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研究生:葉天忻
研究生(外文):Tian-Shin Yeh
論文名稱:門診心臟復健對於冠狀動脈心臟病族群次強度運動心肺測試參數之影響
論文名稱(外文):Effect of Outpatient Cardiac Rehabilitation Program on Parameters of Submaximal Cardiopulmonary Exercise Testing among Patients with Coronary Heart Disease
指導教授:謝松蒼謝松蒼引用關係陳思遠陳思遠引用關係
口試委員:蔡佳醍
口試日期:2016-06-15
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2016
畢業學年度:104
語文別:中文
論文頁數:69
中文關鍵詞:冠狀動脈心臟病次強度運動心肺功能測試參數攝氧效率斜率攝氧效率高原期心臟復健
外文關鍵詞:Oxygen uptake efficiency plateauOxygen uptake efficiency slopeSubmaximal cardiopulmonary exercise testing parametersCoronary heart diseaseCardiac rehabilitation
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研究背景
心血管病患通常運動功能不佳,而其做運動的風險也較ㄧ般人大。因此,尋求安全有效評估病人心肺功能的方式是對心血管疾病患者進行復健訓練之首要條件。運動心肺功能測試可提供多項參數來評估病人的心肺功能,其中,次強度運動參數是近年發展以評估心血管病人心肺功能之選項。回顧文獻,對冠狀動脈心臟病病人進行心臟復健訓練,同時以適當的心肺運動參數評估其心肺功能之研究著墨甚少。本研究之目的即在探討門診心臟復健訓練對冠心病患者次強度運動心肺參數之影響,以及探索次強度運動心肺參數之相關因子。
研究方法與結果
本研究藉由回溯性病歷研究,將冠心病患者依參與門診心臟復健訓練與否,分為門診心臟復健訓練組與對照組。其中心臟復健訓練組共收案229 人,皆在接受心導管或冠狀動脈繞道手術之後一年內完成3-6個月之門診復健訓練。復健訓練包括有氧和阻力訓練。本研究另納入56位接受在家運動指導的病人作為對照組。所有受試者在收案前後均接受運動心肺功能測試,並接受生活品質三十六題簡短版(SF-36)評估健康相關生活品質(Health-related quality of life, HRQOL)。
本研究共納入285位冠心病病人。心臟復健組與對照組在收案時之基本特徵、最大攝氧量(peak oxygen uptake, O2 peak)、攝氧效率斜率(oxygen uptake efficiency slope, OUES)、攝氧效率高原期(oxygen uptake efficiency plateau, OUEP),和每分鐘二氧化碳換氣產量斜率(minute ventilation-carbon dioxide production relationship, E/ CO2 slope)皆無顯著差異。在接受門診心臟復健訓練後,復健訓練組在最大攝氧量(18.8±4.4 to 22.7±5.1 mL/kg/min, p<0.0001)、OUES (1710±444 to 1908±496 L/min/log (L/min), p<0.0001)、OUEP (35.1±5.0 to 36.7±4.8 mL/L, p<0.0001)、 E/ CO2 斜率 (32.0±6.4 to 31.0±5.2, p=0.0007)皆有顯著進步,且最大攝氧量與OUES之進步幅度皆顯著高於對照組(乘積性交互作用檢定p<0.01)。健康相關生活品質部分,復健訓練組之身體功能(PFS)、因身體健康所引起的角色限制(RPS)、整體身體面向分數(PCS)、及活力狀況(VTS),均較對照組有更顯著的進步(p<0.05)。將心臟復健訓練組再細分為接受冠狀動脈繞道手術組和心導管組兩組進行比較,冠狀動脈繞道手術組在 E/ CO2 斜率、OUES、與OUEP,及健康相關生活品質中之身體功能(PFS)、因身體健康所引起的角色限制(RPS)、整體身體面向分數(PCS)、身體疼痛(BPS)之進步幅度皆顯著高於心導管組(p<0.05)。相關性分析則顯示,OUES (r = 0.627, p < 0.0001)、OUEP (r = 0.446, p < 0.0001)、 E/ CO2 斜率(r = -0.273, p < 0.0001)皆與每單位體重最大攝氧量顯著相關。與健康相關生活品質之相關性,OUES (r=0.33056, p<0.0001)、OUEP (r=0.22486, p=0.0001)皆與身體功能(PFS)顯著相關;OUES (PCS: r=0.23548, p<0.0001; RPS: r=0.14433, p=0.0147)亦與整體身體面向分數(PCS)和身體健康所引起的角色限制(RPS)顯著相關。
研究結論
門診心臟復健運動訓練可有效改善冠心症病人之心肺功能與健康相關生活品質;次強度運動心肺功能測試參數是評估冠心症病患心肺功能之安全有效的選項。


Background
The effect of cardiac rehabilitation (CR) on submaximal cardiopulmonary exercise testing (CPET) parameters in patients with coronary heart disease (CHD) has not been fully elucidated.
Aims
To investigate the effect of outpatient cardiac rehabilitation program (CRP) on submaximal CPET parameters.
Methods
A total of 285 CHD patients were enrolled in the study. The CR group consisted of 229 patients who completed a 3-6 months outpatient CRP after acute myocardial infarction, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The CRP included both aerobic and resistance training. Each patient underwent CPET with leg cycle ergometry at the beginning and the end of CRP. Fifty-six patients who only received home program instruction were enrolled as the control group and received the same testing at baseline and follow-up. SF-36 was used to evaluate the quality of life of each subject.
Results
A total of 285 CHD patients were recruited (male/female 264/21; training/control 229/56; PCI/CABG 177/52). No significant between-group differences (CR versus control) were found at baseline in baseline characteristics, peak oxygen uptake ( O2 peak), oxygen uptake efficiency slope (OUES), oxygen uptake efficiency plateau (OUEP), and minute ventilation-carbon dioxide production relationship ( E/ CO2 slope). The CR group had significant increase in O2 peak (18.8±4.4 to 22.7±5.1 mL/kg/min, p<0.0001), OUES (1710±444 to 1908±496 L/min/log (L/min), p<0.0001), OUEP (35.1±5.0 to 36.7±4.8 mL/L, p<0.0001), and decrease in E/ CO2 slope (32.0±6.4 to 31.0±5.2, p=0.0007) after CRP. The changes of O2peak and OUES in CR group were significantly greater than that of the control group during follow-up (p<0.01). As for quality of life, the CR group had significantly greater improvements in physical functioning score (PFS),role-physical score (RPS),physical component summary score (PCS), and vitality score (VTS) then the control group (p<0.05). The CABG group had significantly greater improvements in OUES, OUEP, E/ CO2 slope, also in PFS,RPS,PCS, and bodily pain score (BPS) after CRP than the PCI group (p<0.05). O2 RCP (r = 0.846, p < 0.0001), O2 AT (r = 0.810, p < 0.0001), and OUES/BW (r = 0.769, p < 0.0001) correlated best with O2 peak/kg. Changes in O2 peak/kg correlated better with changes in O2 AT (r = 0.559, p < 0.0001), O2 RCP (r = 0.522, p < 0.0001), and OUES/BW (r = 0.483, p < 0.0001). OUES (r=0.33056, p<0.0001), OUEP (r=0.22486, p=0.0001) significantly correlated with PFS; OUES (PCS: r=0.23548, p<0.0001; RPS: r=0.14433, p=0.0147) also significantly correlated with PCS and RPS.
Conclusions
Exercise-based CRP significantly improves peak aerobic capacity as well as submaximal CPET parameters and quality of life among CHD patients. Submaximal parameters may be clinically useful for quantification of exercise performance and improvements after physical training in patients with CHD.


口試委員會審定書 i
中文摘要 ii
英文摘要Abstract iv
第一章 緒論 1
第一節 前言 1
第二節 OUES與OUEP之發展及臨床上之應用與文獻 2
第三節 研究假說與目的 5
第二章 研究方法與材料 6
第一節 研究對象 6
一、 納入條件 6
二、 排除條件 6
三、 分組方法 6
四、資料收集 6
第二節 運動心肺功能測試 7
ㄧ、測試方法 8
二、終止條件 8
第三節 門診心臟復健治療 10
ㄧ、心肌梗塞與冠狀動脈繞道術後 10
二、心導管術後 10
第四節 資料分析 11
第三章 結果 12
第一節 心臟復健組與對照組追蹤前後之運動心肺功能測試參數差異 12
第二節 冠狀動脈繞道手術組與心導管組間之運動心肺功能測試參數差異 13
第三節 運動心肺參數之相關性 14
ㄧ、與最大攝氧量之相關性 14
二、次強度運動參數間之相關性: 14
第四節 心肺運動測驗參數訓練前後變化量之相關性 15
ㄧ、與最大攝氧量變化量之相關性: 15
二、次強度運動參數變化量間之相關性: 15
第五節 心臟復健組與對照組追蹤前後之健康相關生活品質差異 16
第六節 冠狀動脈繞道手術組與心導管組間之健康相關生活品質差異 17
第七節 運動心肺參數與健康相關生活品質之相關性 18
第八節 運動心肺參數變化量與健康相關生活品質變化量之相關性 19
第四章 討論 20
第一節 心臟復健組與對照組追蹤前後之運動心肺功能測試參數差異 20
第二節 冠狀動脈繞道手術組與心導管組間之運動心肺功能測試參數差異 22
第三節 各運動心肺參數間之相關性 24
第四節 運動心肺參數與健康相關生活品質 25
第五節 研究限制 27
第五章 結論與展望 28
參考文獻 29
附圖 33
圖一、門診心臟復健訓練組與對照組治療追蹤前後心肺運動指標之比較 33
圖二、心導管手術組與冠狀動脈繞道組治療追蹤前後心肺運動指標之比較 34
圖三、健康相關生活品質(SF-36)身體功能及整體身體面向分數於治療前後之比較 35
附表 36
表一、門診心臟復健訓練組與對照組基本資料之比較 36
表二、 心臟運動復健治療前後之運動心肺參數比較 (心臟復健組與對照組間之差異) 38
表三、冠狀動脈繞道手術組與心導管組間之基本資料之比較 44
表四、冠狀動脈繞道手術組與心導管組間與心臟復健治療前後之差異 46
表五、急性心肌梗塞後接受心導管組(AMI+PCI)與接受選擇性心導管組(PCI)基本資料之比較 52
表六、急性心肌梗塞後接受心導管組(AMI+PCI)與接受選擇性心導管組(PCI)間與心臟復健治療前後之差異 54
表七、運動心肺功能測試參數之相關性 60
表八、次強度運動指標訓練前後變化量與最大攝氧量變化量之相關性(心臟復健組) 62
表九、心臟復健組與對照組追蹤前後之健康相關生活品質 64
表十、冠狀動脈繞道手術組與心導管組訓練前後之健康相關生活品質 65
附錄 66
碩士班修業期間所發表之相關論文清冊 66
倫理委員會審查同意書 67


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