Transcript 適者生存： 心臟運動測試的新風貌 Survival of the fittest: A new look at cardiac exercise test

適者生存：
心臟運動測試的新風貌
Survival of the fittest:
A new look at cardiac exercise test
講員：黃千惠
2007物理治療繼續再教育課程
中華民國物理治療學會主辦
慈濟技術學院物理治療系與研發中心承辦
2016/5/22
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主題大綱
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傳統心臟運動測試（cardiac ex test，
CET）介紹：歷史沿革與方法；強
調『運動中』的變化
新近心臟運動測試發展：預測死亡
率；強調『運動開始』『運動恢復』
的變化，主要是心跳
文獻回顧：運動後心跳恢復率的預
後意義
台灣資料：血管正常者之心跳恢復
率
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Cardiac exercise test: CET
Cardiac pulmonary exercise test: CPET
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傳統心臟運動測試
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起源：the discovery that exercise in p’t
with coronary disease produced ST
segment depression
Feil &Siegel (1928) exercised p’t with
angina to bring about pain.
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They performed stress test by sit-ups.
Master（1929） published paper using
pulse and BP to evaluate the cardiac
capacity. （His contribution : exercise
protocol rather than use of ECG. ）
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傳統心臟運動測試
重要沿革1
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Goldhammer & Scherf (1932): ST
depression was present in 75% p’t with
angina and proposed the use of exercise
to confirm the diagnosis of coronary
ischemia.
Katz & Landt (1935): lead 5 is better in
terms of discrimination than lead 4. Use of
anoxia to bring changes in ST segment.
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傳統心臟運動測試
重要沿革2
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Missal (1938): having p’t run up 3-6 flights
of stairs and he might be the first to use a
max stress test and to the point of pain
and emphasized the necessity of taking
the recording as quickly as possible
thereafter.
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傳統心臟運動測試
重要沿革3
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Riseman et al (1940): the first to use
continuous monitoring and discovered that
ST depression appeared before the onset
of pain and persisted for a time after the
pain subsided.
They concluded that exercise was of little
value because of its poor discrimination
between the normal and the abnormal
subjects.
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傳統心臟運動測試
重要沿革4
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Johnson et al (1942): developed Harvard
Step Test. Use pulse counts during
recovery and provide an index of physical
fitness.
Hellerstein & katz (1949): ST depression
is primarily a diastolic injury current
manifested during the TQ interval.
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傳統心臟運動測試
重要沿革5
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Wood et al: Push the p’t to the max level
of their capacity
The amount of work should not be fixed,
but adjusted to the individual
 The more strenuous work would produce a
higher percentage of positive tests
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Recommend the use of the stress test to
uncover latent myocardial ischemia.
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傳統心臟運動測試
重要沿革6
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Bruce (1956): work test performed on a
treadmill and established guideline that
would more or less group p’t into the
NYHDC I through IV
Astrand & Ryhming: max oxygen uptake
could be predicted by the HR at submax
exercise
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傳統心臟運動測試
重要沿革7
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Blackburn (1969):90% of the ischemic
changes could be demonstrated in the
CM5 or V5 lead. So spread the use of test
outside the research lab.
Conventional exercise test, done with a
treadmill, is being supplemented by many
other techniques to improve the disgnostic
certainty and help localize the disease
vessels.
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新近心臟運動測試發展
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功能量（functional capacity）預測死亡
率；體適能越佳存活率越高
不正常的運動後心跳恢復率與死亡危
險性有關
心跳加速不能（chronotropic
imcompetence）與心跳保留量（heart
rate reserve）在測試上的應用
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新近心臟運動測試發展1
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Greater fitness results in longer survival
(Myers et al, NEJM 2002):
 3679
men with CVD V.S. 2534 men without
CVD on treadmill max ET
 After adjusting for age, peak exercise
capacity measured in METs is the strongest
predictor of the risk of death in both groups.
 Absolute peak ex ca is a stronger predictor
than age-predicted value achieved.
 Risk of death doubled among those MET
less then 5 when compared to whose MET
more than 8
2016/5/22
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Exercise capacity is a more powerful predictor of mortality
among men than other established risk factors for CV disease
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新近心臟運動測試發展2
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Abnormal heart rate recovery and risk of
death
HRR after ex as a predictor of mortality（Cole et
al, NEJM 1999）
 Slow HRR after ex is associated with carotid
atherosclerosis (Jae et al, Atherosclerosis)
 Prognostic value of HRR in pt with HF (Arena, Am
HJ)
 HRR after ex is a predictor of mortality,
independent of the angiographic severity of CD
(Vivekananthan et al, J Am Col Cardio)
 HRR improved as a result of ex training during
CR (MacMillan et al, Heart Lung)
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運動後心跳恢復率的預後
意義
Cole et al, NEJM 1999
12 bpm, 26% abnormal HRR,
No further improvement for
value above 20
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A strong association between ↓ ex ca and ab HRR
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新近心臟運動測試發展3
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Chronotropic incompetence（心跳加速不
能）：最快的心跳數不易達到預期之目標心
跳數
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HR reserve（心跳保留量, HRR）：安靜與
最大心跳數之差異
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Peak HR is related to age: referred as CI when
＜85％ of the age-predicted HR is achieved.
Azarbal et al found that failure to reach 85％ of
the age-predicted maximum HR was predictive
of death but that failure to use 80％of HRR was
a stronger predictor of risk.
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女性功能量常模的預後價值
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The prognostic value of a normogram for
ex ca in women (Gulati et al, NEJM 2005):
Ex ca: an independent predictor of mortality
 5721 asymptomatic women underwent a
symptom-limited max ex test.
 A nomogram established on the basis of
age and ex ca
 Use the nomogram to determine the % of
original women and another 4471 women
with CVD
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♀: 14.7-(0.13*age)
♂: 14.7-(0.11*age)
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Active ♀:17.9-(0.16*age)
Sedentary ♀: 14.7-(0.12*age)
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新近心臟運動測試發展3
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HR reserve approach should be used
when assessing HR to ex
The ex test provides critical prognostic
information beyond that provided by
nuclear imaging
Azarbal et al also found that
chronotropic response predicts
outcome over and above functional
capacity, one of the most powerful
predictors of all-cause and cardiac
death.
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傳統CET V.S. 現代CET
傳統CET
現代CET
診斷
診斷 +預後
運動中
運動中+恢復期
ST-segment depression:
ST depression: CAD
CAD
Ventricular arrhythmias :
Lacking Q wave: ischemia predict mortality better
Chronotropic incompetence
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傳統CET V.S. 現代CET
During exercise
During recovery
Maximal exercise
capacity
ST-segment depression
HR response
Delay slowing of HR
ST-segment depression/
elevation
Angina pectoris
Ventricular arrhythmia
Inadequate BP/HR
response
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Ventricular arrhythmia
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運動後心跳恢復率的臨床意
義:
緣
起
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傳統上重視運動中的心跳變化，現發現運動
停止後的心跳恢復變化具顯著的臨床意義
運動中的心跳的上升變化是副交感退縮與交
感興奮的合併結果；運動後的心跳降低則是
副交感神經系統再活化的結果
因迷走活化的提高經常與死亡率降低相伴發
生，研究開始朝向運動後的心跳率與預後因
子的關係
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運動後心跳恢復率的臨床
意義1:
初
步
發
現
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Cole et al 1999：2428 subjects without
HD history undergoing symptom-limited
ex test. Heart rate recovery (HRR) was
defined as the reduction in the HR from
the peak ex to one min after the cessation
of ex
An abnormal HRR was found using logrank chi-square test statistic. HRR＜＝12
beats per min is considered abnormal
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運動後心跳恢復率的臨床
意義2:
非
關
心
疾
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傳統上認為運動後快速的心跳回復是體適
能好的表徵，現在則加上了預後的價值
Rapid HRR is due to high vagal tone
associated with fitness and good health
HRR is prognostic usually at 1 or 2 min
after ex in populations related to ex test
Vivekananthan et al: HRR predicts
mortality, independent of the
angiographic severity of CD
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運動後心跳恢復率的臨床
意義3:
應
用
於
各
類
病
人
Cheng 2003,
Diabetes
Spies 2005,
Metabolic Sd
Watanabe
2001, LVSD
HRR5,
Quartile 1＜
55
MET＜5,
HRR1＜16
HRR1＜18
Panzer 2002, HRR2 ＜42
healthy Sub
2016/5/22
↓HRR independently
predictive of CV and all
cause death
Metabolic Sd is associated
with low ex ca and HRR
↓HRR remained predicitve
of death after accounting for
LVSD
Impaired plasma glucose
indep. Predictor of ab HRR
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運動後心跳恢復率的臨床
意義4:
尋
求
解
釋
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在心肌梗塞上發現自主神經異常與死亡的
密切關係
自主神經不平衡（autonomic imbalance）：
指迷走神經活動相對或絕對的降低或交感
神經活動的升高
最普遍的現象是，一旦迷走降低，死亡危
險性即升高
可證諸baroreflex sensitivity, heart rate
variability, and heart rate recovery
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血管正常者之心跳恢復率：前言
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根據先前國外研究結果，推論體適能水準
與心跳恢復應有某程度相關（體適能及心
跳恢復皆成功預測死亡率）
肥胖程度與自主神經系統有關（Mona Lisa
Hypothesis: most obesities known are low
in sympathetic activity）
副交感神經與脂肪儲存、胰島素釋放有關
基於以上結果，推論體適能與肥胖程度應
會影響心跳恢復
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血管正常者之心跳恢復率：方法
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本篇研究乃是以接受導管檢查者證實冠狀
動脈正常未阻塞者為對象
受測者接受 symptom-limited maximal
treadmill exercise（Bruce protocol），達
90％ age-predicted maximal heart rate
reserve者進入接下來之分析
將合格之受測者依體適能水準與肥胖程度
各分為3組。
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血管正常者之心跳恢復率：方法
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以雙因子變異數分析（two way ANOVA）
探討體適能與 肥胖（ BMI ：body mass
index）對心跳恢復的影響
體適能：分為below average（BA）,
average (A), above average (AA) 三組
肥胖：分為NOR（BMI＜25）, OW（25 ≦
BMI ＜30 ）, OB（BMI≧30）三組
心跳恢復：運動停止後的第一分鐘、第三
分鐘及第五分鐘之心跳率與運動中最大心
跳率之差異，稱為HRR1, HRR3, HRR5
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Estimated Functional Capacity (METs)
Age (yr)
BA
Average (A)
AA
Women
≦29
≦10
10-13
≧13
30-39
≦9
9-11
≧11
40-49
≦8
8-10
≧10
50-59
≦7
7-9
≧9
≧60
≦6
6-8
≧8
Men
2016/5/22
≦29
≦11
11-14
≧14
30-39
≦10
10-12.5
≧12.5
40-49
≦8.5
8.5-11.5
≧11.5
50-59
≦8
8-11
≧11
≧60
≦7
7-9.5
≧9.5
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Total subjects
Male subjects
Female subjects
P value
N
55
30
25
Age (yrs)
59.7±10.1( 41-79)
61.6±10.8(41-79)
58.1±9.1(42-75)
Height (cm)
161.0±8.4(146-179)
166.8±6.3(156-179)
154.6± 4.9(146-166)
＊
Weight (kg)
69.2±12.9(46.4-100)
73.28±6.3(46.4-100)
64.4±10.5(47-86.4)
＊
BMI
26.6±4.2(18.3-39.6)
26.4±4.1(18.3-35.0)
27.0±4.3(20.3-39.6)
Number (%) of
people having
dyslipidemia
14(25.4%)
9(30.0%)
5(20.0%)
Number (%) of
people having
hypertension
21(38.2%)
16(53.3%)
5(20.0%)
Number (%) of
people having
diabetes
9(16.4%)
5(16.7%)
4(16.0%)
Number (%) of
people smoke
5(9.1%)
5(16.7%)
0(0%)
＊
Number (%) of
people drink
8(14.5%)
7(23.3%)
1(4.0%)
＊
Number (%) of
people chew
bittle nuts
6(10.9%)
5(16.7%)
2(8.0%)
Number (%) of
people over 65
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16(38.5%)
7(36.7%)
5(20.0%)
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Group
BA
Group
A
Group
AA
N
9
19
27
Female: Male
3:6
7:12
15:12
Age
63.0±12.59
58.3±11.22
59.6±8.4
Height
163.0±11.0
162.2±8.7
1.59±7.4
Weight
70.9±10.3
72.3±14.2
66.5±12.6
BMI
27.3±3.9
27.3±3.9
26.0±4.5
Age over 65: Age
under 65
6:3
7:12
8:19
Resting HR
89.9±17.5
80.7±15.8
75.2±9.3※
Resting SBP
139.9±21.9
143.4±25.7
143.0±29.9
Maximal HR
157.1±11.2
161.6±12.5
162.0±9.7
Maximal SBP
172.8±27.3
176.9±27.0
187.2±23.8
% predicted HR
100.1±2.2
100.0±3.6
101.1±4.5
2016/5/22
P value
＊
37
Group
BA
Group
A
Group
AA
P
value
METs
6.1±1.1
8.8±1.5※
10.7±1.3※
＊
Slope MHR-HR1
-17.3±7.2
29.6±10.5※
33.3±13.2※
＊＊
Slope MHR-HR3
-16.3±3.5
--20.5±4.8※ -21.2±4.2※
Slope MHR-HR5
-11.6±2.4
-12.8±2.3
-13.6±2.4
Number of people
taking NTG
0
5
4
Number of people
having abnormal
ECG
2
8
9
2016/5/22
＊
38
Group
BMI＜25
Group
25≦BMI＜
30
Group
BMI≧30
N
20
26
8
Female: Male
10:10
15:11
4:4
Age
62.5±7.8
56.8±11.1
59.9±8.7
Height
159.0±7.7
163.1±8.5
159.3±9.2
Weight
57.2±7.1
73.8±8.4※
86.4±10.4※#
＊＊
BMI
22.6±1.8
27.7±1.4※
33.5±3.1※#
＊＊
Age over 65: Age
under 65
8:12
8:18
4:4
Resting HR
82.7±12.9
77.2±13.7
77.3±17.7
Resting SBP
139.0±30.9
143.5±20.0
145.0±32.4
Maximal HR
159.8±7.9
162.8±11.8
161.3±13.4
Maximal SBP
183.6±26.5
177.8±27.2
185.5±21.7
2016/5/22
P value
39
Group 1
BMI＜25
Group 2
25≦BMI＜30
Group 3
BMI≧30
% predicted HR
101.5±4.1 99.8±3.5
100.6±4.5
METs
9.5±2.2
9.7±1.9
8.0±1.9
Slope MHR-HR1
-26.8±7.3
-33.115±14.9
-26.5±12.4
Slope MHR-HR3
-19.0±3.5
-21.1±4.7
-20.6±6.1
Slope MHR-HR5
-12.7±1.7
-13.169±2.6
-13.675±2.6
Number of people 2
taking NTG
5
2
Number of people 7
having
abnormal ECG
9
3
2016/5/22
P value
40
血管正常者之心跳恢復率：結果
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交互作用未達顯著
體適能因子呈顯著(F (2,45) =3.66,
p<.05) ，LSD事後比較顯示AA組與A
組之HRR1與 HRR3顯著高於BA組
肥胖水準因子未達顯著
41
80
*
Heart rate recovery (bpm)
BA
A
AA
*
60
40
**
*
20
0
HRR1
HRR3
HRR5
Recovery period
2016/5/22
42
80
Heart Rate Recovery (bpm)
NOR
OW
OB
60
40
20
0
HRR1
HRR3
HRR5
Recovery period
2016/5/22
43
血管正常者之心跳恢復率：討論

本研究發現冠狀動脈血管正常者,體適
能水準顯著影響運動後的心跳恢復率;
體適能高於,等於平均者有較高的心跳
恢復率
與已知趨勢符合, 體適能高→心跳反
應及時
 雖本研究未探討死亡率, 但過去研究
結果顯示,體適能高→死亡率低, 心跳
恢復率高→死亡率低, 兩者方向一致

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血管正常者之心跳恢復率：討論

而肥胖的程度對心跳恢復率的影響在
本研究中並無發現
肥胖對自主神經的影響不一,有的認為
腹部脂肪影響較大
 本研究所使用的肥胖指數為BMI, 無法
從BMI得知肌肉骨骼脂肪之相對比例
 另一思考方向, 所有危險因子的加總結
果為血管正常, 亦即肥胖之效果為其他
因子所抵銷
 統計上因素, 肥胖組有較少的人
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血管正常者之心跳恢復率：結果
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在導管證實冠狀動脈正常者之受試者身
上, 接受最大運動測試, 達90% 年齡預
測心跳保留量者發現, 體適能較佳者有
較高之運動後心跳恢復率
但在以BMI分類的肥胖指數上, 不同的
肥胖指數對運動後心跳恢復率並未造成
影響
為台灣首度以冠動正常者為對象所完成
的運動後心跳恢復率研究, 更多這方面
的研究可以幫助我們更進一步了解機轉
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要運動多少才夠？
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2016/5/22
The amount, intensity, and duration of
physical activity required to reduce the risk
of coronary heart disease is debated.
Harvard Alumni Study: no further reduction
in events associated with CAD in men with
an energy expenditure of more than 2000
Kcal per week.
Either a threshold effect or a progressive
decline with progressive activity, possibly
because of differences in the range of
activity in the populations.
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要運動多少才夠？
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2016/5/22
大多數文獻將運動強度大於6MET定義
為強烈，中度強烈則是產生輕微的喘及
達到50％的最大運動強度。
一天一個小時中度以上運動即接近最佳
狀況，而漸進增加運動量則導致漸進降
低心臟危險性。
ACSM的運動建議是謹慎的，當作一個
最低的建議量。More vigorous exercise
is probably more beneficial, but also
carries a cardiovascular risk, especially
for those who are usually inactive. 48
Survival of the fittest
適者生存


2016/5/22
Cardiorespiratory fitness enables a person to
perform physical activity and is influenced by
several other factors, including age, sex,
heredity, and medical status.
A nearly linear reduction in mortality was
observed as fitness levels increased, and each
increase of 1MET in exercise capacity
conferred a 12% improvement in survival.
49
結論


2016/5/22
The lowest threshold for a dose and an
intensity that would confer specific survival
and cardiovascular benefits is not known.
To compel the clinician to go beyond the
identification of risk to the initiation of
interventions, such as the prescription of
increased physical activity and exercise to
modify risk, particularly in patients with low
levels of fitness.
50
結論

2016/5/22
建議盡量每日運動，因為運動對於
部分危險因子的效果；如三高的血
糖、血壓，血脂的三酸甘油脂、與
HDL皆具有程度上的運動急性效果。
51