心臟復健對冠狀動脈繞道手術後患者睡眠品質及睡眠時間之成效：隨機對照試驗

Abstract

研究背景：心臟疾病是導致世界人口死亡最主要的原因之一，其中以冠狀動脈疾病（coronary artery disease, CAD）最為常見。造成心臟疾病的危險因子，包括：年紀、肥胖、代謝性疾病、家族史、抽菸，以及身體活動不足的生活型態。許多文獻顯示睡眠品質不佳及睡眠時間不足等睡眠困擾，也與冠狀動脈疾病有關。有睡眠困擾的人罹患心血管疾病的風險較高，若冠狀動脈疾病處置後仍持續存在睡眠困擾，可能會提高患者的再住院率及死亡率，因此睡眠對冠狀動脈疾病患者是重要因子，但卻鮮少被討論。此外，過去的文獻顯示運動訓練可改善不同族群的睡眠困擾，但較少文獻報告心臟復健改善冠狀動脈疾病患者睡眠困擾之成效。 研究目的：本研究目的是探討心臟復健對冠狀動脈繞道手術後患者之睡眠品質與睡眠時間之成效；睡眠品質及睡眠時間的改變量與尖峰攝氧量及心跳變異性之關係。 研究方法：本研究採取隨機對照試驗設計（randomized controlled trial），在新光醫院徵召24位符合收案條件且有意願之受試者參與，並隨機分配至心臟復健組（n = 12）和控制組（n = 12）。心臟復健組需接受為期12週、每週3次、每次1小時的心臟復健。訓練期間內兩組受試者均維持日常之飲食、運動習慣和藥物服用。每位受試者在12週訓練前後均分別進行評估，包括：身高、體重、體脂肪百分比、匹茲堡睡眠品質量表（Pittsburgh Sleep Quality Index, PSQI）、腕動計（actigraphy）、愛普沃斯嗜睡量表（Epworth Sleepiness Scale, ESS）、睡眠日誌（sleep log）、疼痛量表（visual analogue scale, VAS）、醫院焦慮憂鬱量表（Hospital Anxiety and Depression Scale, HADS）、心跳變異性（heart rate variability, HRV），以及心肺運動測試（cardiopulmonary exercise testing, CPET）。統計分析使用SPSS第26版（IBM Statistical Package for the Social Sciences Statistics for Mac, Version 26.0. Armonk, NY: IBM Corp.）進行資料處理與分析。所有資料以獨立樣本t檢定（independent sample t-test）及卡方檢定分析（Chi-Square test）比較兩組受試者之間的基本資料差異。檢定心臟復健組及控制組前後測試值之組間差異時，以兩因子混合變異數分析（two way mixed ANOVA test）檢定；另以皮爾森積差相關係數（Pearson''s product-moment correlation coefficient, r）檢定睡眠品質、心肺運動測試及心跳變異性之相關性，以及利用多元迴歸統計（multiple regression analysis）分析影響睡眠品質改善的因素。本研究定義雙尾檢定顯著水準為α值等於0.05。 結果：經過12週介入後，心臟復健組的匹茲堡睡眠品質量表總分（p = 0.009）及部分分項較控制組顯著下降（p < 0.05）。12週介入後，心臟復健組的腕動計量測參數，包括：睡眠效率及睡眠中斷時間呈現顯著改善（p < 0.05），但與控制組相比無顯著組間差異。心臟復健組的心跳變異性參數，包括：低頻功率（p = 0.004）及高頻功率（p = 0.003）皆較控制組顯著進步。皮爾森積差相關係數顯示，睡眠品質改變量與匹茲堡睡眠品質量表總分與自然對數總功率、自然對數低頻功率、及自然對數低高頻功率比呈現中度負相關（r = -0.493 - -0.532）；睡眠時間改變量與尖峰攝氧量、尖峰攝氧量預測值、自然對數總功率、自然對數低頻功率、及自然對數低頻功率呈現中度負相關（r = -0.460 - -0.576）。心臟復健介入是影響冠狀動脈繞道手術後患者匹茲堡睡眠品質量表分數（β = -3.356, p = 0.009）的顯著獨立因子。 結論：經過12週心臟復健介入，有效改善睡眠品質不佳之冠狀動脈繞道手術患者之主觀及客觀睡眠品質，且在睡眠時間、睡眠效率及睡眠潛伏期皆可觀察到進步。此外，也可以提升心肺適能及心跳變異性之表現，以利改善冠狀動脈繞道手術後患者之預後。

Background: Heart disease, predominantly coronary artery disease (CAD), is a leading global cause of death. Risk factors include age, obesity, metabolic disease, family history, smoking, and insufficient physical activity. Recent literature highlights a correlation between poor sleep quality, insufficient sleep duration, and CAD. Persistent sleep problems in patients with CAD post revascularization may elevate readmission and mortality rates. Therefore, sleep quality is crucial for patient care in patients with CAD. Previous studies have shown that regular exercise training can improve sleep quality in various populations, but there are limited studies on the effectiveness of cardiac rehabilitation in improving sleep disturbances in patients with CAD after coronary artery bypass surgery (CABG). Purpose: This study aims to investigate the effects of cardiac rehabilitation on sleep quality and duration in patients after CABG; and investigate the correlation of change in V̇O2 peak, heart rate variability (HRV), sleep quality, and sleep duration. Methods: In this randomized controlled trial, 24 patients who underwent CABG were assigned to either the cardiac rehabilitation (CR) group (n = 12) or the control group (n = 12). The CR group participated in supervised thrice-weekly training sessions over 12 weeks. Assessments included subjective sleep quality (PSQI), objective sleep parameter (actigraphy), Epworth Sleepiness Scale (ESS), sleep log, pain scale (visual analog scale, VAS), depression and anxiety (Hospital Anxiety and Depression Scale, HADS), HRV, and cardiopulmonary exercise testing (CPET). Statistical analysis was performed by Statistical Package for the Social Sciences (SPSS) statistical package v.26.0 for Mac (IBM SPSS Statistics for Mac, Version 26.0. Armonk, NY: IBM Corp.), with a significant level set at α < 0.05. Data were analyzed using independent sample t-test, Chi-Square test, two-way mixed ANOVA, and multiple regression analysis. Results: The CR group demonstrated notable improvements in sleep quality, as evidenced by enhanced global PSQI scores (p = 0.009) and certain PSQI sub-scores. Actigraphy measurements indicated significant enhancements in sleep efficiency and reductions in wake time after sleep onset within the CR group. HRV also showed significant improvements, particularly in low frequency (LF, p = 0.004) and high frequency (HF, p = 0.003) domains, in comparison to the control group. The Pearson''s product-moment correlation coefficient revealed a moderate negative correlation between the global PSQI score and the natural logarithms of total power, LF, and HF (r ranging from -0.493 to -0.532). Additionally, a moderate negative correlation was observed between sleep duration and key parameters such as peak V̇O2, predicted V̇O2, and the natural logarithms of LF and HF (r ranging from -0.460 to -0.576). Multiple regression analysis indicated that CR is a predictive factor for changes in PSQI scores (β = -3.356, p = 0.009). Conclusion: CR significantly enhances both subjective and objective sleep quality in patients after CABG. Improvements were noted in total sleep time, sleep efficiency, and latency, as well as in exercise capacity and HRV, suggesting a positive impact on post-CABG prognosis.