臺灣博碩士論文加值系統

背景與目的：心跳反應不全是指最大運動極限下存在相對較低的心跳反應，為判定心臟自律神經功能的重要指標，傳統以最大預測心跳率 (220-年齡) 作為運動強度的設定基準，但是對於心肌梗塞病患而言，此預測公式可能無法準確的預測實際的最大心跳率，進而影響復健處方的開立。本研究透過心肺運動測試，比較具心跳反應不全問題的急性心肌梗塞患者，探討有無服用乙型交感神經阻斷劑其運動生理特質，並探討預估公式預測率及有無服用乙型交感神經阻斷劑對最大心跳率的影響。
方法：本研究共收集104位具心跳反應不全的急性心肌梗塞患者，依照病患本身有無服用乙型交感神經阻斷劑區分為服用乙型交感神經阻斷劑 (79位)、無服用乙型交感神經阻斷劑 (25位) 兩組，透過心肺運動測試收集相關參數 (休息心輸出量、最大運動時心輸出量、休息心搏量、最大運動時心搏量、年齡預測最大心跳率、休息心跳率、實際最大心跳率、實際最大心跳率/年齡預測最大心跳率、最大攝氧量、最大代謝當量、最大作功負荷)。及使用新預估公式 (164-0.72*年齡) 計算最大心跳率，並比較有無服用乙型交感神經阻斷劑的影響。
結果：具心跳反應不全問題的急性心肌梗塞患者，當有服用乙型交感神經阻斷劑，其休息心輸出量 (p=0.03)、休息心跳率 (p=0.04)、實際最大心跳率 (p<0.001)、實際最大心跳率/年齡預測最大心跳率 (p<0.001)、最大攝氧量 (p=0.01) 及最大代謝當量(p=0.02)，比起未服用乙型交感神經阻斷劑，心跳數皆下降，且達顯著差異。使用新預估公式 (164-0.72*年齡) 計算最大心跳率，較能貼近實際最大心跳，且有服用乙型交感神經阻斷劑，其實際最大心跳率心跳數下降較多，達顯著差異(p<0.001)。
結論：具心跳反應不全問題的急性心肌梗塞患者，使用新預估公式能較貼近實際最大心跳，且當有服用乙型交感神經阻斷劑，與無服用乙型交感神經阻斷劑相比，當服用乙型交感神經阻斷劑會加強心跳反應不全的效應。往後使用預測最大心跳率公式設計運動強度介入治療時，要特別留意心跳反應不全並使用乙型交感神經阻斷劑的病患帶來的相關影響。

Background & Purpose : Chronotropic incompetence (CI) , broadly defined as the inability of the heart to increase its rate commensurate with increased activity or demand. It has been used to be an important predictor of autonomic nervous system. Traditionally, it has been using the predicted maximal heart rate formula (220-age) as an indicator for rehab exercise intensity prescription in clinical practice. However, it may not be suitable to apply in the patients with acute myocardial infarction (AMI) who accompanied with CI. Therefore, the current study was to investigate the influence of beta-blockers on exercise physiological profile of patients with AMI and CI. The current predict maximal heart rate formulas were also evaluated in the AMI patients with/without beta-blockers medication.
Methods : One hundred and four AMI patients were recruited in this study. Patients were assigned to beta-blocker group (n=79) or non beta-blocker group (n=25) according their medical history. The exercise physiology profile was collected by Cardiopulmonary Exercise Testing, includes resting cardiac output, maximal cardiac output, resting stroke volume, maximal stroke volume, predict maximal heart rate, resting heart rate, maximal heart rate, maximal heart rate/ predict maximal heart rate, maximal oxygen uptake, metabolic equivalent, maximal workload. The maximal heart rate predictive formula was evaluated by comparing the effect of beta-blockers uses.
Results：The beta- blockers group in AMI patients with CI showed the lower resting cardiac output (p=0.03), resting heart rate (p=0.04), maximal heart rate (p<0.001), maximal heart rate/predict maximal heart rate (p<0.001), maximal oxygen uptake (p=0.01) and metabolic equivalent (p=0.02) than the non beta-blocker group. Using the new predictive formula (164-0.72*age) to calculate the maximum heart rate, showed more closed to the actual maximum heart rate. The beta-blockers group demonstrated lower in actual maximum heart rate than non beta-blockers group (p<0.001).
Conclusion : The current study demonstrated the influence of beta-blockers on exercise physiological profile in AMI patients with CI. The new forecast formula for maximal heart rate was closer to the actual maximum heart rate among these patients. The patients under beta-blockers medication showed a stronger CI effect. In the clinical practice, it is suggested to be carefully using maximal heart predictive formula for exercise prescription in particular for the CI patients under beta-blockers medication.

中文摘要 i
Abstract ii
目次 iii
圖表目次 iv
第一章 緒論 1
第一節 研究背景 1
第二節 研究目的 3
第三節 研究假設 3
第四節 研究範圍與限制 3
第二章 文獻探討 4
第一節 年齡與心跳率反應之相關探討 4
第二節 急性心肌梗塞後心跳率反應之相關探討 5
第三節 乙型交感神經阻斷劑對心跳率影響之相關探討 7
第四節 心跳反應不全對心跳率影響之相關探討 8
第三章 研究方法與步驟 9
第一節 研究對象 9
第二節 研究設計與實驗流程 10
第三節 統計和數據分析 13
第四章 結果 14
第一節 受試者基本資料 14
第二節 心肺運動測試各項參數統計 16
第三節 心跳反應不全與有無服用乙型交感神經阻斷劑心肺運動測試各項參數統計 17
第五章 討論 18
第一節 急性心肌梗塞患者最大運動下心跳反應不全的反應 18
第二節 心跳反應不全對與服用乙型交感神經阻斷劑的影響 18
第六章 結論 23
參考文獻 25
中文文獻 25
西文文獻 26

中文文獻
行政院衛生福利部統計處。(2016)。104年國人死因統計結果。台北市：作者。
吳英黛 (2010)。呼吸循環系統物理治療基礎實務。三版。台北：金名圖書有限公司。
林正常 (2011)。運動生理學。台北市：師大書苑.
林威佑 (2008)。彩色圖解藥理學手冊。合記圖書出版社.
林郁珊、蔡美文、殷偉賢、黃心怡、許青翎、魏崢、莊義成 (2012)。急性心肌梗塞後之運動訓練。重症醫學雜誌，13(3)，138-147。
翁珮嘉、龔紹龍、陳智宏、林澤安 (2010)。急性心肌梗塞症藥物之應用。THE JOURNAL OF TAIWAN PHARMACY，26(1)，132-137。
張祐華、謝錦城 (2013)。運動對心血管疾病的影響。交大體育學刊，(5)，61-69。
陳志堯、薛又仁、顏宗賢 (2002)。最新圖解藥理學。合記圖書出版社，185。
陳彥文、溫雁凱、吳錫昆、唐誌陽、張幸初、呂欣善 (2014)。 以年齡預估最大心跳率在急性心肌梗塞病患運用之探討。台灣復健醫學雜誌，42(1)，1-9。
賴文源、顏兆熊 (2012)。急性心肌梗塞。當代醫學，(461)，221-229。
西文文獻
Abhishekh, H. A., Nisarga, P., Kisan, R., Meghana, A., Chandran, S., Raju, T., & Sathyaprabha, T. N. (2013). Influence of age and gender on autonomic regulation of heart. Journal of Clinical Monitoring and Computing, 27(3), 259-264.
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., . . . Kontos, M. C. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Circulation, CIR. 0000000000000134.
Anand, S. S., Islam, S., Rosengren, A., Franzosi, M. G., Steyn, K., Yusufali, A. H., . . . Yusuf, S. (2008). Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. European Heart Journal, 29(7), 932-940.
Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A.-D., Rees, K., Martin, N., & Taylor, R. S. (2016). Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Journal of the American College of Cardiology, 67(1), 1-12.
Arvan, S. (1988). Exercise performance of the high risk acute myocardial infarction patient after cardiac rehabilitation. The American Journal of Cardiology, 62(4), 197-201.
Bangalore, S., Sawhney, S., & Messerli, F. H. (2008). Relation of beta-blocker–induced heart rate lowering and cardioprotection in hypertension. Journal of the American College of Cardiology, 52(18), 1482-1489.
Brawner CA, Clinton A, Jonathan K, et al. Predictingmaximum heart rate among patients with coronaryheart disease receiving beta-adrenergic blockadetherapy. Am Heart J 2004;148:910-4.
Brubaker, P. H., & Kitzman, D. W. (2007). Prevalence and management of chronotropic incompetence in heart failure. Current cardiology reports, 9(3), 229-235.
Brubaker, P. H., & Kitzman, D. W. (2011). Chronotropic incompetence. Circulation, 123(9), 1010-1020.
Burns, N. (2013). Cardiovascular Physiology. Retrieved from School of Medicine, Trinity College, Dublin: http://www. medicine. tcd. ie/physiology/assets/docs12_13/lecturenotes/NBurns/Trinity% 20CVS% 20lecture.
Chen, J., Radford, M. J., Wang, Y., Marciniak, T. A., & Krumholz, H. M. (2001). Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma. Journal of the American College of Cardiology, 37(7), 1950-1956.
Ciarka, A., Borne, P. v. d., & Pathak, A. (2008). Myocardial infarction, heart failure and sympathetic nervous system activity: new pharmacological approaches that affect neurohumoral activation. Expert Opinion on Investigational Drugs, 17(9), 1315-1330.
Coote, J. H. (2010). Recovery of heart rate following intense dynamic exercise. Experimental Physiology, 95(3), 431-440.
Diaz, A., Bourassa, M. G., Guertin, M.-C., & Tardif, J.-C. (2005). Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease. European Heart Journal, 26(10), 967-974.
Dyer, A. R., Persky, V., Stamler, J., Paul, O., Shekelle, R. B., BERKSON, D. M., . . . LINDBERG, H. A. (1980). Heart rate as a prognostic factor for coronary heart disease and mortality: findings in three Chicago epidemiologic studies. American Journal of Epidemiology, 112(6), 736-749.
Elhendy, A., Mahoney, D. W., Khandheria, B. K., Burger, K., & Pellikka, P. A. (2003). Prognostic significance of impairment of heart rate response to exercise: impact of left ventricular function and myocardial ischemia. Journal of the American College of Cardiology, 42(5), 823-830.
Eston, R. G., & Thompson, M. (1997). Use of ratings of perceived exertion for predicting maximal work rate and prescribing exercise intensity in patients taking atenolol. British Journal of Sports Medicine, 31(2), 114-119.
Faff J, Sitkowski D, Ładyga M, et al. Maximal heartrate in athletes. Biol.Sport 2007;24:129-42.
Fairbarn MS, Blackie SP, McElvaney NG, et al.Prediction of Heart Rate and Oxygen Uptake DuringIncremental and Maximal Exercise in Healthy Adults.Chest 1994;105:1365-9.
Ferrara, N., Komici, K., Corbi, G., Pagano, G., Furgi, G., Rengo, C., . . . Bonaduce, D. (2013). β-adrenergic receptor responsiveness in aging heart and clinical implications. Frontiers in Physiology, 4.
Ferrari, R., Censi, S., Mastrorilli, F., & Boraso, A. (2003). Prognostic benefits of heart rate reduction in cardiovascular disease. European Heart Journal Supplements, 5(suppl G), G10-G14.
Fisher, J. P., Young, C. N., & Fadel, P. J. (2015). Autonomic adjustments to exercise in humans. Comprehensive Physiology.
Fleg, J. L., Schulman, S., O'Connor, F., Becker, L. C., Gerstenblith, G., Clulow, J. F., . . . Lakatta, E. G. (1994). Effects of acute beta-adrenergic receptor blockade on age-associated changes in cardiovascular performance during dynamic exercise. Circulation, 90(5), 2333-2341.
Fox, K., Borer, J. S., Camm, A. J., Danchin, N., Ferrari, R., Sendon, J. L. L., . . . Tendera, M. (2007). Resting heart rate in cardiovascular disease. Journal of the American College of Cardiology, 50(9), 823-830.
Freemantle, N., Cleland, J., Young, P., Mason, J., & Harrison, J. (1999). β Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ, 318(7200), 1730-1737.
Gellish RL, Goslin BR, Olson RE, et al. Longitudinalmodeling of the relationshipbetween age and maximalheart rate. Med Sci Sports Exerc 2007;39:822-9.
Hsu, C.-J., Chen, S.-Y., Lan, C., Han, D.-S., & Lai, J.-S. (2007). Exercise training may enhance functional capacity and improve heart rate impairment in coronary artery disease patients with chronotropic incompetence. 台灣復健醫學雜誌, 35(4), 189-196.
Huikuri, H. V., & Stein, P. K. (2013). Heart rate variability in risk stratification of cardiac patients. Progress in Cardiovascular Diseases, 56(2), 153-159.
Hulo, S., Inamo, J., Dehon, A., Le Rouzic, O., Edme, J.-L., & Neviere, R. (2016). Chronotropic incompetence can limit exercise tolerance in COPD patients with lung hyperinflation. International Journal of Chronic Obstructive Pulmonary Disease, 11, 2553.
John Camm, A., & Fei, L. (1996). Chronotropic incompetence—part I: normal regulation of the heart rate. Clinical cardiology, 19(5), 424-428.
Jolliffe, J., Rees, K., Taylor, R. R., Thompson, D. R., Oldridge, N., & Ebrahim, S. (2001). Exercise‐based rehabilitation for coronary heart disease.Cochrane Database Syst Rev. 2001;(1):CD001800.
Jouven, X., Empana, J.-P., Schwartz, P. J., Desnos, M., Courbon, D., & Ducimetière, P. (2005). Heart-rate profile during exercise as a predictor of sudden death. New England Journal of Medicine, 352(19), 1951-1958.
Khan, M. N., Pothier, C. E., & Lauer, M. S. (2005). Chronotropic incompetence as a predictor of death among patients with normal electrograms taking beta blockers (metoprolol or atenolol). The American Journal of Cardiology, 96(9), 1328-1333.
Kiviniemi, A. M., Tulppo, M. P., Hautala, A. J., Mäkikallio, T. H., Perkiömäki, J. S., Seppänen, T., & Huikuri, H. V. (2011). Long-term outcome of patients with chronotropic incompetence after an acute myocardial infarction. Annals of Medicine, 43(1), 33-39.
Kleiger, R. E., Miller, J. P., Bigger, J. T., & Moss, A. J. (1987). Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. The American Journal of Cardiology, 59(4), 256-262.
Kovar, D., Cannon, C. P., Bentley, J. H., Charlesworth, A., & Rogers, W. J. (2004). Does initial and delayed heart rate predict mortality in patients with acute coronary syndromes? Clinical Cardiology, 27(2), 80-86.
Lombardi, F., Sandrone, G., Pernpruner, S., Sala, R., Garimoldi, M., Cerutti, S., . . . Malliani, A. (1987). Heart rate variability as an index of sympathovagal interaction after acute myocardial infarction. The American Journal of cardiology, 60(16), 1239-1245.
Luks, A. M., Glenny, R. W., & Robertson, H. T. (2014).Introduction toCardiopulmonary exercise testing: Springer.
Medicine, A. C. o. S. (2013). ACSM's guidelines for exercise testing and prescription: Lippincott Williams & Wilkins.
Meine, M., Achtelik, M., Hexamer, M., Kloppe, A., WERNER, J., & TRAPPE, H. J. (2000). Assessment of the chronotropic response at the anaerobic threshold: an objective measure of chronotropic function. Pacing and Clinical Electrophysiology, 23(10), 1457-1467.
Nes BM, Janszky I, Wisløff U, et al. Age-predictedmaximal heart rate in healthy subjects: The HUNTFitness Study. Scand J Med Sci Sports2013;23:697-704.
Nishime, E. O., Cole, C. R., Blackstone, E. H., Pashkow, F. J., & Lauer, M. S. (2000). Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG. JAMA, 284(11), 1392-1398.
North, B. J., & Sinclair, D. A. (2012). The intersection between aging and cardiovascular disease. Circulation research, 110(8), 1097-1108.
O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., De Lemos, J. A., . . . Franklin, B. A. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Journal of the American College of Cardiology, 61(4), e78-e140.
Powers, S. K., & Howley, E. T. (2004).Exercise Physiology: Theory and application to fitness and performance: McGraw-Hill.
Samejima, H., Omiya, K., Uno, M., Inoue, K., Tamura, M., Itoh, K., . . . Suzuki, N. (2003). Relationship between impaired chronotropic response, cardiac output during exercise, and exercise tolerance in patients with chronic heart failure. Japanese Heart Journal, 44(4), 515-525.
Saul, J. P. (1990). Beat-to-beat variations of heart rate reflect modulation of cardiac autonomic outflow. Physiology, 5(1), 32-37.
Seals, D. R., Taylor, J. A., Ng, A. V., & Esler, M. D. (1994). Exercise and aging: autonomic control of the circulation. Medicine and Science in Sports and Exercise, 26(5), 568-576.
Singh, B. (2003). Increased heart rate as a risk factor for cardiovascular disease. European Heart Journal Supplements, 5(suppl G), G3-G9.
Stapleton, M. P. (1997). Sir James Black and propranolol. The role of the basic sciences in the history of cardiovascular pharmacology. Texas Heart Institute Journal, 24(4), 336.
Steg, P. G., Ferrari, R., Ford, I., Greenlaw, N., Tardif, J.-C., Tendera, M., . . . Investigators, C. (2012). Heart rate and use of beta-blockers in stable outpatients with coronary artery disease. PloS one, 7(5), e36284.
Tanaka H, Monahan KD, Seals DR. Age-predictedmaximal heart rate revisited. J Am Coll Cardiol2001;37:153-6.
Tesch, P. A. (1985). Exercise performance and β-blockade. Sports Medicine, 2(6), 389-412.
Watanabe, E., Kiyono, K., Yamamoto, Y., & Hayano, J. (2017). Heart Rate Variability and Cardiac Diseases.Clinical Assessment of the Autonomic Nervous System (pp. 163-178): Springer.
WhaleyMH,Kaminsky KL, Dwyer GB, et al.Predictors of over- andunderachievement ofage-predicted maximal heart rate. Med. Sd. SportsExerc 1992;24:1173-9.
Wonisch, M., Hofmann, P., Fruhwald, F. M., Kraxner, W., Hödl, R., Pokan, R., & Klein, W. (2003). Influence of beta-blocker use on percentage of target heart rate exercise prescription. European Journal of Cardiovascular Prevention & Rehabilitation, 10(4), 296-301.
Zhu N, Suarez J , Sidney S, et al. Longitudinalexamination of age-predicted symptom-limitedexercise maximum HR. Med Sci Sports Exerc2010;42:1519-27.