心脏康健导引功对慢性心力衰竭易损期患者的干预效果_沈瑞丽.pdf

Hainan Med J,Jul.2023,Vol.34,No.13海南医学2023年7月第34卷第13期心脏康健导引功对慢性心力衰竭易损期患者的干预效果沈瑞丽，林嘉文，张自秀，孟园园，赵心韵，陈军上海市杨浦区中医医院心病科，上海200000【摘要】目的观察心脏康健导引功对慢性心力衰竭易损期患者的干预效果。方法选取2020年10月至2022年5月期间上海市杨浦区中医医院心病科收治的66例慢性心力衰竭易损期患者以随机数表法分为观察组和对照组，每组33例。对照组患者给予常规干预，观察组患者采用心脏康健导引功干预。两组患者连续干预3个月，干预结束后比较两组患者的心肺功能、心率变异性，并采用6 min步行试验(6MWT)、明尼苏达心力衰竭生活质量评分量表(MLHF-Q)和中医证候积分评估两组患者的预后。结果 干预后，观察组患者的左心室射血分数(LVEF)和每搏输出量(SV)分别为(63.446.02)%、(74.938.02)mL，明显高于对照组的(57.036.06)%、(66.217.61)mL，差异均有统计学意义(P0.05)；左室舒张末径(LVEDD)和QT间期离散度(QTd)分别为(46.345.01)mm、(57.225.61)ms，明显低于对照组的(53.715.21)mm、(65.676.26)ms，差异均有统计学意义(P0.05)；干预后，观察组患者的用力肺活量(FVC)、肺泡通气量(VA)和最大呼气中段流量(MMEF)分别为(2.440.51)L、(5.310.80)L/min、(2.280.51)L/s，明显高于对照组的(2.010.47)L、(4.560.75)L/min、(1.900.46)L/s，差异均有统计学意义(P0.05)；干预后，观察组患者的心率变异性指标总标准差(SDNN)、两个相邻RR间期互差(PNN50)、差值均方根(RMSSD)分别为(132.8116.51)ms、(6.810.90)%、(43.285.51)ms，明显高于对照组的(121.4015.47)ms、(6.120.85)%、(36.895.46)ms，差异均有统计学意义(P0.05)；干预后，观察组患者的MLHF-Q评分、中医证候积分分别为(26.303.42)分、(15.002.53)分，明显低于对照组的(31.425.15)分、(17.553.17)分，6MWT距离为(356.4849.96)m，明显长于对照组的(293.4869.64)m，差异均有统计学意义(P0.05)，具有可比性，见表1。本研究方案获得我院医学伦理委员会批准，所有患者知情并签署知情同意书。1.2干预方案两组患者于出院后1 d进行治疗干预，出院后在专人管理下进行院外训练，每周5日，3次/d，10 min/次，3个月后进行回访。所有患者均按照指南指导标准慢性心力衰竭药物治疗和常规康复建议8。对照组给予常规护理干预，主要包括低盐饮食，控制体质量，控制其他危险因素，监测血压血糖，提高患者的疾病认知，指导患者进行散步、步行等有氧运动训练。患者在无禁忌证情况下，使用ACEI或ARB以及受体阻滞剂，醛固酮拮抗剂，必要时加用利尿剂。对患者的基础疾病包括冠心病、高血压进行相chronic heart failure in vulnerable stage.MethodsA total of 66 patients with chronic heart failure in vulnerable stageadmitted to the Department of Cardiology,Shanghai Yangpu District Hospital of Traditional Chinese Medicine from Oc-tober 2020 to May 2022 were randomly divided into an observation group and a control group,with 33 patients in eachgroup.The patients in the control group were given routine intervention,while those in the observation group were givenheart health guidance function intervention.The patients in the two groups were continuously intervened for 3 months.After intervention,the cardiopulmonary function and heart rate variability were compared between the two groups.Andthe prognosis of the two groups of patients was evaluated using the 6-minute walking test(6MWT),Minnesota HeartFailure Quality of Life Scale(MLHF-Q),and Traditional Chinese Medicine Syndrome Score.ResultsAfter interven-tion,the left ventricular ejection fraction(LVEF)and stroke volume(SV)of the patients in the observation group were(63.446.02)%and(74.938.02)mL,which were significantly higher than(57.036.06)%and(66.217.61)mL of thecontrol group(P0.05);the left ventricular end diastolic diameter(LVEDD)and the QT interval dispersion(QTd)were(46.345.01)mm and(57.225.61)ms,which were significantly lower than(53.715.21)mm and(65.676.26)ms ofthe control group(P0.05).After intervention,the forced vital capacity(FVC),the alveolar ventilation volume(VA),and the maximum middle expiratory flow(MMEF)of the patients in the observation group were(2.440.51)L,(5.310.80)L/min,and(2.280.51)L/s,which were significantly higher than(2.010.47)L,(4.560.75)L/min,and(1.900.46)L/s of the control group(P0.05).After intervention,the heart rate variability index standard deviation of all N-Nintervals(SDNN),percent of NN50 in the total number of N-N intervals(PNN50),and root mean square of successivedifferences in adjacent N-N intervals(RMSSD)of the patients in the observation group were(132.8116.51)ms,(6.810.90)%,and(43.285.51)ms,which were significantly higher than(121.4015.47)ms,(6.120.85)%,and(36.895.46)ms in the control group(P0.05).After intervention,the MLHF-Q score and the TCM syndrome score ofthe patients in the observation group were(26.303.42)points and(15.002.53)points,which were significantly lowerthan(31.425.15)points and(17.553.17)points in the control group;the distance of 6MWT was(356.4849.96)m,which was significantly longer than(293.4869.64)m of the control group;the differences were statistically significant(P0.05).ConclusionThe intervention of heart health guidance function on patients with chronic heart failure in vul-nerable stage can improve their cardiopulmonary function,heart rate variability,quality of life and exercise tolerance.【Key words】Heart health guidance function;Chronic heart failure;Vulnerable stage;Cardiopulmonary function;Heart rate variability;Quality of life1852Hainan Med J,Jul.2023,Vol.34,No.13海南医学2023年7月第34卷第13期应的干预。观察组患者在对照组治疗的基础上，以心脏康健导引功训练替换步行训练。心脏康健导引功的全套功法除预备式和收势(引气归元)外，总共有8节动作，分别是呵诀养心、开工射雕、推摩胸骨、推摩肋骨、推擦胁肋、揉养心肾。观察组患者出院前待症状平稳后有专门培训的医生进行教授心脏康健导引功并在监护下不少于6次的院内训练。两组患者连续干预3个月，均在院外居家进行康复训练干预，每周医护人员通过电话随访掌握患者的训练效果。1.3观察指标与评价方法比较两组患者治疗干预前1 d、治疗干预结束后1 d的心功能指标、肺功能指标、心率变异性指标和预后生活质量。(1)心功能指标：采用GE730型多功能彩色多普勒超声诊断仪(美国GE公司)检测两组患者的左心室射血分数(LVEF)、每搏输出量(SV)、左室舒张末期内径(LVEDD)，采用MD120A型心电监护仪(深圳迈瑞医疗科技有限公司)检测两组患者的QT间期离散程度(QTd)。(2)肺功能指标：采用MasterScreen型肺功能仪(德国Jaeger公司)检测患者的肺通气功能指标包括用力肺活量(FVC)、肺泡通气量(VA)、最大呼气中段流量(MMEF)水平。(3)心率变异性指标：采用 DMS300-4A 型 12 导联动态心电图仪(美国迪姆公司)进行24 h动态心电图检查，检查操作步骤按仪器操作规程进行，24 h动态心电图监测完成后采用计算机软件系统对两组患者的心率变异性指标包括总标准差(standard deviation of allN-N intervals，SDNN)、两个相邻RR间期互差(percentof NN50 in the total number of N-N intervals，PNN50)、差值均方根(root mean square of successive differencesin adjacent N-N intervals，RMSSD)进行计算分析，数据处理中去除干扰和伪差对实验结果的影响。(4)生活质量：采用6 min步行试验(6MWT)10、明尼苏达心力衰竭生活质量评分量表(MLHF-Q)11、中医证候积分12评估两组患者的生活质量。6 min 步行试验要求患者在平直走廊里尽可能地行走，测定6 min的步行距离；MLHF-Q 量表共有 21 个评分项，每项得分05分，总分为105分，分值越低患者的生活质量越好；中医证候积分得分范围028分，分值越低患者的中医证候越轻。1.4统计学方法应用SPSS25.0统计学软件分析数据。计量资料均符合正态分布和方差齐性规律，以均数标准差(x-s)表示，组间比较采用独立样本t检验，组内前后比较采用配对t检验，计数资料比较采用2检验。以P0.05)；干预后，两组患者的LVEF、SV明显升高，LVEDD、QTd明显降低，且干预后观察组患者的LVEDD、QTd明显低于对照组，LVEF、SV明显高于对照组，差异均有统计学意义(P0.05)；干预后，两组患者的 FVC、VA、MMEF明显升高，且观察组患者干预后的FVC、VA、MMEF 明显高于对照组，差异均有统计学意义(P0.05)，见表3。表2两组患者干预前后的心功能指标比较(x-s)Table 2Comparison of cardiac function indexes between the twogroups of patients before and after intervention(x-s)组别对照组观察组例数3333时间点干预前干预后t值P值干预前干预后t值P值LVEF(%)44.195.1157.036.067.3910.00143.235.0563.446.02a10.3380.001SV(mL)53.565.1166.217.619.3770.00152.325.0874.938.02a10.7610.001LVEDD(mm)63.986.1253.715.219.6560.00162.436.0746.345.01a8.5740.001QTd(ms)81.428.4365.676.267.6610.00179.438.0757.225.61a14.2870.001注：与对照组干预后比较，aP0.05。Note:Compared with that in the control group after intervention,aP0.05.表1两组患者的一般资料比较例(%)，x-sTable 1Comparison of general data between the two groups of patients n(%),x-s例数3333组别观察组对照组2/t值P值男性15(45.45)16(48.48)女性18(54.55)17(51.52)0.0610.805年龄(岁)75.878.6276.347.28(0.239)0.812病程(年)6.371.286.521.36(0.461)0.646级16(48.48)17(51.52)级17(51.52)16(48.48)冠心病23(69.70)25(75.76)高血压4(12.12)5(15.15)其他6(18.18)3(9.09)0.0610.8061.1940.550NYHA分级(例)原发疾病性别表3两组患者干预前后的肺功能指标比较(x-s)Table 3Comparison of pulmonary function indexes between the twogroups of patients before and after intervention(x-s)组别对照组观察组例数3333时间点干预前干预后t值P值干预前干预后t值P值FVC(L)1.750.402.010.471.4640.0181.820.332.440.51a12.7200.001VA(L/min)3.980.704.560.753.6220.0013.910.725.310.80a6.9930.001MMEF(L/s)1.660.401.900.462.7030.0111.610.372.280.51a8.1890.001注：与对照组干预后比较，aP0.05。Note:Compared with that in the control group after intervention,aP0.05)；干预后，两组患者的SDNN、PNN50、RMSSD均升高，且观察组患者干预后的SDNN、PNN50、RMSSD明显高于对照组，差异均有统计学意义(P0.05)；干预后，两组患者的 MLHF-Q 评分和中医证候积分明显下降，6MWT距离增加，且观察组患者干预后的MLHF-Q评分和中医证候积分明显低于对照组，6MWT距离明显长于对照组，差异均有统计学意义(P0.05)，见表5。3讨论慢性心力衰竭的发生会导致患者心脏负荷的增加，肺循环压力升高、周围循环阻力增加及呼吸困难、水肿、乏力等复杂的临床综合征13-14。慢性心力衰竭患者入院经过标准治疗后，多数慢性心力衰竭症状和体征都能得到缓解甚至很快地消失，但处在慢性心力衰竭易损期内的患者仍有可能复发。有研究显示，运动康复治疗干预有助于改善心功能15。因此，对处于慢性心力衰竭易损期的慢性心力衰竭患者除了给予常规药物治疗外，有必要同时给予运动康复治疗干预以改善患者心功能、恢复患者的各项身体机能从而降低患者在慢性心力衰竭易损期内的死亡和再住院率，提高患者预后。虽然目前关于慢性心力衰竭运动康复的研究日益增多，且临床实施的运动康复方案不尽相同，但尚无普适性运动处方，很多运动处方需在严格的评估下进行，否则存在一定风险。因此，普适性强、风险低、康复效果好的运动处方已成为当下临床研究的重点。本研究中观察组患者在康复期以心脏康健导引功干预，患者的康复效果得到显著提升，表现为观察组患者的LVEF、SV均高于对照组，LVEDD、QTd均低于对照组，且观察组患者的FVC、VA、MMEF均高于对照组，差异均有统计学意义(P0.05)，表明心脏康健导引功的应用能够改善慢性心力衰竭患者的心肺功能。这是因为心脏康健导引功是基于中医理论的指导，以中国古代导引术为理论依据，将八段锦、六字诀以及经络学说相结合的一种心脏康复体操，既往在心血管疾病的康复治疗中有良好的效果16。根据中医理论对于慢性心力衰竭的病机剖析，心脏导引功中第一式取自“六字诀”，目前认识中六字诀中“呵”字诀主要用于调整五脏中“心”的气机疏泄，长期练习六字诀可有效改善循环。第二式取自八段锦中左右开弓似射雕，主要作用对应心肺，可刺激三阴、三阳经，调节手太阴肺经，发展下肢肌肉力量，提高平衡和协调能力，增强心肺功能的作用17。心率变异性是反映慢性心力衰竭患者心脏功能周期性变化的一个重要指标。本研究结果显示，观察组患者干预后的心率变异性指标均高于对照组，差异均有统计学意义(P0.05)，表明心脏康健导引功的应用能改善患者的心率变异性。这是因为心脏康健导引功通过一系列的康复干预手段可有效提升患者的运动能力，增强患者的自主神经的支配功能，保持患者心脏调节功能的稳定，减少了患者的心率的异常波动18。预后效果评分是评估慢性心衰患者治疗后恢复状况的重要指标，本文中观察组患者治疗后的6MWT距离长于对照组，MLHF-Q、中医证候积分低于对照组，差异均有统计学意义(P0.05)，表明心脏康健导引功的应用能够改善患者的运动功能，提高患者的生活质量，降低患者的中医证候，提高患者的预后康复效果，体现了心脏康健导引功在慢性心力衰竭易损期中良好的应用价值。综上所述，心脏康健导引功对慢性心力衰竭易损期患者的干预效果良好，能改善患者的心率变异性和心肺功能，提高患者的生活质量和预后运动耐量，可在临床实践中推广应用。参考文献1Xu JH,Hu SL.The epidemiology and prevention of chronic heart表5 两组患者干预前后的生活质量评分比较(x-s)Table 5Comparison of quality of life score between the two groupsof patients before and after intervention(x-s)组别对照组观察组例数3333时间点干预前干预后t值P值干预前干预后t值P值MLHF-Q(分)39.454.9631.425.157.5990.00037.214.2226.303.42a7.3130.0006MWT距离(m)261.6472.11293.4869.644.4840.000279.6475.15356.4849.96a3.3360.002中医证候积分(分)21.123.7517.553.172.6600.01220.213.8515.002.53a8.8290.001注：与对照组干预后比较，aP0.05。Note:Compared with that in the control group after intervention,aP0.05.表4 两组患者干预前后的心率变异性指标比较(x-s)Table 4Comparison of heart rate variability index levels betweentwo groups of patients before and after intervention(x-s)组别对照组观察组例数3333时间点干预前干预后t值P值干预前干预后t值P值SDNN(ms)70.358.40121.4015.4731.1980.00171.828.33132.8116.51a34.8970.001PNN50(%)3.480.516.120.8514.3070.0013.340.496.810.90a46.3570.001RMSSD(ms)24.965.4936.895.469.5180.00124.015.3743.285.51a18.0580.001注：与对照组干预后比较，aP0.05。Note:Compared with that in the control group after 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