RU2757967C1 - Selection method for patients with risk factors (rf) for development of cardiovascular diseases (cvd) for repeated courses of comprehensive preventive programs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, in particular to diagnosis and preventive treatment of cardiovascular diseases (CVD) in patients with risk factors (RF) for their development. As a preventive measure a set of cardio aerobic exercises in water and carbon dioxide baths are used, only 2-3 times a week with a course of 10 procedures. At the same time, with the help of the hardware and software complex (HSC) "Physiocontrol-P", the values of the following parameters are determined before and after the course of preventive treatment: pulse-wave velocity (PWV), cm /sec, in the process of oscillometry as part of the HSC, index of activity of the regulatory systems (IARS), ru, in process of cardiointervalography (CIG) as part of the HSC, indicator of actual fat mass (aFM) and body mass index, kg, the process of bioimpedance measurement as part of the HAC. In 3 months after completion of the previous course, a repeated course of preventive treatment is carried out if, immediately after previous course completion, there is no dynamics or following dynamics of parameter values compared to their values before the preventive treatment: PWV decreased by no more than 100 cm/sec, IARS decreased by no more than 1.5 units, aFM decreased by no more than 2 kg, body weight decreased by no more than 2 kg.

EFFECT: method allows individualizing the mode and frequency of complex preventive treatment courses in patients with CVD by highlighting the criteria for preventive treatment effectiveness and determining the long-term positive effect, which in turn allows either to postpone the next course or accelerate its implementation.

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Description

The invention relates to medicine, diagnosis and prevention of cardiovascular diseases (CVD) in patients with risk factors (RF) for their development. It can be used in specialized hospitals, rehabilitation centers, sanatoriums for planning repeated courses of cardioprophylaxis using physiotherapy methods.

CVDs are the leading cause of death worldwide. At the same time, reducing the severity of RF and maintaining a healthy lifestyle play an important role in the primary and secondary prevention of CVD development, and in improving the prognosis. Since physical inactivity is a recognized risk factor for cardiovascular complications (CVD), increased physical activity is a significant part of both CVD and CVD prevention programs. For this purpose, aquatherapy, i.e. the use of physical exercises in an aquatic environment can be used both in patients and in practically healthy individuals with RF of CVD development. As balneotherapy, carbon dioxide baths (HC) can be used, which have a beneficial effect on autonomic regulation, contractile and diastolic functions of the heart, improve lipid metabolism, and have a hypotensive effect. The complex application of both factors - HC and aquatherapy, due to the alleged potentiation of the effects of the two methods, seems to be the most justified.

However, prevention requires systematic measures, which, in turn, require the use of many resources. At the same time, their use is often not rational - the frequency of courses held, the intensity of classes, the use of several types of influences at once. This not only incurs economic losses with minimal results, but also overloads the patients themselves, without bringing them real benefits, without improving their health. Accordingly, it seems relevant to search for methods for assessing the effectiveness of ongoing prevention methods in order to select patients with RF of CVD for longer prophylaxis, criteria for establishing the suitability and expediency of influencing such patients with certain methods of physiotherapy. If a set of certain methods is not effective in reducing the severity of RF, a different set of actions can and should be developed for the patient, or the frequency of such prevention complexes can be increased. But this requires the development of criteria for the effectiveness of a particular set of impacts. This is what the proposed method is devoted to.

There is a known method (RU 2413458 C2, YuZGU, 03/10/2011), which, along with the assessment of cardiovascular risk (CVR) in patients with arterial hypertension, by constructing regression models of CVR taking into account unmodified and modified RF (age, pulse blood pressure, pulse wave velocity (PWV), a factor characterizing blood viscosity and viscoelastic properties of blood vessels), through a non-invasive analysis of the functional state of the cardiovascular system (CVS), can also be used to correct antihypertensive therapy, for example, in the case of establishing that in the process already ongoing therapy, CVR does not decrease. Thus, the indicated RFs within the framework of the regression model used in this case can play the role of criteria for assessing the effectiveness of antihypertensive therapy.

However, this known method concerns a group of patients who already suffer from arterial hypertension. It is not intended for people with pre-existing RF in the absence of CVD.

A known method of treating patients with increased activity of regulatory systems (RU2617197 C1, Ivanov V.V., 04.21.2017), in which electrical stimulation of the surface areas of the skin is carried out. The parameters of the heart rate variability are preliminarily measured and the indicator of the activity of regulatory systems ( PARS ) is determined. When the PARS value is more than three, its components are revealed that exceed the normal values. On the basis of these components, contraindications for electrical stimulation are determined. An additional examination is carried out, the diagnosis is clarified and the zones of stimulation are determined. The method allows to increase the effectiveness of treatment and reduce complications, which is achieved by taking into account the activity of regulatory systems and the mode of electrical stimulation.

Thus, in this known invention, PARS is used as one of the criteria for establishing the possibility of using one of the methods of physiotherapy in a patient. However, this known method is not applicable to the establishment of indications, contraindications, selection of patients for other methods of physiological or balneotherapy.

There is also known a method for assessing and predicting the functional state of workers in the transport professions (RU 2378979 C1, JSC "Russian Railways", 01/20/2010), which allows you to obtain a conclusion on the employee's condition, on the need for the next examination or rehabilitation procedures. For this, the dynamics of the values of 3 groups of indicators is recorded: physiological, reflecting the state of the CVS, psychophysiological, reflecting the state of the nervous-analytical system, and psychological, characterizing the level of anxiety and mental adaptation of the body. They are assessed according to population norms in accordance with four gradations: 1 - poor condition, 2 - decreased, 3 - satisfactory, 4 - good. Determine the average scores for the selected groups of indicators, with a certain calculation. Based on the results of assessments of the values of individual indicators and the results of their comparison with the data of previous studies, they give a forecast about the nature and severity of changes in the functional state. The need for an extraordinary extended psychophysiological examination of an employee is considered indicated with a certain decrease in the obtained values of the assessment of indicators. Thus, in a short period of time, it is possible to conduct a comprehensive assessment of the current functional state of workers in the transport professions, to predict its changes, to determine the need for an in-depth psychophysiological examination, to conduct rehabilitation procedures, and to assess their effectiveness.

This known method is aimed at a certain group of patients - transport employees, for its implementation use a special hardware and software complex (AIC) "EXPROM" - "examination and forecast of the driver", so its use in other groups of patients does not seem justified.

The aforementioned well-known complex allows you to evaluate the following indicators:

-physiological: heart rate at rest, index of heart rate stress according to Baevsky, Rufier-Dixon index;

-psychophysiological: tapping test, time of a simple visual-motor reaction, time of a complex visual-motor reaction, Wechsler's symbolic-digital test;

-psychological: general health according to Goldberg, personal anxiety according to Taylor, situational anxiety according to Spielberger-Khanin, coefficient of vegetative balance according to the Luscher-Shiposh color test, subjective minute according to Halberger-Moiseeva.

A known method for assessing the effectiveness of medical rehabilitation of patients with essential hypertension associated with coronary artery disease (RU 2724488 C1, FSBI "National Medical Research Center of the Republic of Kazakhstan" of the Ministry of Health of Russia, 06/23/2020). APC is used, which allows psychological research, oscillometry, cardiointervalography, and additionally echocardiography with the determination of the diastolic function of the left ventricle of the heart and the function of the left atrium, myocardial hypertrophy in the process of exposure to reflexotherapy on the auricular and electroacupuncture on the paravertebral points. These procedures are prescribed every other day with general iodine-bromine baths with a predominance of psychoasthenic symptoms in patients, radon baths with a predominance of vegetative balance disorders - in combination with subsequent magnetic laser therapy in the amount of 10 procedures of each type of treatment, prescribed alternately, every other day. At the end of the course, a repeated clinical and functional examination of patients is performed (complaints, anamnesis, blood pressure measurement, electrocardiography, ECG monitoring, echocardiography, psychodiagnostic research, evaluation of treatment results). The examination of patients is repeated in the same volume, 3 months, six months and 1 year after the end of the main course of treatment, assessment of the clinical and economic efficiency of treatment results and, if necessary, a repeated preventive course of non-drug rehabilitation.

However, this method is intended for patients already suffering from CVD, receiving during the course of treatment a whole range of physiological rehabilitation effects.

Our task was to develop criteria for evaluating the effectiveness of the complex cardioprophylaxis of patients with existing RF of CVD development, in the absence of CVDs as such, carried out, in particular, in our Center, in order to identify earlier groups of patients for whom such prevention was ineffective, and who require, thus, repetition of courses of cardioprophylaxis at an earlier date after completion of the first course.

For groups (or individually) of patients with existing RF of CVD development, the Center uses cardio aqua training programs, in particular, in combination with taking carbon dioxide baths (see patents of the Federal State Budgetary Institution “NMIC RK” of the Ministry of Health of Russia RU 2700531 C1, 17.09.2019; RU 2703356 C1, 16.10.2019). When combining aquatraining with procedures for taking carbon dioxide baths, patients receive water aerobic training of medium intensity, with a depth of immersion - at the level of a person's chest. Water temperature 28-29 ° С. Classes are held 3 times a week, 10 lessons of 45 minutes each. The main part includes aerobic exercises in the form of walking in water, running and jumping in combination with movements of the upper and lower extremities in all planes and directions possible for the patient, performed on the basis of basic aerobic movements. With continuous exercise, the patient constantly maintains such a pace and amplitude of the movements performed, which allow maintaining the intensity of the load at the level of 50-70% of the maximum heart rate. After each aquatraining lesson, the procedure for taking HC artificially prepared with a carbon dioxide concentration of 1.2-1.4 g / l, a temperature of 30-32 ° C, the duration of each procedure is 12 minutes, 10 procedures is carried out. The method provides health improvement of the body in the form of an effective reduction in the indicators of existing risk factors for the development of CVD or their initial manifestations in patients of different age groups (reduction of dyslipidemia, weight loss (BMI), improvement of exercise tolerance, taking into account heart rate and blood pressure, an increase in maximum oxygen consumption and physical activity), individualization of the load directly in the process of cardio training in water, universal for a wide range of patients, increasing compliance - the adherence of patients to healthy lifestyle and methods of CVD prevention.

For patients within the framework of this known method (RU 2700531 C1, September 17, 2019), testing was carried out on the Fiziocontrol-R agro-industrial complex for a screening assessment of the level of psychophysiological and somatic health, in the process of which the indicators of the functional reserves of the subject and their dynamics were determined in the process of rehabilitation preventive course, and after its completion (and after 3 months and 6 months). The results of the conducted studies helped us to identify which physiological indicators are most significant for assessing the effectiveness of the procedures received by patients, and, in case of their low effectiveness, to prescribe further courses of cardioprophylaxis as early as possible, for example, 3 months after the end of the previous course.

In general, the functional state of a person is judged by the totality of psychophysiological indicators. A known method of assessing the indicator of the activity of regulatory systems, calculated by the spectral and mathematical-statistical characteristics of the heart rate (Baevsky PM Predicting states on the verge of norm and pathology. - M., 1979). On the basis of this method, a "Device for monitoring and correcting the functional state of a person" (RF patent No. 2028078) was developed, which made it possible to present physiological parameters and an integral point assessment of a person's condition both to the researcher and the subject for express control and self-control, to evaluate the integral indicator CCC - PARS . However, the disadvantage of such a device is the assessment of only one of the components of the functional state of a person - the state of the CVD, while the RF CVD can relate not only to the functional state of the CVS, but also to the work of other systems of the patient's body (lipid profile, fat mass, body weight etc.).

Regulatory systems are a multilevel internal control system consisting of the circulatory system, cerebral cortex, hypothalamus, spinal cord, adrenal glands, etc., which, in one way or another, determine the quality of the body's relationship with the external environment. To assess the quality of regulation, the method of cardiointervalography (CIG) (heart rate variability, HRV) is often used. Moreover, each of the regulation systems has its own values of activity in points. The scores of individual systems determine the integral indicator of the activity of regulatory systems - PARS (PM Baevsky, A.P. Berseneva, Introduction to prenosological diagnostics, Moscow, State Scientific Center of the Russian Federation IBMP of the Russian Academy of Sciences. "Word". - 2008).

Strengthening the activity of CVS in patients with depletion of regulatory mechanisms can lead to an increase in the value of PARS and a breakdown in adaptation (PM Baevsky, A.P. Berseneva. Introduction to prenosological diagnostics, Moscow, State Research Center of the Russian Federation, IBMP of the Russian Academy of Sciences. Slovo. - 2008) , for example, in the case of stressful influences, which leads to an increase in blood pressure and, accordingly, to an increase in the value of PARS, which, in turn, can reduce the effectiveness of therapy. Evaluation of HRV makes it possible to identify violations in individual links of regulation even before the clinical manifestations of a particular pathology, to assess the degree of risk of fatal conditions, to determine the correctness of treatment and its effectiveness - by changing the PARS.

The level of regulation activity is expressed in points of PARS and has a numerical value in the range from 1 to 10 (Baevsky R.M., Kirillov OI, Kletskin S.Z. Mathematical analysis of changes in heart rate under stress. - M .: Nauka, 1984). The values of the activity indicators of each of the systems included in the PARS are divided into five ranges according to the degree of their activity from normal to pathology. Further, these indicators are grouped according to functional regulation systems. So, for example, the system responsible for the stability of regulation includes the arrhythmia index and the standard deviation of the value of the cardiointervals. Depending on the degree of their deviation from the norm, each indicator is assigned its own score. Of these, the largest is selected, the value of which is then summed up with the selected points of other systems. So, the value of PARS, equal to 1, corresponds to the optimal tension of regulatory systems, the value equal to 9, - to a pronounced depletion of regulatory mechanisms. A PARS value of 9 shows how much the body has to tensely control vital systems, but it lacks the resources to regulate in a low activity mode.

With PARS values from 1 to 3, it is considered that the parameters of regulation activity correspond to the norm and do not require therapeutic intervention. PARS allows differentiation of various degrees of tension in regulatory systems. Thus, as a result, it is possible to stratify the subjects according to one of 4 functional states according to the classification adopted in prenosological diagnostics [Bayevsky P.M., 1997]:

- the state of the norm or the state of satisfactory adaptation (PARS = 1-3 points);

- the state of functional tension (PARS = 4-5 points) - prenosological state;

- the state of overvoltage or the state of unsatisfactory adaptation (PARS = 6-7 points);

- the state of depletion of regulatory systems or failure of adaptation (PARS = 8-10 points).

The PARS includes such statistical parameters as stress index (IN or its second name is stress index, SI), standard deviation of values of SDNN cardiointervals, HR pulse, etc. The PARS also includes spectral components, such as the total power of the heart rate oscillation spectrum and its components: high-frequency HF, medium-frequency LF, low-frequency VLF, as well as the centralization index IC - the ratio of the sum of LF and VLF to HF, MxDMn - the variation range, t .e. the difference between the maximum and minimum value of cardiointervals, etc. (RM Baevsky, AP Berseneva, Introduction to prenosological diagnostics, M., State Scientific Center of the Russian Federation, IBMP RAS. "Slovo". 2008).

The total power of the spectrum is an indicator of the level of adaptation (quality of regulation) and reflects the resource of vitality. The age of the patient is the most important determinant in determining the level of health and resource of regulation. It is known that the power of the spectrum decreases with age in the interval from 20 to 30 years by 30%, over 30 years of age the decline slows down (Yabluchansky N.N., Martynenko A.V. Heart rate variability. To help a practitioner. Kharkov, 2010. ). Therefore, for the successful correction of the patient's condition, a differentiated approach is often required, taking into account age characteristics, which consists in the need for longer procedures for persons of mature and older age. This is due to a slowdown in the rate of metabolic processes in the body and is expressed in an underestimated reaction of the regulatory systems to external influences.

In research practice, SI is often used as the only indicator of the effectiveness of therapy or rehabilitation. Moreover, the IN value strongly depends even on one value of the cardiointerval and, if a rhythm failure occurs, for example, one extrasystole is recorded, then this already leads to an increase in the variation range of MxDMn and to an unjustified underestimation of the IN value, which follows from its calculation formula:

ID = AMo / (2Mo * MxDMn),

where Mo is the value of the most frequent cardiointervals, and AMo is the number of the most frequent intervals in relation to the total number.

For this reason, MI as such cannot serve as an unambiguous criterion for assessing the effectiveness of an impact. The preferred parameter of the assessment is precisely the PARS. It follows from this that in order to increase the effectiveness of therapy, it is necessary to use such modes and mechanisms of action that would purposefully affect those regulatory systems, in which violations are the cause of an increased value of PARS.

Thus, a comprehensive assessment of HRV is possible by the indicator of activity of regulatory systems (PARS) (Gurfinkel Yu.I. Assessment of the effect of hypomagnetic conditions on capillary blood flow, blood pressure and heart rate / Yu.I. Gurfinkel, A.L. Vasin, T. A. Matveeva, M. L. Sasonko. // Aerospace and Environmental Medicine. - 2014. - T. 48, No. 2. - P. 24-30).

Another important indicator of the functional state of the CVS itself is the pulse wave velocity (PWV).

In the known method for assessing the risk of CVS (RU 2508904 C1, Gurfinkel Yu.I. et al., 03/10/2014), as in the previous ones, the state of CVS is determined and predicted. Using the method of optical capillaroscopy, finger eponychia is used to determine the size of the perivascular zone, the diameters of the venous and arterial capillaries. Determine the speed of the pulse wave and the value of endothelial function on the upper limb synchronously with the R peak of the ECG. Blood pressure is measured. Calculate the K index of the risk of MTR according to the original mathematical formula, which increases the reliability and objectivity of the risk assessment of MTR. The use of an original device in this method makes it possible to measure SPW using a capillaroscopy unit. The computer program evaluates the blood flow velocity in the capillary selected by the operator, determines the frame number N corresponding to the maximum of this velocity. Taking into account the frame period of the video camera and the frame number N, then the delay of the signals in the capillary relative to the sync pulse from the ECG unit is calculated. This is necessary for the subsequent evaluation in the computer of the delay of the image frames relative to the pulse from the ECG unit, which makes it possible to calculate the speed in the selected area.

It should be noted that the parameters characterizing the presence of overweight and, indirectly, visceral obesity (VO) are not included in any of the scoring systems for cardiovascular risk (CVR), and the results of the assessment of classical factors based on the SCORE scale (Systematic Coronary Risk Evaluation), often cannot predict the development of events in individuals belonging to low and moderate risk groups, but already in need of early CVD prevention measures. Historically, the first high-risk model for abdominal obesity (AO) was the concept of metabolic syndrome (MS). However, the results of recent studies, on the basis of which the so-called "reverse epidemiology" of obesity was formed, demonstrate the low specificity of this model with respect to the isolation of persons with high CVR. MS does not take into account other factors of CVS, it is based on an indirect criterion of VO. As one of the conceptual models of pathophysiological models of high CVR, a model of early vascular aging (RSA) is proposed, the core of which is arterial stiffness, assessed by the rate of pulse wave propagation (PWV, PWV) and correlated with the chronological age of the patient (Druzhilov M.A. and other. Pulse wave velocity in the aorta as an additional prognostic criterion in abdominal obesity. // Cardiovascular therapy and prevention, 2015; 14 (3), pp. 49-53.

According to this model, the processes of remodeling of large elastic arteries occur during normal aging; normal and reference values of the carotid-femoral PWV index have been established for each age range of persons without CVR factors and asymptomatic with respect to CVD. At the same time, under the action of various RFs, the processes of vascular remodeling develop at a younger age. VO also accelerates the age-related increase in vascular wall stiffness, and this relationship can be traced even in the absence of carbohydrate metabolic disorders and arterial hypertension (AH). A meta-analysis of 16 population studies has shown that carotid-femoral PWV is an independent risk factor for general and cardiovascular mortality, and its use makes it possible to improve prediction, first of all, with an initially low CVR. Stratification of CVR using indicators of vascular stiffness is poorly understood. Previously, the presence of an association of vascular stiffness indicators with parameters of cardiovascular remodeling in persons with abdominal obesity without hypertension was demonstrated (Druzhilov M.A. et al., Ibid.).

Earlier, we have also shown that when determining several significant parameters of a patient's health status with existing CVDs in dynamics using a diagnostic APC, such as, for example, "Physiocontrol-R", it is possible to evaluate the effectiveness of the physical methods of rehabilitation used, in particular, including laser therapy. and other techniques (O.D. Lebedeva, I.A. Bokova, M.V. Rodkina, G.A. Lebedev. Evaluation of the effectiveness of physical rehabilitation methods with the inclusion of laser therapy for cardiovascular diseases using new diagnostic technology // Laser Medicine . - 2020. - T. 24, No. 2-3. P.54-61. Https://doi.org/10.37895/2071-8004-2020-24-2-3-54-61).

This APC has been used in our Center for several years and has repeatedly shown itself in the diagnosis of patients' condition, predicting and evaluating the effectiveness of various methods of physiotherapy and balneotherapy (Lebedeva O.D., Yakovlev M.Yu., Ambrazhuk I.I., Banchenko A. D. Development of innovative methods for assessing the effectiveness of complex programs for the treatment of hypertension. // Laser medicine. - 2016. - T. 20, issue 1. P. 5-7). The consultative and diagnostic system developed on the basis of the Federal State Budgetary Institution "RNTs MRiK" of the Ministry of Health of Russia in conjunction with LLC "IVNMT" Ramena ", made in the form of" Fiziocontrol-R "agro-industrial complex, was used as the main method of examination with subsequent assessment of the effectiveness of treatment. This APK fully meets the above requirements and includes hardware and software (software). The hardware part is made in the form of a single device that combines a cardiointerval analyzer, a hemodynamic analysis unit, a bioimpedance meter, an electronic spirometer, a pulse oximeter and others. The software, in turn, provides hardware management, as well as verbal-communicative research, measurement, calculation and display of indicators of the functional state of the body, quantitative assessment of the level of functional reserves and calculation of the risks of developing non-communicable diseases. The assessment is based on the results of: HRV analysis; analysis of the main hemodynamic parameters by high-resolution compression oscillometry; bioimpedansometry of the internal environment of the body; spirometry; pulse oximetry; measurement of glucose and cholesterol in the blood; questionnaires on the severity of complaints about poor health (author's method); questionnaires on living conditions and the presence of bad habits (author's method); anthropometric measurements; carrying out stress tests; psychological tests; analysis of the results of psychophysiological research; assessments of the neuropsychic state; calculated integral values.

The study of the effectiveness of cardio workouts in the pool water in combination with the procedures for taking general carbon dioxide baths (HC) using this APC in patients with existing RF development of CVD, in the actual absence of these diseases, made it possible to establish a number of changing physiological parameters, for which, then, in the dynamics of observation after patients, it was found that only a number of them are really significant for assessing the effectiveness of ongoing cardioprophylaxis courses and, accordingly, for the subsequent selection of patients for repeating its courses.

The technical result of the proposed method is the individualization of the regimen and frequency of courses of complex preventive programs in patients with RF of CVD development by highlighting the criteria for the effectiveness of preventive measures and, accordingly, determining the long-term positive effect produced by it, which in turn makes it possible to individually or postpone the next course, or speed up its implementation.

To achieve this result, we have proposed a method for selecting patients with RF of CVD development for repeated courses of comprehensive preventive programs. As a prophylaxis, a set of aerobic cardio training exercises in water and carbon dioxide bath procedures are carried out 2-3 times a week, in total - in a course of 10 procedures, with the definition using the hardware-software complex (APC) "Physiocontrol-R" before and after the course of prevention following parameters:

- pulse wave velocity (PWV), cm / sec, in the process of oscillometry as part of the AIC,

-indicator of activity of regulatory systems (PARS), conventional units, in the process of cardiointervalography (CIG) as part of the APC,

- the indicator of the actual fat mass (FFM) and the indicator of body weight, in kg, in the process of bioimpedance measurement as part of the AIC.

After 3 months at the end of the previous course, a repeated course of prophylaxis is carried out if immediately after the end of the previous course there is no dynamics or the following dynamics of the values of these parameters is observed in comparison with their values before the prophylaxis:

-SPV decreased by no more than 100 cm / sec,

-PARS decreased by no more than 1.5 conventional units,

-fZhM decreased by no more than 2 kg,

-the body weight has decreased by no more than 2 kg.

As a complex of physiotherapeutic procedures for cardioprophylaxis, sequential procedures of aquatherapy (ACT) and taking carbon dioxide baths (HC) are carried out 2-3 times a week.

The act is carried out in the form of water aerobic training of medium intensity, with a depth of immersion - at the level of the human chest, the water temperature is 28-29 ° С, in total - 10 sessions of 45 minutes each. An in-water activity includes:

- warm-up - 5 min, consisting of exercises for warming up the muscles of the body in the form of free swimming in a free style, walking, jumping and running in place, with a gradually increasing tempo and amplitude of movements until the heart rate level is reached in the main part of the training, equal to 50-70% of the patient's maximum heart rate during physical activity, determined before the start of the course,

- the main part - 35 minutes,

-the final period (hitch) - 5 minutes.

The main part includes aerobic exercises in the form of walking, running and jumping in combination with movements of the upper and lower extremities in all planes and directions possible for the patient, performed on the basis of basic aerobic movements. Moreover, with continuous exercise, the patient constantly maintains such a pace and amplitude of the movements performed, which allow maintaining the intensity of physical activity at the level of 50-70% of the patient's maximum heart rate during physical activity, determined before the start of the course.

The final period includes exercises for coordination of movements, muscle stretching, free swimming in a free style and exercises to restore calm breathing.

After each AkT lesson, the procedure for taking HC, artificially prepared with a carbon dioxide concentration of 1.2-1.4 g / l, a temperature of 30-32 ° C, the duration of each procedure 12 minutes, is carried out, is carried out, a total of 10 procedures.

Maintaining the heart rate at a level of 50-70% of the maximum is carried out without interrupting the lesson, by using an individual pulse oximeter, or by using a 20-point scale for subjective assessment of physical activity in the classroom - the Borg scale, according to which this level of heart rate corresponds to the green level of the scale - 12- 14 points. The maximum heart rate during physical activity for the patient before the start of the course in water is set according to the mathematical formula maxHR = 220-age in years - 13. The maximum heart rate during physical activity for the patient before the start of the course can also be set on a bicycle ergometer or treadmill. Classes are held in groups of up to 10 people or individually.

At the same time, in the course of the research, we used various sets of ACT exercises with the subsequent intake of HC. As one of the complexes (patent RU 2703356 C1), for example, the following set of aerobic exercises in water can be used. The water temperature is 28-29 ° C, the water level is up to the patient's chest, a course of 10 sessions (sometimes up to 16 sessions were carried out to consolidate), 2 times a week, using a 20-point scale for subjective assessment of Borg's physical load to select the individual load for patients.

The complex included a warming up warm-up for 5 minutes, the main part for 30-35 minutes, a cool down for 5 minutes.

The warm-up included exercises, each lasting 1 min:

- free swimming in free style up to 25 m,

- walking on the spot, while the arms at the elbows bend-unbend under water on the sides of the body - they "cut" the water with their hands,

- walking in place with legs apart shoulder-width apart, while the arms at the elbows bend-unbend under the water on the sides of the body - they "cut" the water with their hands,

- jumping in place on straight legs,

- running on the spot, raising the hip of the bent leg forward to the maximum possible height for the patient, while the arms at the elbows bend-unbend under water on the sides of the body - they “cut” the water with their hands.

The main part included 30 consecutive exercises from the initial position (I.p.) standing on the bottom of the pool, each exercise lasting 1 min, and the pace of execution and the amplitude of movements each patient chose individually during each lesson, maintaining his state according to the green level of the Borg scale - 12 -14 points:

1) running in place, bending the knees with lifting the shins back, at the same time bending and unbending the arms in front of the chest at the elbows, pushing the water in front of you;

2) the same movements with the hands with alternating swings of straight legs back;

3) from I. p. while standing, arms to the sides in a jump are alternately raised, taking the right and left legs to the side, at the same time the direction of the arms is changed to the side opposite to the raised leg;

4) swing straight legs forward alternately, with both hands the patient reaches for the toe, change of legs - in a jump;

5) running in place, raising the thigh of the bent leg forward to the maximum possible height for the patient, at the same time the arms in front of the chest bend-unbend at the elbows, pushing the water in front of you;

6) "frog" - from I. p. while standing, hands are clasped in front of the chest, legs are wider than shoulders in a jump, they straighten their arms down in front of the stomach, while bending the knees and lifting the knees up and apart;

7) "ski run" - from I. p. standing, legs together, one leg is put forward, the other is laid back, hands are lowered down; they change legs with simultaneous movement along the body of straight arms opposite to the legs, imitating skiing;

8) "asterisk" - from I. p. standing, legs together, arms along the body simultaneously spread the arms and legs to the sides in a jump and return to the IP in a jump;

9) from I. p. standing, feet shoulder-width apart, arms to the sides in a jump, simultaneously crossing the arms in front of the chest and crossing the legs;

10) running in place, bending the knees with lifting the shins back, at the same time bending and unbending the arms in front of the chest at the elbows, pushing the water in front of you;

11) from I.p. standing, legs together, arms in front of the chest in a jump, raise forward and straighten

a leg from the knee with the toe towards itself, then the other leg, while the patient pulls the arm of the opposite side to the raised leg;

12) from I. p. while standing, hands are lowered in a jump, alternately raise, taking away, the right and left legs to the side, at the same time both hands are moved to the side opposite to the raised leg;

13) "ski run";

14) "asterisk";

15) from I.p. standing, hands in front of the chest run in place, raising the hip of the bent leg to the maximum possible height for the patient forward, at the same time the arms in front of the chest bend-unbend at the elbows, pushing water in front of them;

16) from I.p. standing, legs together, arms bent at the elbows performing jumps in place while simultaneously pressing the knees to the abdomen, while the patient straightens his elbows down at the time of the jump;

17) "horse" - from I. p. standing, one leg is in front, the other is set backward, arms are stretched forward and backward, opposite to the legs, they jump on bent legs, transferring body weight from one leg to another - from front to back and back;

18) repeat the exercise "horse", changing legs in SP. - the other leg forward;

19) from I.p. standing, legs together, arms bent at the elbows perform jumps in place, alternating landing in the position of the legs together and legs apart, to the sides, the patient straightens down his arms at the elbows at the moment of the jump;

20) from I. p. standing, hands in front of the chest run in place, raising the hip of the bent leg to the maximum possible height for the patient forward, at the same time the arms in front of the chest bend-unbend at the elbows, pushing water in front of them;

21) "wide ski run", in which all movements of the "ski run" are performed with the maximum possible for the patient amplitude of the legs in their position: one - in front, the other - behind;

22) "asterisk";

23) alternation of skiing and asterisk exercises at a pace that is comfortable for the patient;

24) from I. p. standing, legs together, arms bent at the elbows performing jumps in place while simultaneously pressing the knees to the stomach, the patient straightens his arms down at the elbows at the time of the jump;

25) "ski run";

26) from I. p. standing, legs together, hands in front of the chest, perform alternating swings with straight legs back, changing legs in a jump, while bending and unbending at the elbows in front of the chest, pushing water in front of them;

27) running in place with an alternating rise of the legs backward, while the arms are bent-unbend at the elbows in front of the chest, pushing water in front of them;

28) running in place with alternate lifting of bent legs anteriorly, touching the lower leg with the opposite hand;

29) jogging in place with alternating backward lifting of the shins with touching the shins with the opposite hand;

30) from I. p. standing, arms bent at the elbows, run in place, raising the thigh of the bent leg forward to the maximum possible height for the patient, while the patient flexes and unbends his elbows in front of the chest, pushing water in front of him.

The cool down consisted of the following sequence of exercises, each lasting 1 minute:

- "bicycle" - from I. p. lying on the water on your back, covering your elbows behind your back behind your back sports equipment (SI) in the form of a stick, designed to be kept on the water (for example, noodles), swim in the water with alternate circular movements with your legs, imitating cycling,

- swimming lying on its side in the water, leaning with hands on the SI,

- swimming on the other side, leaning hands on the SI,

- from I. p. standing, hands down, relaxed, running in place,

- from I. p. standing, arms lowered, relaxed on exhalation, they pull up alternately bent legs to the chest, clasping the shins with their hands and returning to the SP.

After completing the cool down, you can additionally perform free swimming in a free style for 5 minutes. From the 3rd lesson, the exercise can be complicated by additional techniques, for example:

- performing jumps in which the hands were not involved is complicated by the fact that the hands are held on the belt, or hands to the shoulders, or hands vertically upward,

- when walking on the spot, performing side steps,

- when walking in place with feet shoulder-width apart - with rotation around the axis of the supporting leg,

- when running in place, the body moves in 4 steps left-right and forward-backward, always returning to the I.P.,

- when performing the "asterisk", increasing the height of the hops, bending the knees when jumping, turning 180 ° C on the hop,

- when performing the exercise "horse", moving in 4 steps in each direction - to the right, to the left during jumps,

- during the "ski run" exercise, alternate on landing, setting the legs wider and narrower: one in front, the other behind, performing jumps with bending the knees and turning by 180 ° C, performing movements in each direction - back and forth in 4 steps with a return to and. NS.,

- when jumping on the spot, alternate pressing the knees to the stomach with raising the legs in the jump to the sides with landing in the position of the legs together,

- when running in place with alternating lifting of the bent legs anteriorly, touching the lower leg with the opposite hand, the body is tilted backward,

- when running in place with an alternating rise of the legs posteriorly, the body is tilted anteriorly,

- when running with the maximum possible lifting for the patient, the hips touch the knee with the opposite elbow,

- when performing the exercise "bicycle" acceleration of the pace of movements.

Exercises can also be made more difficult by increasing water resistance by using webbed water gloves.

At the same time, at the request of patients and the availability of the capabilities of the medical center, individual exercises can be replaced with equivalent ones in a functional, load-bearing plan, since for the proposed method of selecting patients for repeated courses of cardioprophylaxis, in this case, systematic, course physical activity is significant as such, in particular, in water, where exercise is easier to do because of the reduced axial load (gravity on the body).

In the course of the research, 60 apparently healthy persons aged from 25 to 60 years old, 44 women and 16 men, with the presence of at least two risk factors for CVD, were examined. The examinations were carried out before and after the patients were given a course of carbon dioxide baths and water training (ACT). Psychological testing (tests by Spielberger, SAN, Lusher) was carried out as a survey within the framework of the work of APK "Physiocontrol-R"; cardiointervalography (CIG) for the study of autonomic function; study of central and peripheral hemodynamics (high-resolution oscillometry); bioimpedansometry to determine body composition; spirometry to study the function of external respiration. Anthropometry, dynamometry, determination of the thickness of the fat fold using a caliper were performed.

When carrying out oscillometry within the framework of the work of APK "Physiocontrol-R" were determined: systolic, diastolic, mean and pulse blood pressure; Heart rate; indicators of cardiac hemodynamics: minute volume (MV), cardiac index (SI), stroke volume (SV), stroke index (SI); vascular indicators: artery diameter, artery compliance, linear blood flow velocity (LFV), pulse wave velocity ( PWV ), vascular compliance, total peripheral vascular resistance (OPSR), degree of peripheral artery patency. Systolic and diastolic blood pressure was also determined by the Korotkov method.

When conducting CIG as part of the APC, such indicators as heart rate (HR), standard deviation - SDNN, coefficient of variation (CV), stress index (SI), centralization index (IC), indicator of activity of regulatory systems (PARS) were determined , frequency analysis: power of HF, LF, VLF, total power of the TP spectrum, assessment of the state of regulatory systems: level of functioning, degree of centralization of control of functioning, stability of regulation, vegetative homeostasis, activity of the sympathetic vascular center.

When conducting bioimpedansometry (bioimpedansography) during the operation of the APC, body composition indicators were determined: weight, waist size, hips, waist / hip index, proper indicators - basal metabolic rate (BM), body mass index (BMI), body surface area, extracellular fluid ( ECF), intracellular fluid (ECF), total fluid (OB), total water (OM), active cell mass (ACM), fat-free mass (FFM), fat mass (FM), dry cell mass. Determined the percent deviation of the actual above indicators to the due values.

When carrying out spirometry, the following indicators were determined: vital capacity of the lungs inhalation (VC), vital capacity of the lungs exhalation (VC), Evd, respiratory rate (RR), T inhalation, T expiration, minute volume of respiration (MOV), TO, RO inhalation, RO exhalation, the ratio of Tpdokh to Tp exhalation.

The results were statistically processed using the SPSS computer program, version 23. Descriptive statistics, correlations, dimensionality reduction (factor analysis) and other types of analysis were used. The average indices for the group in the form of mean and standard deviation (M ± σ) are presented in Table 1 for a number of indicators (the table does not indicate the values of spirometry indices and a number of hemodynamic and metabolic indices, the dynamics of which were not statistically significant).

Table 1

Dynamics of agro-industrial complex indicators before, after and after 3 months

after the end of treatment .

N Index Before treatment Immediately after graduation In 3 months Oscillometry within the framework of the agro-industrial complex 1 SBP, mm Hg 124.9 ± 9.5 118.2 ± 10.1 122.36 ± 15.98 2 DBP, mm Hg 62.3 ± 9.47 59.9 ± 11.6 62.7 ± 10.1 3 HELL mean 93.6 ± 7.89 89.06 ± 8.97 92.5 ± 12.4 4 Heart rate, beats / min 67.04 ± 11.76 64.53 ± 9.37 65.36 ± 6.7 5 MO, l in 1 min 5.26 ± 1.11 4.83 ± 1.39 5.02 ± 1.137 6 SI, l / min / m2 2.96 ± 0.59 2.75 ± 0.79 2.8 ± 0.526 7 UO, ml 81.46 ± 26.58 71.4 ± 29.03 78.45 ± 22.23 eight UI, ml / m2 45.83 ± 14.49 43.87 ± 16.24 43.7 ± 10.75 nine SPV, cm / sec 712.5 + 10.11 610.9 + 9.18 645.3 + 10.28 ten GARDEN according to Korotkov, mm Hg 130.5 ± 9.7 125.3 ± 8.84 126.0 ± 14.5 eleven DBP according to Korotkov, mm Hg 82.3 ± 7.6 78.4 ± 8.42 81.45 ± 11.9 Cardiointervalography in the process of work of the agro-industrial complex 12 Heart rate, beats / min 70.05 ± 11.2 71.67 ± 9.06 72.18 ± 5.76 13 SDNN, mc 59.3 ± 45.2 49.9 ± 35.46 44.97 ± 22.5 fourteen CV,% 6.87 ± 5.53 5.96 ± 4.7 5.37 ± 2.68 15 SI, conventional units 308.2 ± 216.1 322.25 ± 227.85 385.18 ± 272.1 16 IC, conventional units 3.85 ± 4.29 3.28 ± 3.56 3.13 ± 2.94 17 PARS, conventional units 4.32 ± 0.43 3.17 ± 0.38 3.73 ± 0.45 eighteen HF,% 33.7 ± 21.24 36.24 ± 24.58 39.33 ± 15.1 19 LF,% 39.33 ± 15.1 36.84 ± 16.03 31.59 ± 15.46 twenty VLF,% 26.97 ± 11.98 28.92 ± 17.77 28.62 ± 19.54 21 TR, ms2 7541.16 ± 221.5 3002.3 ± 5344.17 1822.4 ± 1876.94 Bioimpedancemetry in the process of AIC operation 22 Weight (body weight, kg) 72.18 ± 1.26 70.27 ± 1.92 70.48 ± 1.90 23 Caliper, cm 3.56 ± 1.058 3.51 ± 0.75 3.04 ± 0.575 24 Waist, cm 88.08 ± 11.3 90.1 ± 8.046 87.2 ± 7.19 25 Hip, cm 60.08 ± 7.35 61.6 ± 7.95 56.5 ± 2.17 26 Index Waist / Hip 1.47 ± 0.499 1.47 ± 0.22 1.568 ± 0.176 27 Should. VKZH, l 10.65 ± 1.19 10.53 ± 0.95 10.55 ± 0.96 28 Fact. VKZH, l 8.788 ± 1.166 8.72 ± 1.05 9.17 ± 1.38 29 Should. VKZH, l 21.24 ± 2.44 21.05 ± 1.89 21.097 ± 1.91 thirty Fact. VKZH, l 20.665 ± 2.396 20.54 ± 1.9 20.43 ± 1.867 31 Should. Coolant, l 31.94 ± 3.58 31.58 ± 2.838 31.65 ± 2.87 32 Fact. Coolant, l 29.48 ± 3.32 29.22 ± 2.77 29.596 ± 3.075 33 Should. Weight, kg 65.39 ± 7.265 64.1 + 6.1 64.25 ± 6.79 34 Fact. Weight, kg 73.49 ± 11.99 72.26 ± 10.45 72.48 ± 6.15 35 Should. BZHM, kg 49.6 ± 6.79 48.17 ± 6.17 50.056 ± 6.63 36 Fact. BZHM, kg 47.4 ± 0.53 47.12 ± 5.27 47.37 ± 5.88 37 Due RH, l 36.31 ± 4.97 36.1 + 5.1 35.59 ± 4.45 38 Actual OV, l 34.73 ± 4.78 34.493 ± 3.86 34.67 ± 4.3 39 Due AKM, kg 32.55 ± 4.45 31.35 + 4.22 31.898 ± 3.99 40 Fact. AKM, kg 32.77 ± 4.496 32.538 ± 3.58 32.177 ± 3.61 41 Due FM, kg 15.557 ± 1.375 15.455 + 5.1 15.626 ± 1.335 42 Fact. LM, kg 25.61 ± 0.835 24.14 ± 0.87 23.116 ± 0.80

As follows from Table 1, among the hemodynamic data, significant (p <0.05) dynamics were noted, both after the end of treatment and persisting after 3 months, in relation to the pulse wave velocity (PWV), which can be explained by a decrease in resistance in the vascular system. Initially, PWV is usually elevated with CVD risk due to increased vascular wall stiffness. After the treatment-and-prophylactic measures, the PWV should decrease. However, this does not occur in all patients after a course of complex cardioprophylaxis, which gives grounds for their systematic repetition.

As for the indicators of cardiointervalography (CIG) (table 1), there was also a significant dynamics (p <0.05) to the normalization of the indicator of the activity of regulatory systems ( PARS ) immediately after the end of the treatment-and-prophylactic course of complex cardioprophylaxis, with a slight increase to 3- month after its end, which indicates positive dynamics in terms of normalization of the activity of the sympatho-adrenal system after such courses, but also requires their repetition in case of indications after a certain time interval.

With regard to indicatorsbioimpedancemetry(Table 1) we can talk about a tendency (p <0.1) to decrease the average body weight of patients, as well as significant dynamics (p <0.05) of the actual fat mass, which is also the result of the course of prevention.

During subsequent examinations of patients after 3 months, 6 months and 1 year, using the above statistical methods, significant indicators were established, the values of which remained at the optimal level in patients who underwent the first course of cardioprophylaxis (45 patients). At the same time, of the remaining patients in five (who refused to continue further courses of prevention due to personal motives or lack of opportunities), the values of these indicators significantly worsened, which was expressed in patients in an increase in the number of complaints from the CVS, and after a year two people from this group suffered an acute myocardial infarction, and two more were diagnosed with hypertension.

Ten other patients underwent repeated courses of cardioprophylaxis (aquatherapy exercises and carbon dioxide bath procedures) according to the same scheme 2 and 3 times during the study year, since by 3-6 months after the end of the initial course of prevention, the values of these indicators significantly worsened (PARS, PWS, weight body according to bioimpedance data, actual fat mass). The repeated course of the complex of procedures for such patients was carried out with their voluntary consent. Timely implementation of repeated preventive procedures made it possible to maintain the severity of their CVD risk factors at the same level and even reduce their severity, which was ensured by the selection of a number of the most significant physiological indicators from the total number of monitored physiological indicators (criteria for assessing the effectiveness of prevention) to control the severity of existing risk factors development of CVD in such patients.

Claims (9)

A method for selecting patients with risk factors (RF) for the development of cardiovascular diseases (CVD) for repeated courses of complex preventive programs, including conducting, as a preventive measure 2-3 times a week, a set of aerobic cardio training in water and carbon dioxide bath procedures, the whole course of 10 procedures, with the definition of the following parameters using the hardware and software complex (APC) "Physiocontrol-R" before and after the course of prophylaxis: - pulse wave velocity (PWV), cm / sec, in the process of oscillometry as part of the AIC, -indicator of activity of regulatory systems (PARS), conventional units, in the process of cardiointervalography (CIG) as part of the APC, - the indicator of the actual fat mass (fFM) and the indicator of body weight, kg, in the process of bioimpedance measurement as part of the AIC, and 3 months after the end of the previous course, a repeated course of prophylaxis is carried out if there is no dynamics immediately after the end of the previous course or the following dynamics of the values of these parameters is observed in comparison with their values before the prophylaxis: -SPV decreased by no more than 100 cm / sec, -PARS decreased by no more than 1.5 conventional units, -fZhM decreased by no more than 2 kg, -the body weight has decreased by no more than 2 kg.