心臟移植及冠狀動脈繞道手術患者接受運動治療復健後心肺功能及生活品質改善之研究

Abstract

隨著醫藥的進展及心臟手術技術的進步，心臟病患存活率增加，這類病患也有慢性化的趨勢。心臟病患普遍運動耐力不佳的現象，低運動體能往往導致不良預後及不佳的生活品質。運動訓練乃心臟復健重要項目之一，藉由運動訓練可以改善心臟病患的運動體能。雖然如此，這類患者與同齡正常人相比，運動體能仍低於正常人。面對於心臟病患，復健運動訓練的目標在於增加運動體能，同時也能達到改善生活品質。近年來，以病患為中心的醫療成效評估，例如：健康相關生活品質量表，被使用於心臟復健領域，做為評估醫療介入及處置的成效評估。 健康相關生活品質量表可分為通用量表及特定疾病量表。特定疾病量表探討某一特定疾病病患的狀況，相對的，通用量表可適用於不同疾病的所有病患也可以與正常人比較。我們利用Short Form 36（SF-36）通用量表來探討手術後心臟病患，以冠狀動脈繞道手術病患（CABG）及心臟移植（HT）病患接受運動訓練前後，運動體能及生活品質改善的成效。運動體能指標包括最大攝氧量、最大心跳率、無氧閾值等。SF-36有八個面向，分別為身體生理功能(physical functioning)、因生理功能角色受限(role limitation due to physical problems)、身體疼痛(bodily pain)、一般健康(general health)前四個面向（PF、RP、BP、GH）屬於生理範疇（Physical Compartment Scale，PCS）；以及活力(vitality)、社會功能(social functioning)、因情緒角色受限(role limitation due to emotional problems)、心理健康(mental health)，後四個面向（VT、SF、RE、MH）屬於心理範疇（Physical Compartment Scale，MCS）；八個面向再細分成36個子題。 本研究擬針對接受心臟外科手術的CABG(冠狀動脈繞道手術)及HT(心臟移植)病患，於門診接受心臟復健第二期的運動訓練12週後，運動體能，以及生活品質改善之研究。研究對象為某醫學中心接受CABG及HT手術之患者，經心肺功能測試後測得最大攝氧量（maximal oxygen consumption, VO2 max）以及無氧閾值(anaerobic threshold, AT)，並且填答SF-36問卷以評估生活品質，根據最大攝氧量及無氧閾值，開立運動處方，接受12週之運動訓練治療計畫，復健治療完成後再接受第二次之心肺功能測試以及SF-36生活品質問卷，測得其運動訓練治療計畫後之最大攝氧量及生活品質。比較病患於12週運動復健治療前後在最大攝氧量及生活品質改善的情形，並比較CABG及HT兩組病患對運動復健治療的效果有無差異。 研究結果發現，CABG及HT病患，在運訓前心肺體能明顯低於年齡的正常人。在接受12週運動訓練後，心臟運動體能有明顯的改善，最大攝氧量CABG組由16.6±4.5進步為→20.2±5.7，HT組由14.9±3.5→18.5±4.7；最大心跳率CABG組由130.2±20.5進步為→140.3±23.2，HT組由132.4±15.8→142.6±18.6；無氧閥值攝氧量CABG組由12.2±2.9進步為→14.0±3.4，HT組由10.4±2.5→12.8±3.3。最大的攝氧量進步幅度CABG組達到19.3%，HT組達到24.2%。 兩組病患在運動訓練治療計畫前，健康相關生活品質量表評估結果相似，都比同年齡對照組低。運動訓練後，CABG組在4個面向有明顯進步，包括三個生理面向（PF、RP、BP），以及一個心理面向（SF）。【physical function (60.0±22.9 to 73.4±18.0)、physical role(19.1±24.9 to 27.9±38.3)、bodily pain(57.1±20.0 to 70.3±16.1)、social functioning(54.0±21.3 to 69.9±21.1)】。運動訓練後，HT組在6個面向有明顯進步，包括三個生理面向（PF、RP、BP），以及三個心理面向（SF、RE、MH）。【physical function (59.7± 18.9 to 77.0±14.0)、physical role (21.1±34.1 to 38.3±37.9)、bodily pain(57.4±24.3 to 73.6±21.5)、social functioning(63.6±23.4 to 72.8±22.1)、emotional role(59.2±43.7 to 76.3±37.4)、mental health(67.1±17.9 to 73.4±14.6)】。雖然HT組訓練後心肺體能較差，然而生活品質改善的程度卻優於CABG組。經由皮爾森相關分析顯示，CABG及HT兩組病患，運動體能改善的幅度與生活品質改善的程度並無明顯相關。 心臟病患手術後，即早運動訓練介入，在CABG及HT病患，可改善運動體能及生活品質。訓練期間，兩組病患並無發生不良意外事件，顯示運動訓練是安全而且有效，可以改善CABG及HT病患的運動體能及生活品質。運動體能進步的幅度約為20%到25%。而生活品質改善的面向，HT組包括生理以及心理面向，CABG組則以生理面向為主。兩組病患由於疾病程度不同，在運動體能以及生活品質有不同程度的改善。

Exercise intolerance is a common symptom among patients with heart disease such as coronary artery bypass graft (CABG) or heart transplantation (HT). Low exercise capacity leads to poor clinical outcome and quality of life. Thereby, exercise training is crucial to heart patients with low functional capacity. the goal of exercise training is not only to enhance the physical capacity, but also to improve the quality of life. In recent years, increasing use of more patient-focused outcome, such as health-related quality of life, has been applied in cardiac rehabilitation. Health-related quality of life may be disease specific or generic. Disease specific measures focus on the complaints that are attributable to a specific patient population. In contrast, the generic quality of life measures may be applied to patients with different diseases. The short form 36 (SF-36), a common generic measure, is a multi-purpose health survey with only 36 questions. It yields an 8-scale profile of functional health and well-being scores as well as physical and mental health summary measures. The purpose of this study was to investigate the effect of an out-patient phase II cardiac rehabilitation exercise program, which aimed to improve exercise capacity and health-related quality of life. In this study, we recruited two groups of patients, including 34 patients with coronary artery bypass graft (CABG) (age: 57.2±12.5 years; M/F: 27/7) and 45 clinically stable orthotopic heart transplant patients (HT) (age: 47±14 years; M/F: 36/9) completed a phase II cardiac rehabilitation program. Patients with CABG started training 46±28 days after surgery; HT started rehabilitation 70±33 days after transplantation. Patients participated in a 12-week supervised exercise training program 3 times per week. Each training session comprised 10 minutes of warm up, 25-30 minutes of cycling or treadmill walking, and 10 minutes of cool down. The exercise intensity was set at 50-80% of peak oxygen uptake ( O2peak) according to patient’s condition. The health-related quality of life of subjects was evaluated by the SF-36 at baseline and upon the completion of rehabilitation. In the CABG group, the O2peak, and 4 subscales of the SF36 showed significant increase after training. The O2peak increased 20% from 16.6 to 20.2 mL•kg-1•min-1. The CABG group exhibited increase of scores in physical functioning (60.0±22.9 to 73.4±18.0), role physical (19.1±24.9 to 27.9±38.3), bodily pain (57.1±20.0 to 70.3±16.1) and social functioning (54.0±21.3 to 69.9±21.1). Before training, the HT group showed 24.8% lower in peak oxygen uptake ( O2peak) than the CABG group. After training, the HT group showed significant improvement in O2peak and 6 subscales of SF-36. The O2peak increased 24% from 14.9 to 18.5 mL•kg-1•min-1. The HT group showed significant increase of SF-36 scores in physical functioning (59.7±18.9 to 77.0±14.0), physical role (21.1±34.1 to 38.3±37.9), bodily pain (57.4±24.3 to 73.6±21.5), social functioning (63.6±23.4 to 72.8±22.1), emotional role (59.2±43.7 to 76.3±37.4) ,and mental health (67.1±17.9 to 73.4±14.6) . Compared with the age-matched norm of Taiwanese, the CABG group showed significant lower scores of SF-36 in all subscales than the norm before training. After training, general health, and vitality subscales reached the age-matched normal standard. The HT group before training showed significant lower scores of SF-36 in seven subscales except general health subscale. After training, general health, emotion role and mental health subscales reached the age-matched normal standard. In conclusion, early post-operative outpatient rehabilitation program is beneficial to exercise capacity and health-related quality of life among heart transplant recipients and patients with CABG. Although the HT group showed lower physical capacity than the CABG at baseline, both groups displayed similar increase of O2peak after training. Additionally, heart transplant recipients showed greater improvement in health-related quality of life than patients with CABG regardless of poorer physical capacity. Outpatient exercise training rehabilitation program improves exercise capacity and health related quality of life at different range among HT patients and patients with CABG.