina pectoris. In October 2018, he applied for a second course.

Complaints of general weakness, shortness of breath and discomfort behind the sternum with irradiation to the left arm with moderate physical exertion, climbing 2-3 flights of stairs, fatigue, heart palpitations, pasty legs, short-term respiratory stops during sleep and periodic rises in blood pressure to 150-160 / 110-120 mm Hg during the day (connects this with the nervous load at work).

General condition on examination: satisfactory. Position: active. Body type: normosthenic. Food: excess, height 172 cm, weight 99 kg. Skin: clean, normal color. Lymph nodes: not enlarged.

The musculoskeletal system. The muscles are well developed. Muscle tone is normal. There is no hypotrophy or muscle atrophy. Joints: the shape is not changed. Crackling in joints (auscultatory): no. The range of motion in the joints: saved. Bones: shape unchanged. Spine: shape - physiological curves are preserved.

Respiratory system. Nose: breathing is free, no discharge. Pharynx: pink mucous membrane. Breathing type: chest, respiratory rate (RR) 17 per min. Chest percussion: clear pulmonary sound. The boundaries of the lungs: not displaced, the mobility of the lower edge is not changed. Auscultation of the lungs: vesicular breathing is carried out in all sections evenly on both sides. Wheezing, crepitus, no pleural friction.

Circulatory system. The apical impulse is palpated in the V intercostal space 1.5 cm medially from the mid-clavicular line. The boundaries of the heart are within normal limits. Auscultation of the heart: clear, rhythmic sounds. BP 130/70 mm Hg Pulse 67 per minute, rhythmic.

Digestive system. The tongue is clean and moist. The abdomen is of normal shape, soft and painless on palpation. Symptoms of peritoneal irritation are negative. Liver at the edge of the costal arch.

Genitourinary system. The beating symptom is negative on both sides. Diuresis is adequate.

Endocrine system. Thyroid gland: not palpable.

Mental status. Appearance, behavior, mood, speech, memory, orientation are not changed.

Echocardiography on admission . The diameter of the aortic root (AO) is 3.5 (the norm is N 2.0-3.7 cm), the ascending part of the AO, the opening (AO) is 2.0. Left atrium (LA) - diameter - 3.7 (N 2.0-4.0 cm), volume 53 ml (N up to 65). Left ventricle: CRD - 5.3 (N - 3.6-5.6 cm); DAC - 3.4 (N - 2.3-3.7 cm.).
Global contractility of the left ventricle: Ejection fraction (EF), M-mode - 64% (N ≥ 60%), B-mode 56% (N ≥ 55%), TgVS - 1.0 (N 0.6-1.1 cm); in average parts of TDZS - 1.0 (N 0.6-1.1 cm).
Right ventricle (RV), diameter 2.8 (N ≤ 3.0 cm). RV wall thickness ~ 0.3 cm. Right atrium (RA), diameter - 3.5 (N 2.0-3.8 cm).
Areas of violation of local contractility are revealed.
Doppler echocardiography: no pathological flows in the cardiac cavities were detected. Aortic valve - no regurgitation; the stream is not accelerated. Gradient max. - 4.9 mm. rt. Art. (N up to 10-15). V - 1.54 m / s (N up to 1.6 m / s). Mitral valve, regurgitation: 1 tbsp; the stream is not accelerated. Gradient max. 4.3 mm. rt. Art. (N to 5). V - 1.15 m / s (N up to 1.2 m / s). E / A - 1.1 (N> 1). Tricuspid valve, regurgitation: 1 tbsp. Pulmonary valve, regurgitation: 1 tbsp. Signs of pulmonary hypertension are absent downstream in the VTP. Systolic. the pressure in the aircraft is ~ 23 mm Hg. Art. (N up to 25 mm Hg). The inferior vena cava is not dilated, 1.5 cm, collapses on inspiration> 50%. CONCLUSION based on the results of instrumental studies: The aorta is hardened, hardening of the cusps of the aortic and mitral valves. The cavities are not enlarged. The systolic function of the heart is preserved. The diastolic function is preserved. Slight hypokinesis of the basal LV lower segment. Minor regurgitation in MC and TC. There are no signs of pulmonary hypertension. Areas of violation of the local contractility of the left ventricle.

ECG conclusion . Sinus rhythm with a heart rate of 67 / min. Cicatricial changes in the myocardium of the lower wall. ECG control after a week: no negative dynamics.

Cardiopulmonary test on admission. Recommended level of aerobic training with max. up to 4.8 METs, with a heart rate of 120 per min. The test is negative.

Stress test upon admission ... At the peak of the load, frequent ventricular premature beats (VES) up to 16 complexes. Max. load 125 W in 5 steps load at 10:52 min, 53% of proper load 233 W, MET 5: 3. Resting heart rate 85 / min. Max. Heart rate 129 / min. 78% of proper load 233 W, MET 5.3. Resting heart rate 85 / min. Max. ST rise in channel V4, 0.10 mV in stup. load 3, max. ST depression in the fVR channel -0.02mV in st. load 1, ZhES 16, isolator. -13, bigeminy -1. The reason for the termination of the test is the appearance of ventricular extrasystoles (VES).

Duplex scanning of veins lower. limbs on admission.
The common femoral, femoral, popliteal, posterior tibial veins (TSPV), large (GSV) and small saphenous veins (SSV) of both lower extremities were examined. The sappheno-femoral anastomosis is not dilated, the GSV trunk is on the thigh, the SSV on the left is not dilated, completely compressible when compressed by a transducer, the blood flow is phasic. The Valsalva maneuver was not performed. Large saphenous vein (PCV): the trunk of the thigh is not widened, the walls are not thickened.

In the area of the lower leg on the left, it is convoluted, slightly expanded - 5 mm, completely compressible when compressed by the sensor, phase blood flow. The MPV on the right (trunk) is widened in / 3 to 6 mm, the walls are thin, the lumen is passable. Deep veins (common femoral, femoral, PCV, ZBVV) are passable, compressed by the sensor, completely stained in the CFM mode, phase blood flow, synchronized with respiration. The sural veins are completely passable, compressed by the sensor, and stained in the CDC mode.

CONCLUSION: 1. Varicose veins in the basin of the GSV of the left tibia (non-stem form), the MPV on the right (stem form).

2. The patency of the deep and superficial veins of the lower extremities is preserved.

Consulted by a nutritionist. Receives a low-calorie diet, the daily recommended calorie intake for smooth weight loss is 1700-1800 kcal, with a basal metabolic rate of 1991 kcal. It is recommended to carry out unloading days 2 times a week for a month, then 1 unloading day a week.

Mukofalk receives 1 sachet (or 1 tsp) 2 times a day, after dissolving in a glass of cool boiled water, 30 minutes before lunch and dinner. Phosphogliv 1 caps. x 2 rubles / day, course 1 month.
Stimbifid, 2 tablets. x3 times a day one hour after meals.

Prescribed medications for the state of the cardiovascular system: prasugrel 10mg at lunchtime, losartan 25mg in the morning and evening, thrombosis 100mg in the evening, metoprolol succinate 50mg in the morning, rosuvastatin 40mg in the morning, blood pressure control in the morning and evening.

The proposed complex of secondary prevention was carried out within the framework of the claimed method.

Discharge condition. Against the background of the performed procedures, a decrease in the severity of weakness was noted, anginal attacks did not recur, exercise tolerance increased, pastiness regressed, and the state of health improved. Hemodynamics are stable. BP 110/70 mm Hg Heart rate 67 / min. At discharge, the condition is satisfactory, corresponds to SHRM 3b.

From the end of 2018 to 2020, the patient received 3 more courses of secondary prevention using this method. During this period, angina attacks, pronounced increases in blood pressure were not noted, including with moderate physical exertion, he continues to take prescribed drugs and moderate physical exertion. On control ECGs (2-3 times a year), no deterioration was noted.

Thus, the proposed method helped to improve the adaptation of the patient after suffering ACS and cardiac surgery, to carry out effective secondary prevention, for which the rehabilitation course according to the prototype method was not enough.

Example 2.

A patient E.I.O., 60 years old.Primary diagnosis: Cardiac ischemia. Acute myocardial infarction of the anterior wall without ST elevation from 01/16/2018. Condition after transluminal balloon angioplasty and stenting of LAD (Resolut Onyx stent 3.5 x 26 mm from 01.16.2018.
Background diseases: Hypertension 3 tbsp., ОВРССО. Hyperlipidemia. Complications: NK IIF Art., 3FC according to NYHA.
Concomitant diagnosis: Chronic prostatitis. Chronic gastritis, remission.

After the operation in 2018, he underwent a rehabilitation course according to the prototype method at the National Medical Research Center of the Republic of Kazakhstan, however, by the end of the year that had passed after the end of this course, complaints about periodic attacks of angina pectoris resumed, especially often against the background of physical activity, despite medical support with selected drugs.

Complaints at admission : shortness of breath with moderate physical activity, walking a distance of about 200 m, climbing 2 flights of stairs, periodically swelling of the legs, fatigue, heart palpitations.

Anamnesis of the disease : for a long time suffers from rises in blood pressure with maximum numbers - 220/120 mm Hg, adapted to 120-130 / 70-80 mm Hg. 01/16/2018 was admitted to the hospital with the clinic for anterior LV myocardial infarction without ST elevation. With coronary angiography, occlusion with / 3 immediately after the passage of DV-1. There were no other hemodynamically significant stenoses in the arteries. Echocardiography from 01/16/2020 EF 33%, SDLA 40 mm Hg. Art., regurgitation on TC 1 tbsp., DAC 99 ml, KDR 148 ml, UO 49 ml. Dilation of the heart chambers. Hypokinesis of the apical and middle segments of the anterior septal wall, hypokinesis of the anterior wall, middle and basal segments of the lateral wall. Sealing of sash AK, MK. On the ECG series from 01/16 to 01/20/2018, the T wave inversion in aVL, V2-5.

After the operation, the patient was sent for rehabilitation at the National Medical Research Center of the Republic of Kazakhstan (according to the prototype method).

Heredity is not burdened. Denies bad habits. Not working, pensioner.

General examination upon admission for re-rehabilitation in the summer of 2019 for the purpose of secondary prevention of myocardial infarction: the general condition is satisfactory. Adequate. Conscious. Oriented in time and space. The skin is clean, normal color, edema, n / 3 legs, symmetrical. NPV 16 per minute. Breathing over the lungs is vesicular, carried out in all sections evenly on both sides. No wheezing. Heart sounds are rhythmic, muffled. BP 120/80 mm Hg. Heart rate 71 per minute, rhythmic pulse. Liver at the edge of the costal arch. The beating symptom is negative on both sides. FMN without features. There are no neurological disorders.

Echocardiography from 06/05/2020: the diameter of the aortic root (AO) - 3.5 (N 2.0-3.7 cm), the ascending part of the AO, opening (AO) - 1.8. Left atrium (LA), diameter - 4.2 (N 2.0-4.0 cm); volume - 68 ml (N up to 65), CDR - 4.9 (N 3.6-5.6 cm); DAC - 3.1 (N 2.3-3.7 cm); KDO - 143 (N 62-170 ml), KSO - 76.
Global contractility of the left ventricle: ejection fraction (EF) M-mode - 66% (N≥60%), B-mode - 47% (N≥55%), TdVS - 1.0 (N 0.6-1.1 cm); in average parts - TdZS - 1.0 (N 0.6-1.1 cm); right ventricle (RV): diameter - 3.2 (N≤3.0 cm), wall thickness of the RV ~ 0.3; right atrium (PP): diameter - 3.9 (N 2.0-3.8 cm). Areas of violation of local contractility are revealed.
Doppler echocardiography: no pathological flows in the cardiac cavities were detected.
Aortic valve - no regurgitation; the stream is not accelerated. Gradient max. - 10.6 mm. rt. Art. (N up to 10-15), V - 1.6 m / s (N up to 1.6 m / s). Mitral valve, regurgitation: 1 tbsp; the stream is not accelerated; Gradient max. 4.8 mm. rt. Art. (N up to 5), V - 1.2 m / s. (N up to 1.2 m / s), E / A - 1.1 (N> 1). Tricuspid valve, regurgitation: 1 tbsp. Pulmonary valve, regurgitation: 1 tbsp. Signs of pulmonary hypertension: no downstream in the HTRV. The inferior vena cava is not dilated, 1.5 cm, collapses on inspiration> 50%. CONCLUSION: The aorta is hardened, hardening of the cusps of the aortic and mitral valves. Slight enlargement of the left atrium and right ventricle. The systolic function of the heart is slightly reduced. Diastolic function is normal. Hypokinesis in the region of the lower septal and lateral apical segments of the LV. The flow through the aortic orifice is not accelerated. Minor regurgitation on the mitral, tricuspid, and pulmonary valves. The pressure in the pulmonary artery is normal or slightly increased. Conclusion: there are zones of violation of the local contractility of the left ventricle.

ECG conclusion from 06/13/2019: sinus rhythm with a heart rate of 78 per minute. Single ZhES. Cicatricial changes in the myocardium of the anterior septal wall. With the control ECG from 06/17/2019 - no negative dynamics.

During 2019-2020, the patient received three courses of re-rehabilitation (secondary prevention of AMI) according to the proposed method.

Drug treatment: brilinta 90 mg in the morning and evening, cardiomagnyl 75 mg in the evening, perindopril 4 mg in the morning, atorvastatin 40 mg in the evening, bisoprolol 2.5 mg in the morning, spironolactone 25 mg in the morning.

Condition at discharge: against the background of the received physiotherapy, balneotherapy, exercise therapy according to the claimed method, there is a decrease in the severity of weakness, anginal attacks did not recur over the entire observation period, exercise tolerance increased significantly, leg pastiness regressed, well-being with improvement. 6-MTX 300-400 m. Stable hemodynamics. BP 110/70 mm Hg Heart rate 68 / min. When discharged, the state corresponds to SHRM 4b. At the end of 2020, there are no complaints of anginal attacks, according to control examinations, no deterioration, no correction of drug treatment is required.

Example 3.

Patient Ch.G.A., 67 years old. Main diagnosis : Ischemic heart disease. Acute myocardial infarction of the LV lower wall with ST elevation, dated 01.02.2019. Multifocal stenosing atherosclerosis of the coronary arteries. Condition after TLBAP and stenting of RCA from 01.02.2019
Background diseases : Hypertension 3 tbsp., 3 tbsp. ОВРССО. LV myocardial hypertrophy. Complications : NK IIA Art., 2 FC according to NYHA. Violation of the heart rhythm: ventricular fibrillation from 02/01/2019, arrested. Concomitant diagnosis : Chronic gastritis, remission.

Complaints of fatigue, general weakness, shortness of breath with moderate physical exertion, climbing 1-2 flights of stairs, memory loss.

Anamnesis of the disease: For about 5 years, GB has been suffering from max. figures HELL 180/100 mm Hg. Art., adapted to 120/80 mm Hg. Art. Previous anginal history, stroke, diabetes mellitus, heart rhythm disturbances denies. There was an episode of syncope 3 years ago. The reason has not been established.

Since the fall of 2017, he began to complain of shortness of breath during normal physical activity. 02/01/2019 for the first time there were pains behind the sternum radiating to the left arm, shortness of breath, was hospitalized in a hospital with a clinic of acute myocardial infarction of the lower wall of the LV with ST elevation. CAG revealed multivessel coronary artery disease: RCA occlusion, RCA LMV stenosis 65%, orifice stenosis 85%, DI-2 orifice stenosis 70%, VTK in p / 3 70%. PKA stenting was performed. In the postoperative period, there was an episode of ventricular fibrillation, arrested by EIT. Echocardiography EF 51%, hypokinesis of the posterior wall of the LV. According to HmECG data min. Heart rate 41, max. 74, cf. - 51 beats / min, cf. - 50. NZHES - 25, ZHES - 3. No pauses of more than 2.0 seconds were detected. There are no ST speakers.

After surgical treatment, he received a rehabilitation course at the National Medical Research Center of the Republic of Kazakhstan according to the prototype method.

Denies bad habits.

During 2019 and early 2020, anginal attacks and rises in blood pressure were observed several times against the background of continued drug support. In this regard, he received 3 courses of secondary prevention of recurrent AMI according to the proposed method.

Upon admission to the 1st course in August 2019, the general condition is satisfactory. Active position. The body type is normosthenic. The food is normal. The skin is clean, of normal color. The lymph nodes are not enlarged.

Musculoskeletal system: muscles are well developed. Muscle tone is normal. There is no hypotrophy or muscle atrophy. Joints: the shape is not changed. Crackling in joints (auscultatory): no. The range of motion in the joints is preserved. Bones: shape unchanged. Spine: physiological curves are preserved.

Respiratory system: nasal breathing is free, there is no discharge. The type of breathing is thoracic, the frequency of respiratory movements (RR) is 16 per minute. Auscultation of the lungs: vesicular breathing is carried out in all sections evenly on both sides. No wheezing. Crepitation, no pleural friction noise.

Circulatory system: the apical impulse is palpated in the V intercostal space 1.5 cm inward from the mid-clavicular line. The boundaries of the heart are within normal limits. Auscultation of the heart: rhythmic tones, muffled, rhythmic. Heart murmurs: no. BP 110/70 mm Hg Pulse 69 bpm, rhythmic. Peripheral vessels: pulsation in the limbs is preserved.

Digestive system: tongue clean, moist. The abdomen is of normal shape, soft and painless on palpation. Symptoms of peritoneal irritation are negative. Stool is normal. Liver at the edge of the costal arch, b / w on palpation.

Genitourinary system: the "tapping" symptom is negative on both sides. Free, painless urination. The bladder is not palpable.

Endocrine system: the thyroid gland is palpable, not enlarged.

Nervous system: FMN was normal, tendon reflexes were normal. Mental status: appearance, behavior, mood, speech, memory, orientation - not changed.

Echocardiography from 08/12/2019: the diameter of the aortic root (AO) - 3.3 (N 2.0-3.7 cm), the ascending part of the AO, opening (AO) - 1.8. Left atrium (LA): diameter - 3.8 (N 2.0-4.0 cm); volume - 44 ml (N up to 65); left ventricle: CRA - 4.5 (N - 3.6-5.6 cm); DAC - 2.9 (N - 2.3-3.7 cm). Global contractility of the left ventricle: ejection fraction (EF) M-mode - 63% (N ≥ 60%), B-mode - 56% (N ≥ 55%), TgVS - 0.9 (N 0.6-1.1 cm); in average parts - TdZS - 0.9 (N 0.6-1.1 cm). Right ventricle (RV): diameter - 2.9 (N ≤ 3.0 cm). RV wall thickness ~ 0.3. Right atrium (PP): diameter - 3.4 (N 2.0-3.8 cm). Areas of violation of local contractility are revealed.

Doppler echocardiography: no pathological flows in the cardiac cavities were detected. Aortic valve, regurgitation: no; the stream is not accelerated. Gradient max. - 5.6 mm. rt. Art. (N up to 10-15), V - 1.5 m / s. (N up to 1.6 m / s). Mitral valve, regurgitation: 1 tbsp; the stream is not accelerated. Gradient max. 4.8 mm. rt. Art. (N up to 5), V - 1.22 m / s. (N up to 1.2 m / s). E / A - 0.75 (N> 1). Tricuspid valve, regurgitation: 1 tbsp. Pulmonary valve, regurgitation: 1 tbsp. Signs of pulmonary hypertension: no downstream in the HTRV.
The inferior vena cava is not dilated, 1.5 cm, collapses on inspiration> 50%.
CONCLUSION: The aorta is hardened, hardening of the cusps of the aortic and mitral valves. The cavities are not enlarged. The systolic function of the heart is preserved. Diastolic dysfunction, type 1. Slight hypokinesis of the basal lower and middle lower septal segments of the LV. Minor regurgitation in MC and TC. There are no signs of pulmonary hypertension. Conclusion. Areas of violation of the local contractility of the left ventricle.

Conclusion ECG + right chest leads from 08/12/2019 Sinus rhythm, heart rate 55 per min. Positive dynamics after myocardial infarction of the lower wall with the transition to the right ventricle. With the control ECG of 08/19/2019, there was no deterioration.

The patient received secondary prevention courses according to the claimed method. Medication: roxera 20 mg in the evening, brilinta 90 mg 2p / d: morning and evening, acecardol 100 mg in the evening, concor 1.25 mg in the morning, enalapril 2.5 mg in the morning under blood pressure control, verospiron 50 mg at lunch, pantoprazole 20 mg in the morning. Blood pressure control in the morning and evening. Observation honey. staff.

Condition at discharge: against the background of physical and balneological procedures, exercise therapy, there is a decrease in the severity of weakness, anginal attacks did not recur, exercise tolerance increased significantly, and the state of health improved. 6-MTX 350 m (upon admission 6-MTX was noted - no more than 150 m). Hemodynamics are stable. BP 115/65 mm Hg. Art. Heart rate 64 / min. When discharged, the state corresponds to SHRM 4b. During the entire observation period, angina attacks, including those with moderate physical exertion, were not observed.

The proposed method for the secondary prevention of acute myocardial infarction in cardiovascular patients after acute coronary syndrome and / or endovascular intervention - cardiac surgery (coronary artery stenting, CABG, MABG), was used in 20 patients from among those who had previously undergone primary rehabilitation according to the prototype method, both in the National Medical Research Center of the Republic of Kazakhstan and in a number of its branches. The control group consisted of patients who also underwent the first and subsequent courses of rehabilitation, but without the use of our modified regime (first - by methods of metabolic adaptation, then - by methods - physical adaptation, in the structure of each of the courses). So, patients of the control group received rehabilitation courses using such sequences of effects as: 7 people - first, physical adaptation was carried out, then metabolic adaptation procedures (i.e., repeated courses similar to that described in the prototype method), 8 people - at first, as and in the claimed method, metabolic adaptation was carried out, but the first, in contrast to the proposed sequence, was the procedure of enhanced external counterpulsation, then SUV and ILT.

At the same time, the distribution of patients into the experimental (20 people) and control (15 people) groups was random, the groups were comparable in terms of the main clinical manifestations. All patients were in the hospital under the supervision of a cardiologist for 10 days, 7 of which patients in the group received a course of secondary prevention according to the proposed method (experimental group) or without using the sequence of physiological effects of the prototype method modified by us (control group).

Before and after the course, all patients underwent detailed diagnostics, including clinical, biochemical blood tests, determination of a number of hormones, instrumental studies to assess the state of the cardiovascular system, detect myocardial ischemia and arrhythmias in the heart, the presence of systolic or diastolic heart failure, disorders of endothelial function and hemodynamics, changes in microcirculation, blood clotting properties, lipid metabolism disorders, ultrasound of the vessels of the lower extremities for the absence of contraindications in the form of acute thrombosis of the lower extremities, assessment of psychosomatic parameters and quality of life (test SAN, CTL, Spielberger). The obtained research results were statistically processed using the STATISTICA 10 software package.

As a result of the application of the proposed method of secondary prevention, a pronounced positive preventive effect was established. So, in ~ 80% of patients in the main group, the severity of the functional class of angina pectoris (p <0.01) decreased, and only in ~ 15% of patients in the control group (p <0.01), which indicates a potentiating anti-ischemic, antianginal effect of the proposed method secondary prevention. In the main group of patients, along with a significant decrease in angina pectoris episodes, there were no repeated myocardial infarctions within 1.5-2 years against the background of periodic, after 5-6 months, courses of secondary prevention according to the proposed method. At the same time, in two patients of the control group, respectively, 2 cases of repeated infarction (against the background of previous colds) were noted after 1 g 7 months and 1 g 9 months after undergoing cardiac surgery and undergoing repeated courses of rehabilitation without using the sequence of physiotherapeutic procedures modified by us. impacts.

In all patients of the main group, the number of episodes of angina pectoris within 1.5-2 years after surgery and undergoing repeated courses of secondary prophylaxis decreased from 1.1 ± 0.06 to 0.12 ± 0.03 by 85% (p <0, 01), shortness of breath decreased, according to the Borg scale from 1.7 ± 0.03 to 0.71 ± 0.02 points (p <0.01). At the same time, in the control group, data on a decrease in angina attacks and shortness of breath were statistically insignificant.

The patients of the experimental group had increased physical performance and exercise tolerance. So, according to the data of bicycle ergometry, the power of the threshold load significantly increased only in the main group of patients from 74.0 ± 2.73 to 119.75 ± 7.59 W, by 25.1%, (p <0.02), but did not change in the control group in comparison with its indicators obtained after passing 2 or even 3 courses of rehabilitation without using a modified sequence of effects, which indicates a significant increase in the coronary and aerobic reserves of the body under the influence of the proposed method.

The distance covered, based on the 6-minute walk test (6-MTX), increased on average in the main group from 400.2 ± 12.72 to 455.5 ± 15.2 meters, (p <0.02), in control - from 360.02 ± 16.18 to 405.0 ± 9.1 meters, (p <0.05), respectively.

Clinical resting heart rate significantly decreased in ~ 65% of patients in the main group from 71.0 ± 0.91 to 67.4 ± 0.77 beats / min., (P <0.01), and only in ~ 35% of the control group ( p <0.01), which indicates a potentiating sympatholytic, economizing and training effect of the proposed method as a result of a more significant development of the effect of preconditioning and cardioprotection compared with the use of a complex of physiotherapeutic effects without their modified sequence.

Significantly, compared with the control group, systolic blood pressure (SBP) decreased in ~ 83% of patients in the main group (p <0.01), in the control group, increased diastolic blood pressure (DBP) decreased in ~ 80% of patients in the main group with ( p <0.01), in the control - DBP remained at the same level, which indicates a normalizing potentiating effect of the proposed method on the indicators of systolic and diastolic blood pressure.

The patients of the experimental group also showed an improvement in the lipid profile, which was manifested in a further decrease in the increased level of total blood cholesterol by 15.6%, (p <0.01), and in the patients of the control group (after 1.5-2 years and passing 2 -3 courses of rehabilitation without modification of the sequence of procedures) - only by 10.2% (p <0.1), as well as a decrease in the increased level of LDL, a decrease in the increased level of triglycerides under the influence of the proposed method - by 15-35% (p <0, 01), which was not observed in patients of the control group. This indicates a potentiating positive effect of the proposed method of secondary prevention on hypercholesterolemia, hyperlipidemia and hypertriglyceridemia.

There was also an improvement in the psychoemotional state of patients with coronary artery disease, mainly in the main group. So, situational anxiety decreased in the main group of patients within the normal range by 20%, (p <0.1), in the control group it remained at the same level.

Increased personal anxiety, according to the Spielberger test, decreased in patients of the main group within the normal range by 15% (p <0.05), in the control group - by 5%, (p <0.5), which indicates the greatest positive effect of the proposed a method for increased anxiety, which is due to more pronounced positive shifts in the clinical and functional state of patients, their hemodynamics, lipid spectrum under the influence of repeated courses.

Thus, the proposed method for the secondary prevention of acute myocardial infarction in cardiovascular patients, including after various cardio-interventional interventions, in addition to the usual (as in the prototype method, carried out as the first course of rehabilitation after surgery), simultaneous integration of cardio training techniques with a set of procedures metabolic protection of the myocardium, which includes UNK, ILT and SUV, uses repeated courses of secondary prevention, in which the sequence of the applied rehabilitation methods is changed (modified): first, methods of metabolic adaptation are carried out, and in a physiologically determined sequence (SUV-ILT-UNK), and only then - methods of physical adaptation in the form of interval training (treadmill). Such an improvement in the regimen, the sequence of applied actions leads to a more significant prophylactic effect in terms of duration both in relation to repeated episodes of angina pectoris, including with moderate physical exertion, and in relation to repeated myocardial infarctions in patients.

Bibliography:

1. RU 2715209 C1, publ. 02/25/2020.

2. T.A. Knyazeva, V.A. Badtieva, T.I. Nikiforov. Combining physical training with physiotherapeutic methods of restoring myocardial metabolism in the rehabilitation of patients after acute coronary syndrome and cardiosurgical revascularization of the myocardium. 5-12.

3. Aronov D.M. et al. Rehabilitation and secondary prevention in patients with acute ST-segment elevation myocardial infarction. Russian clinical guidelines, M., 2014, S. 71-81.

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Claims (9)

A method for the prevention of recurrent myocardial infarction in patients with ischemic heart disease (IHD) after acute coronary syndrome and cardiovascular surgery, including a treatment course of complex effects from drug therapy of current cardiovascular disorders and a complex of metabolic procedures and physiotherapeutic methods, in the form of receiving procedures " dry "carbon dioxide baths, infrared laser therapy, enhanced external counterpulsation and interval cyclic physical training, different in that that repeated courses of secondary prevention are carried out within 6 months after acute coronary syndrome or cardiovascular surgery, and each course is carried out in the following sequence, regimen and dosages: from the first day of the course of preventive treatment, they are carried out daily in the first half of the day, at the beginning, sequential procedures of metabolic adaptation in the form of: 1) "dry" carbon dioxide baths with a gas flow rate of 15 l / min, under a pressure of 2.3 atm until its concentration is 1.5 g / l, at a bath temperature of 26-28 ° C for 10-15 minutes, s subsequent rest for at least 30 minutes, 2) infrared laser therapy from the device "Mustang 2000+" according to a stable technique, continuous mode, wavelength 0.85 microns, frequency 50 Hz, radiation power 5-6 W, affect the region of the apex of the heart, middle third of the sternum, left subscapularis region along 1 min for each of the indicated areas, 3) immediately after the laser therapy, intensified external counterpulsation is performed for 20-30 minutes, followed by a rest for at least 40 minutes, at the same time, the whole complex of metabolic adaptation is carried out in a course of 7 daily procedures, and from day 3 from the beginning of the course, every day at the end of all sequential metabolic adaptation procedures, a physical adaptation procedure is added in the form of an interval cyclic physical training on a treadmill - treadmill, 5 daily sessions, with mandatory rest for 20 minutes after each session, daily with increasing duration from session to session: 5 minutes, 10 minutes, 15 minutes, 20 minutes, 25 minutes, and increasing training intensity - from 10% of the maximum heart rate on the first day of training, adding 10% for each next day of training - up to 60% from maximum heart rate to the 5th day of training; the course is repeated every 5-6 months.