Kardiyak Rehabilitasyonda Egzersiz Testleri

S.UFUK YURDALANMARMARA ÜNİVERSİTESİ

KR Fazları Faz I:Hastane İçi: Rehabilitasyon prosedürleri ve hastalık seyrini yavaşlatıcı başlangıç düzeyi preventif girişimler

Faz II:Hastane dışı ve telemetrik izlemli:Risk modifikasyonu, sağlıklı yaşam stili, güvenli FA

Faz III:Denetimli rehabilitasyon, risk modifikasyonu, ev ve toplum tabanlı güvenli FA

Faz IV:İdame Etme/İzlem:Yaşam boyu sağlıklı alışkanlıklar, KV takip, maksimal egzersiz testleri ile hastaya geri bildirim

Klinik Egzersiz Testleri (GXT)

• Diagnostik ( anormal fizyolojik yanıtların belirlenmesi)

• Prognostik ( yan etkilerin belirlenmesi )

• Terapötik ( girişimin etkinliğinin belirlenmesi )

• Fiziksel aktivite danışma ve egzersiz programını düzenleme

• Sağlık taramalarından egzersiz programının içeriği ve sürdürülmesinde

klinik karar vermeye değişen amaçlar

ACSM 2014

SIGNED CONSENT

Before proceeding with the test we need your signed consent.

The signing of this form is voluntary and you are absolutely free to deny consent if you so desire, if so, the test will not be done. Before signing the consent form, please feel free to ask any questions you have about exercise stress testing andabout any risks and benefits.

I have read this form and had the opportunity to ask questions. I understand the test which I will carry out and I have been made aware of the risks involved. I consent to participate in this stress test.

Signature of patient

Witness Date

http://dx.doi.org/10.1016/j.hlc.2015.01.022

Safety of Exercise-Based Cardiac Rehabilitation and Exercise Testing for Cardiac Patients in Japan– A Nationwide Survey –

383,096 patient-hours of exercise training

(3.13* and 0.26** events/100,000 patient-hours)

* İstenmeyen olay

**Yaşam tehditi

(death, cardiac arrest, acute myocardial infarction, cardiac rupture) Circulation 2014 ;78:1646-53

Fonksiyonel Kapasitenin Objektif Değerlendirilmesi Ergospirometrik Testler

Fonksiyonel limitasyonların intrinsik mekanizması ve patofizyolojik nedenlerinin belirlenmesine yönelik kardiyak ve respiratuar değişkenlerin kapsamlı analizi ve yorumlanması

Balady GJ, Arena R, Sietsema K, Myers J, Coke L,Fletcher GF, et al. Clinician’s guide to cardiopulmonary exercise testing in adults. A scientific statement from the AHA. Circulation 2010;122(2):191-225

Cohen-Solal A, Carré F. Practical guide to cardiopulmonary exercise testing. Issy-lesMoulineaux Cedex: Elsevier: Masson SAS; 2012

CorSalud 2013 Jul-Sep;5(3):232-236

Endikasyon ve Klinik Amaçlar

I- Hastalığın şiddeti ve prognozu belirleme

II-MI sonrası

III-Fonksiyonel egzersiz testleri

I- Hastalığın Şiddeti ve Prognozu Belirleme

• ST segment depresyonu, derivasyonları, toparlanmada görülmesi

• ST segment depresyonu görülen KH max,DP ve METs düzeyi

• KKY, PH ve KOAH’da hastalığın şiddetine bağlı progresif VE,VE/VCO2,PETCO2’de anormallikler

• Kötü prognozla progresif azalan aerobik kapasite ( KY)

KH, hemodinami, ventilatar gaz değişimi

Heart Fail Rev. 2008;13(2):245–69

Curr Vasc Pharmacol. 2009;7(4):557–69

J Heart Lung Transplant. 2010;29(2):159–73

Bisergo Testinin Hastane Dışı KR’da Prognostik Değeri

Programa alınan 2146 ardışık olgu

Programı tamamlayan 1853 olgu (%86)

33 ay izlem

Program öncesi : İleri yaş, DM, düşük LVEF, Ca kanal bloker kullanımı, düşük iş yükleri bağımsız KV ölüm belirteçleri.

Program sonu: İleri yaş, düşük LVEF, düşük iş yükleri, peak KH’na ulaşamama tüm mortalitelerden sorumlu.

International Journal of Cardiology 2010; 140:34–41

II- MI Sonrası Submaksimal Egzersiz Testleri

Medikal / revaskülarizasyon girişimine karar verme ve FA danışmanlığı

Düşük düzey egzersizde iskemik ST segment depresyonu

Azalmış sol ventriküler sistolik fonksiyon,5 METs, ezgersize düşük SKB yanıtı

College of Cardiology/AHA Task Force on Practice Guidelines

J Am Coll Cardiol. 2002;40(8):1531–40

III- Fonksiyonel Egzersiz Testleri(Progresif Vo 2peak)İşe Dönüşün Gerektirdiği Aerobik Kapasite Tayini

• K: 13 mL kg/dk (3.7 METs)

• E: 15 mL kg/dk (4.3 METs)

• 1 mL kg/dk aerobik kapasite artışı % 9 E% - % 10 K’da kardiyak mortalitede azalma

Circulation 2002;106(6):666–71

J Am Coll Cardiol. 2003;42(12):2139–43

Circulat

ion. 2009;11

9(24):3144–61.

Ölçülen veya önsayım MET kapasitesi hastanın işinin gerektirdiği önsayım aerobik gereksinim ile örtüşmeli.

8 st enerji gerektiren iş GXT’de %50 METs peak değerini karşılamalı. (5-45 dk)

Ev egzersiz programı %80 METs peak’de önerilmeli.

Med Exerc Nutr Health 1995;4:273–89

İŞE

DÖ

NÜ

Ş

Egzersiz Test Öncesi / Sırası ve Sonrası Ölçümleri

12 derivasyonlu EKG / Circulation 2007;115(10):1306–24

KH / Circulation 2009;119(24):3144–61

KB / Circulation 2001;104(14):1694–740

Klinik işaret ve semptomlar / Circulation 2010;122(2):191–225

Borg Skalası / Am J Cardiol. 2008;102(7):879–82

Gaz değişimi / Circulation 2010;122(2):191–225

Test Sonlandırma KriterleriABSOLUTE INDICATIONS

• Drop in systolic BP of 10 mm Hg with an increase in work rate, or if systolic BP decreases below the value obtained in the same position prior to testing when accompanied by other evidence of ischemia

• Moderately severe angina

• Increasing nervous system symptoms ( ataxia, dizziness, or near syncope)

• Signs of poor perfusion (cyanosis or pallor)

• Technical difficulties monitoring the ECG or SBP

• Subject’s desire to stop

• Sustained ventricular tachycardia

• ST elevation ( 1.0 mm) in leads without diagnostic Q waves (other than V1 or aVR)

RELATIVE INDICATIONS

• Drop in systolic BP of 10 mm Hg with an increase in work rate, or if systolic BP below the value obtained in the same position prior to testing

• ST or QRS changes such as excessive ST depression (2 mm horizontal or downsloping ST-segment depression) or marked axis shift

• Arrhythmias other than sustained ventricular tachycardia, including multifocal PVCs, triplets of PVCs, supraventricular tachycardia, heart block, or bradyarrhythmias

• Fatigue, shortness of breath, wheezing, leg cramps, or claudication

• Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia

• Increasing chest pain

• Hypertensive response (SBP of 250 mm Hg and/or a DBP of 115 mm Hg).

Borg’a Alternatif Test Skalaları

Anjina ( 1-4 )

Claducatio ( 1-4 )

Dispne ( 1-4 )

> 3

N Engl J Med. 2005;353(18):1889–98

Am J Cardiol. 2008;102(7):879–82

ACSM işaret ediyor.• Although a clinical exercise test may not be indicated for most individuals about to begin an exercise program, the high value of information obtained from this procedure is not debatable.

• Aerobic capacity may be one of the single best prognostic markers in all individuals regardless of health status.

• Standard clinical exercise testing is well accepted for the assessment of individuals with signs and/or symptoms suggestive of CVD.

• The use of cardiopulmonary exercise testing, which combines standard clinical exercise testing with simultaneous ventilatory expired gas analysis, is common practice in patients with CHF as well as those with unexplained exertional dyspnea.

The recent recognition that appropriately trained nonphysician personnel can safely perform a clinical exercise test may result in the expanded use of this valuable procedure in various clinical settings.

Alan Testleri

6 MWT

Faz II-III KR’da en uygun submaksimal fitnes testi

Klinik ve klinik olmayan popülasyonlarda geçerli, güvenilir

Australian Journal of Basic and Applied Sciences 2011 5(9): 1740-6

Physiotherapy 2012 ; 98 : 277–86

6 MWT : KY ve KV cerrahide fonksiyonel düzey, yürüme otonomisi ve enduransı Gayda,2004

2-minute-walk test :Psikometrik limitli hastalar

2-15- mWT/ 100-mWT / 400-mWT / 200mFWT

Artışlı mekik yürüme testi Pulz,2008Physiotherapy 2013;99: 317–322

EGZER

SİZ TRA

ININ

GLER

İND

E

YÜRÜM

E TESTLERİ

Annals of Physical and

Rehabil i tat ion M

edicine

2013,56:561-75

6MWT’de olgu >500m durmaksızın yürürse, FK diğer testlerden biri ile gerçekleştirilmelidir.

CICRP2011;19:3-19

KR’da Algoritma Odaklı Egzersiz Testleri

Yürüme testlerinin FK ve mortalite ilişkisi

TEST KALİTESİ / KR’DA ROLÜ / FARKLI ETYOLOJİLERDE VALİDASYON ÇALIŞMALARI

Alternatif Egzersiz Öneri Yöntemi

Dinlenme KH’ın 20 atım / dk üzerine çıkan aerobik yük

Dinlenme KH’ının 30 atım / dk altına inen toparlanma

RPE 11-13 / 20’li Borg Skalası

RPE 3 – 5 / 10’lu Borg Skalası

ACSM 2010

Subjektif EK Belirleme Duke Aktivity Status Index- Egzersiz Tolerans Testi

ETT’de test RPE 15 düzeyinde sonlanırken ve %20 hasta semptomatik düzeye ulaşamazken;

DASI skoru gerçek MET düzeyi ve gerçek hayattaki ilişkili aktiviteyi görüntülemede etkin.

ETT METs (5.5 to 5.8) & DASI METs ±1 = 5.5 to 7.5)

Proc (Bayl Univ Med Cent) 2013;26(3):247–251

1.Hamstring stretch (supine position).

2.Standing pectoral stretch.

3.Quadriceps stretch (supine position).

4.Standing levator scapulae arm stretch.

5.Calf stretch (supine position).

6.Standing posterior shoulder capsule stretch each arm.

PRE-EXERCISE STRETCHING

(PES) + TM

EGZERSİZ

TESTİ30 SN G

ERME- 10 SN ARA X 6 TEKRAR

PES test sonrası ilk 5 dk’lık toparlanmada parasempatik reaktivasyonda gecikmeye yol açarak tonik kardiyak otonomide disfonksiyona neden oluyor.

PES 3 tekrarlı yapılırsa VO2 max’ı etkilemiyor.

Potansiyel parasempatik gecikmelerin negatif / pozitif nedenleri araştırılmalı.

Rev Andal Med Deporte. 2013;6(l):3-8

Egzersiz Training Komponentleri

-Kardiyorespiratuar egzersiz

20-60 dk/seans/3 kez/hf

-Dirençli egzersiz

8-12 tekrar / 10 – 15 tekrar */ 15-20 tekrar **

* Orta ve ileri yaş / ** Kassal endurans

-Esneklik egzersizleri

Statik / dinamik / balistik / proprioseptif

-Nöromotor egzersiz : Fonksiyonel fitnes training

Denge / çeviklik / koordinasyon / yürüme ve çok yönlü egzersizler ( TCC )

Cardiovascular Medicine 2011;14(11):299–302

Haemodynamic Response During Exercise Testing in Patients with CAD Undergoing A Cardiac Rehabilitation Program

Thirty (25 M; 5 F) patients were included in the program. The group was divided according to ejection fraction (EF): low – below 50%, normal – equal to or above 50%. The exercise test was performed simultaneously with a four-electrode impedance cardiogram before and after rehabilitation. ECG, blood pressure, thoracic impedance, first derivative dz/dt, stroke volume (SV) and cardiac output were recorded. Contractility index (Heather index – HI) and vascular peripheral resistance were calculated.

The pattern of haemodynamic changes was normal in 24 patients. The deflection points for HI and SV trend patterns were observed among patients with low EF. The contractility index decreased 90s before maximal exercise and after the next 30-60s a deflection point was observed in SV curve trends. In 24 patients with normal EF the contractility index trends did not decrease and SV trends increased until the end of exercise or a deflection point was not noted. The deflection points of the contractility index and SV curves were observed before the clinical indications for exercise test termination appeared in patients with a low ejection fraction.

Impedance cardiography may indicate the threshold of the workload during real-time exercise testing.

Biology of Sport 2011; 28 (3): 189-193

Risk Classification for Exercise Training: Class A: Apparently Healthy Individuals

A1.Children, adolescents, men <45 years of age, and premenopausal women who have no symptoms or known presence of heart disease or major coronary risk factors

A2.Men ≥45 years of age and post menopausal women who have no symptoms or known presence of heart disease and with <2 major cardiovascular risk factors

A3.Men ≥45 years of age and post menopausal women who have no symptoms or known presence of heart disease and with ≥2 major cardiovascular risk factors

Activity guidelines: No restrictions other than basic guidelines

Supervision, ECG and BP monitoring: Not required

Circulation 2013;128:873-934

Risk Classification for Exercise Training: Class B: Presence of Known, Stable CVD With Low Risk for Complications With Vigorous Exercise

B1.CAD (MI, CABG, PTCA, AP, abnormal exercise test, and abnormal coronary angiograms); includes patients whose condition is stable and who have the clinical characteristics outlined below

B2.Valvular heart disease, excluding severe valvular stenosis or regurgitation, with the clinical characteristics as outlined below

B3.Congenital heart disease; risk stratification for patients with congenital heart disease should be guided by the 27th Bethesda Conference recommendations145

B4.Cardiomyopathy: ejection fraction ≤30%; includes stable patients with heart failure with clinical characteristics as outlined below but not HCM or recent myocarditis

B5.Exercise test abnormalities that do not meet any of the high-risk criteria outlined in Class C

Risk Classifi cation for Exercise Training: Class C:Those at Moderate to High Risk for Cardiac Complications

C1. CAD with the clinical characteristics outlined below

C2. Valvular heart disease, excluding severe valvular stenosis or regurgitation with the clinical characteristics as outlined below

C3. Congenital heart disease; risk stratification for patients with congenital heart disease should be guided by the 27th Bethesda Conference recommendations

C4. Cardiomyopathy: ejection fraction ≤30%; includes stable patients with heart failure with clinical characteristics as outlined below but not HCM or recent myocarditis

C5. Complex ventricular arrhythmias not well controlled