Primerjalni učinki telesne vadbe v vodi in na suhem na telesno zmogljivost in druge izbrane srčno-žilne dejavnike pri bolnikih s koronarno boleznijo

Vasić, Danijela (avtor), Jug, Borut (mentor), Kšela, Juš (komentor)

Uvod Kardiološka rehabilitacija, ki temelji na telesni vadbi, je ključna prvina sekundarne preventive bolnikov po srčnem infarktu ali koronarnem posegu, saj zmanjšuje srčno-žilno zbolevnost in umrljivost. V okviru kardiološke rehabilitacije je najbolj raziskana kombinacija aerobne in uporovne telesne vadbe na kopnem; večina priporočil poudarja hojo in kolesarjenje kot dinamično-aerobni vrsti vadbe, ki izboljšata kazalnike srčno-žilnega zdravja pri srčnih bolnikih. Telesne vadbe, ki se izvajajo v vodi, so srčnim bolnikom tradicionalno odsvetovali, ker naj bi bile povezane z zvečanim tveganjem za neželene srčno-žilne dogodke. Povečano zanimanje za izvajanje telesne vadbe v vodi na eni strain ter skope informacije o učinkovitosti kratkoročne telesne vadbe v vodi na drugi strain narekujeta potrebo, da se tovrstna vadba znanstveno ovrednoti z vidika varnosti in učinkovitosti pri koronarnih bolnikih. Domnevali smo, da telesna vadba v vodi enako varno in učinkovito kot vadba na kopnem izboljša i) telesno zmogljivost, ii) žilno funkcijo, iii) avtonomno funkcijo srca, iv) biološke označevalce srčno-žilne bolezni in v) kakovost življenja. Zato smo izvedli randomizirano klinično raziskavo, s katero smo pri koronarnih bolnikih primerjali varnost in učinkovitost 14-dnevne vadbe v vodi oziroma na kopnem z običajno oskrbo (brez nadzorovane vadbe). Metode Bolnike po nedavnem srčnem infarktu ali revaskularizaciji srčne mišice smo naključno razvrstili v dve interventni skupini in eno kontrolno skupino (po 30 bolnikov v vsaki skupini). Interventni skupini sta bodisi v termo-nevtralni vodi bodisi na kopnem izvajali nadzorovani trening aerobnih in kalisteničnih vaj z zmerno intenzivnostjo (60–80 % najvišjega srčnega utripa, doseženega med obremenitvenim testiranjem), in sicer po 30 minut dvakrat na dan 2 tedna. Kontrolna skupina je nadaljevala običajno zdravljenje; bolniki v času raziskave niso bili vključeni v nadzorovan program telesne vadbe, smo jim pa svetovali telesno dejavnost nizke do zmerne intenzivnosti v domačem okolju. Pred obdobjem telesne vadbe in po njem smo pri vseh preiskovancih: i) ocenili aerobno telesno zmogljivost (največjo porabo kisika, V˙O2 peak, med kardiopulmonalnim obremenitvenim testiranjem), ii) ultrazvočno izmerili od pretoka odvisno dilatacijo brahialne arterije med reaktivno hiperemijo, iii) določili kazalnike avtonomne srčne fukcije z 20-minutnim visokoločljivim EKG, iv) izmerili označevalce nevrohumoralne aktivnosti (NT-proBNP), vnetja (hsCRP, IL-6, IL-8, IL-10), endotelijske aktivacije (ICAM, P-selectin) in hemostaze (fibrinogen, D-dimer) v krvi ter v) ocenili z zdravjem povezano kakovost življenja z vprašalnikom SF-36. Rezultati Raziskavo je zaključilo 89 bolnikov (povprečna starost 59.9 ± 8.2 leta, 77.5% moških izhodiščni V˙O2 peak 14.8 ? 3.5 ml kg-1 min-1). En udeleženec pa je nil izključen iz študije zaradi okužbe zgornjih dihal. V opazovanem obdobju v skupinah ni bilo zabeleženih nobenih neželenih dogodkov. Telesna zmogljivost se je v obeh interventnih skupinah v primerjavi s kontrolno skupino znatno izboljšala. Povprečna vrednost V˙O2 peak (ob statističnem upoštevanju izhodiščnega V˙O2 peak in starosti bolnika) se je po telesni vadbi na kopnem izboljšala za 15.3% (16.7 [95%CI 16.0–17.4] ml kg -1 min-1; p<0.001 za spremembo od izhodiščne vrednosti) oziroma po telesni vadbi v vodi za 27.4% (18.6 [95%CI 17.9– 19.3] ml kg-1 min-1; p <0.001 za spremembo od izhodiščne vrednosti), ne pa v kontrolni skupini (–0.6 %, 14.9 [95%CI 14.2–15.6] ml kg -1 min-1, p=0.775 za spremembo od izhodiščne vrednosti). Skupina, ki je telovadila na kopnem, je imela v povprečju 1.8 (95%CI 0.8–2.8) ml kg -1 min-1 višji V˙O2peak na koncu raziskave v primerjavi s kontrolno skupino, skupina, ki je telovadila v vodi, pa 3.7 (95%CI 2.7–4.7) ml kg-1 min-1. Od pretoka odvisna dilatacija brahialne arterije se je izboljšala v obeh vadbenih skupinah. V skupini, ki je telovadila na kopnem, se je povečala s 5.5 % (medkvartilni razpon, IQR: 3.1–8.6) na 8.8 % (IQR: 5.3–11.4), p<0.001), v skupini, ki je telovadila v vodi, pa s 7.2 % (IQR: 4.0–8.7) na 9.2 % (IQR: 7.4–12.9), p<0.001. V kontrolni skupini se ni spremenila značilno (p=0.629). V obeh intervencijskih skupinah se je značilno izboljšala tudi od pretoka neodvisna dilatacija brahialne arterije: v skupini, ki je telovadila na kopnem, se je povečala z 10.6 % (IQR: 7.0 –13.3) na 11.1 % (IQR: 9.0–14.3), p<0.001, v skupini, ki je telovadila v vodi, pa z 10.5 % (IQR: 8.5–14.9) na 11.4 % (IQR: 7.6– 13.4), p=0.042. Vrednosti D-dimera so se v skupini, ki je telovadila v vodi, značilno zmanjšale, in sicer s 400 µg L-1 (IQR: 270–810) na 370 µg L-1 (IQR: 260–590) (p=0.001), medtem ko v skupini, ki je telovadila na kopnem, statistično značilni razlik ni bilo. Tudi vrednosti NT-proBNP so se značilno zmanjšale le v skupini, ki je telovadila v vodi, in sicer s 396 ngL-1 (IQR: 296–541) na 308 ng L-1 (IQR: 187–394) (–22 %, p=0.001), medtem ko v skupini, ki je telovadila na kopnem, statistično značilnih razlik ni bilo. Pri obeh skupinah ni bilo pomembnih sprememb v vrednosti označevalcev vnetja (hsCRP, IL6, IL8, IL10), endotelijske aktivacije (ICAM, selektin) oziroma fibrinogena. Med kazalniki variabilosti srčne frekvence nismo zaznali razlik med skupinami v izbranih linearnih kazalnikih časovne domene; smo pa pri linearnih kazalnikih frekvenčne domene zaznali pomembno spremembo v razmerju med visoko- in nizkofrekvenčnimi kazalniki (HF/LF) v skupini, ki je telovadila v vodi (p=0.036). Prav tako se je pri tej skupini statistično značilno spremenil kazalnik vagalne modulacije ?1 (p=0.043), mejno pa tudi kazalnik SE (p=0.096). Obe vrsti telesne vadbe sta značilno izboljšali duševne in telesne domene z zdravjem povezanih kazalnikov kakovosti življenja. Zaključki Izsledki naše raziskave kažejo, da je pri koronarnih bolnikih razmeroma kratkotrajna (tj. 2-tedenska) nadzorovana telesna vadba v vodi varna in enako učinkovita pri izboljšanju telesne zmogljivosti in endotelijske funkcije (ocenjene s pretokom odvisne dilatacije) kot vadba na kopnem. S tem smo dokazali, da lahko vadbo v vodi vključimo v program rehabilitacije koronarnih bolnikov, če je to njihova želja. Dodatno smo pokazali, da utegne vadba v vodi izraziteje znižati koncentracijo D-dimera in NT-proBNP ter posamezne kazalnike vagalne modulacije. Nasprotno, obe vrsti vadbe primerljivo izboljšata z zdravjem povezano kakovost življenja. Z raziskavo smo prispevali k vse večjemu naboru dokazov o učinkovitosti in varnosti telesne vadbe pri bolnikih s koronarno boleznijo, hkrati pa potrdili, da je telesna vadba v vodi lahko varna in učinkovita možnost za koronarne bolnike, ki opravljajo kratkotrajni program srčno-žilne rehabilitacije.

• Jezik: Slovenski jezik
• Ključne besede: koronarna bolezen, telovadba v vodi, kardiološka rehabilitacija
• Vrsta gradiva: Doktorsko delo/naloga
• Organizacija: MF - Medicinska fakulteta
• Leto izida: 2021
• PID: 20.500.12556/RUL-125112
• Datum objave v RUL: 04.03.2021

Sekundarni jezik

• Jezik: Angleški jezik
• Naslov: Comparative effects of water-based and land-based exercise training on exercise capacity and other selected cardiovascular parameters in patients with coronary artery disease

Izvleček

Introduction Exercise-based cardiac rehabilitation is a cornerstone of secondary prevention in patients after myocardial infarction or coronary procedure, as it reduces cardiovascular morbidity and mortality. So far, the exercise type usually studied has been land-based exercise, aerobic and resistive by nature. In cardac patients, dynamic–aerobic exercise training in the form of walking or cycling is recommended as a mens of improving cardiovascular health. Water-based physical activities, however, have traditionally been cautioned against because of the purportedly higher risk of adverse cardiovascular events. Increased interest in the water exerce, on the one hand, and the lack of sufficient information of the efficacy of short-term water-based exercise on the other, have indicated a need for the scientific evaluation of this type of exercise from the aspect of safety and efficiency in coronary patients. We hypothesized that water-based exercise training is as safe and effective as land-based training in improving: i) physical performance, ii) vascular function, iii) autonomic cardiac function, iv) biological markers of cardiovascular disease, and v) quality of life. Therefore, we conducted a randomized clinical trial comparing the safety and effects of 14-day water- and land-based exercise training to the usual exercise routines (with no supervised training control) in coronary patients. Methods Patients after recent myocardial infarction or coronary revascularization were randomly allocated to two intervention groups and control group (30 patients each).The intervention groups performed supervised aerobic endurance and calisthenics exercise training sessions in thermoneutral water or on land, at a moderate intensity (60–80% peak heart rate achieved at symptom limited exercise testing), for 30 minutes twice a day for 2 weeks. The control group, continued with their usual treatment, but did not participate in any controlled physical exercise program, advised instead to perform low- to moderate-intensity physical activities at home during the course of the study. Before, and after the intervention, the following examinations were made in all study participants: i) estimation of aerobic exercise capacity (peak oxygen uptake, V̇O2 peak, obtained during cardiopulmonary exercise testing), ii) ultrasound assessment of flow-mediated dilation of the brachial artery during reactive hyperemia, iii) analysis of cardiac autonomic function with a 20-minute high-resolution ECG, iv) determination of the serum concentrations of markers of neurohumoral activity (NT-proBNP), inflammation (hsCRP, IL-6, IL-8, IL-10), endothelial activation (ICAM, P-selectin), and hemostasis (fibrinogen, D-dimer), and v) assessment of the health-related quality of life. Results Eighty-nine participants (mean age 59.9  8.2 years; 77.5% males, baseline V̇O peak 14.8  3.5 ml kg-1 min-1) completed the study. One patient was excluded from the study due to upper respiratory tract infection. No adverse events were observed in either of the intervention groups during the course of the study. Exercise capacity, determined as V̇O2 peak, increased significantly in both training groups in comparison to control. When controlling for baseline V̇O2 peak and patients’ age, mean estimate end-of-study V̇O2 peak improved in the land-based exercise group by up to 15.3% (16.7 [95%CI 16.0 – 17.4]; ml kg -1 min-1; p<0.001 for change from baseline) and up to 27.4% (18.6 [95%CI 17.9 – 19.3] ml kg-1 min-1; p<0.001 for change from baseline) in the water-based exercise group, while the increase was not observed in controls (– 0.6%, 14.9 [95%CI 14.2 – 15.6] ml kg-1 min-1; p=0.775 for change from baseline). The land-based exercise group had an, on average, 1.8 (95%CI 0.8 – 2.8) ml kg-1 min-1 and the water-based exercise group 3.7 (95%CI 2.7 – 4.7) ml kg-1 min-1 higher end-of-study V̇O peak in comparison to control. Flow-mediated dilation improved in both training groups, with greater improvements after water-based exercise: in the land-based exercise group from 5.5% (interquartile range, IQR: 3.1 – 8.6) to 8.8% (IQR: 5.3 – 11.4), p<0.001 and in the water-based exercise group from 7.2% (IQR: 4.0 – 8.7) to 9.2% (IQR: 7.4 – 12.9), p<0.001. There was no significant improvement in the control group (p=0.629). Non-flow-mediated vasodilation improved significantly in both intervention groups, i.e. in land-based exercise, from baseline values of 10.6% (IQR:7.0 – 13.3) to end-of-study values of 11.1% (IQR: 9.0 – 14.3), p<0.001, and in water-based exercise from the baseline 10.5% (IQR: 8.5 – 14.0) to end-of-study 11.4% (IQR: 7.6 – 13.4), p=0.042. D-dimer values significantly decreased in the water-based exercise group, from 400 μg L-1 (IQR: 270 – 810) to 370 μg L-1 (IQR: 260 – 590), p<0.001, while in the land-based exercise group we recorded lower but insignificant values in relation to basal. Significant reduction in NT-proBNP values was noticed only in patients in the water-based exercise group, from 396 ngL-1 (IQR: 296 – 541) to 308 ngL-1 (IQR: 187 – 394), ( - 22%, p = 0.001), while in the land-based exercise group no significant changes were noted. There were no significant changes in the values of inflammatory (hsCRP, IL6, IL8, IL 10) and endothelial activation (ICAM, selectin) parameters, or in fibrinogen values. By analyzing the heart rate variability parameters before and after rehabilitation, we observed no significant changes in the selected time-domain parameters in patients undergoing water- or land-based exercise, or in the control group. Regarding the frequency-domain parameters, we observed a statistically significant change in the high frequency and low frequency parameters ratio (HF/LF) in the group of patients who underwent water-based exercise (p = 0.036). Furthermore, a significant change of indicator of vagal modulation - nonlinear parameter 1 (p = 0.043), and a marginally statistically significant change of another nonlinear parameter SE (p = 0.096), were observed in the same group of patients. Both types of exercise training were associated with improvements in the mental and physical domains of health-related quality of life. Conclusion The results of our study indicate that relatively short supervised water-based exercise training is as safe and effective as land-based exercise training in improving exercise capacity and endothelial function (estimated by flow-mediated dilation) in patients with coronary artery disease, thus providing evidence on an additional modality to propose to patients in cardiac rehabilitation, according to their preference. In addition, we confirmed that water-based exercise is efficient in decreasing serum D-dimer and NT-proBNP concentrations as well as certain indicators of vagal modulation. In improving health-dependent quality of life, both types of exercise were equally effective. Besides contributing to the growing body of evidence on the effectiveness of exercise training in coronary artery disease patients, our findings confirms that water-based exercise may be a safe and effective exercise option both for patients after a recent coronary event referred to short-term cardiac rehabilitation and as a life-long exercise modality.

• Ključne besede: coronary artery disease, water-based exercise, cardiac rehabilitation