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The impact of comprehensive cardiac rehabilitation on diastolic dysfunction and the functional status of patients treated with percutaneous coronary intervention after acute coronary event

dc.contributor.advisorDodić, Slobodan
dc.contributor.otherSrdanović, Ilija
dc.contributor.otherPopović, Dejana
dc.contributor.otherPeršić, Viktor
dc.contributor.otherStojšić-Milosavljević, Anastazija
dc.contributor.otherJung, Robert
dc.creatorBjelobrk, Marija
dc.date.accessioned2019-05-30T11:17:20Z
dc.date.available2019-05-30T11:17:20Z
dc.date.available2020-07-03T13:24:26Z
dc.date.issued2019-05-10
dc.identifier.urihttps://www.cris.uns.ac.rs/DownloadFileServlet/Disertacija154719835825296.pdf?controlNumber=(BISIS)110082&fileName=154719835825296.pdf&id=12505&source=NaRDuS&language=srsr
dc.identifier.urihttp://nardus.mpn.gov.rs/handle/123456789/11098
dc.identifier.urihttps://www.cris.uns.ac.rs/record.jsf?recordId=110082&source=NaRDuS&language=srsr
dc.identifier.urihttps://www.cris.uns.ac.rs/DownloadFileServlet/IzvestajKomisije154719836633255.pdf?controlNumber=(BISIS)110082&fileName=154719836633255.pdf&id=12506&source=NaRDuS&language=srsr
dc.description.abstractUvod: U savremenom svetu koronarna arterijska bolest srca (KABS) je vodeći uzrok obolevanja i umiranja, a akutni koronarni sindrom (AKS) je jedna od njenih najčešćih i najopasnijih kliničkih manifestacija. Dijastolna disfunckija leve komore često prati KABS i mogući je doprinosni faktor za loš klinički tok i ishod. Postavlja se pitanje u kom obimu je dijastolna disfunkcija leve komore udružena sa koronarnom arterijskom bolešću i da li savremeni programi ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR) imaju uticaja na bolju prognozu ove grupe kardioloških bolesnika. Uprkos širokoj primeni revaskularizacionih procedura u svakodnevnoj kardiološkoj praksi i brojnih studija koje su ukazale na pozitivne efekte programa SKR na funkcionalni status pacijenata nakon AKS, još uvek postoji mnogo kontroverzi o efektima fizičkog treninga, na srčanu funkciju i poboljšanje funkcionalnog kapaciteta kod pacijenata sa KABS i pridruženom dijastolnom disfunkcijom. Cilj istraživanja: bio je da ispita uticaj superviziranih vežbi fizičkim opterećenjem (VFO) u okviru programa ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR), na dijastolnu disfunkciju leve komore (DDLK) i funkcionalni status pacijenata (FS), nakon AKS, rešenog perkutanom koronarnom intervencijom (PCI), kao i da li, s druge strane, prisustvo i stepen dijastolne disfunkcije na početku istraživanja, utiče na funkcionalni status i pojavu neželjenih kardijalnih događaja, kod ove grupe pacijenata u okviru programa ASKR i van njega  Materijal i metode: Istraživanjem je bilo obuhvaćeno ukupno 85 ispitanika, oba pola, starosti od 18-65 godina, koji su tokom indeksne hospitalizacije lečeni kao klinički dokazani AKS (APNS; NSTEMI; STEMI) i kod kojih je urađena neka od interventnih koronarnih procedura (pPCI; PCI; PTCA). Nakon 4 nedelje od otpusta sa hospitalizacije, zbog NSTEMI ili APNS, odnosno nakon 6 nedelja od otpusta sa hospitalizacije zbog STEMI, pacijenti sa EFLK ≥ 45%, bez značajnih valvularnih i drugih mana i sa nekim od poremećaja dijastolne funkcije, bili su kandidati za učešće u istraživanju. Svi ispitanici su podvrgavani „ulaznom“ehokardiografskom pregledu (EHO) u cilju procene sistolne funkcije i stepena dijastolne disfunkcije leve komore, kao i „ulaznom“ spiroergometrijskom testu (CPET) u cilju procene funkcionalnog statusa, na osnovu kojeg je vršena preskripcija vežbi fizičkim opterećenjem (VFO) u okviru programa ASKR. Program ASKR odvijao se u ukupnom trajanju od 12 nedelja, odnosno 36 pojedinačnih sesija VFO, 3 puta nedeljno u trajanju od po 30 minuta. Kontrolna grupa obuhvatila je grupu pacijenata koja nije živela u blizini IKVBV i koja nije bila u mogućnosti da dolazi redovno na VFO u sklopu ASKR. Njima je bilo pušteno na volju da na osnovu urađenog EHO pregleda i CPET, određuju stepen VFO po sopstvenom nahođenju, uz primenu optimalnog medikamentnog lečenja i ostalih mera sekundarne prevencije. Nakon 3 meseca obe grupe pacijenata bile su podrvrgnute novom –“izlaznom” ehokardiografskom i CPET pregledu u cilju komparacije sa rezultatima na početku istraživanja. Rezultati:Istraživanje je pokazalo da nakon 3 meseca superviziranog treninga VFO, u okviru programa ASKR, kod bolesnika nakon AKS, lečenih perkutanom koronarnom intervencijom, dolazi do poboljšanja stepena dijastolne disfunkcije leve komore, naročito kroz promene vrednosti ehokardiografskih parametara e’l i E/e’ l. U kontrolnoj grupi e’l se smanjio za (0,003 ± 0,025), a u osnovnoj se povećao za (0,011 ± 0,021). U kontrolnoj grupi e’l se nije značajno promenio (p = 0,515), a u osnovnoj grupi se značajno povećao (p < 0,0005). Na početku istraživanja u osnovnoj grupi e’l je bio (0,097 ± 0,027 m/sec), a na kraju (0,108 ± 0,031 m/sec). E/e’l se nije značajno promenio u kontrolnoj grupi (p = 0,226), a u osnovnoj grupi se značajno smanjio (p = 0,002). Na početku istraživanja u osnovnoj grupi E/e’l je bio (8,02 ± 2,98), a na kraju (6,97 ± 2,17). Takođe je utvrđeno da nakon 3 meseca superviziranog treninga u okviru programa ASKR, dolazi do poboljšanja funkcionalnog kapaciteta pacijenata sa KABS i dijastolnom disfunkcijom leve komore, kroz povećanje CPET parametara: peak VO2, VO2 predict i METs. U kontrolnoj grupi peak VO2 se smanjio za (1,79 ± 3,84), a u osnovnoj se povećao za (1,67 ± 4,29). U kontrolnoj grupi peak VO2 se značajno smanjio (p = 0,018), a u osnovnoj grupi se značajno povećao (p = 0,005).Na početku istraživanja u kontrolnoj grupi srednja vrednost peak VO2 iznosila je (23,01 ± 3,99 ml/kgTT/min), a u osnovnoj grupi je iznosila (23,15 ± 4,99 ml/kgTT/min). Na kraju istraživanja u osnovnoj grupi srednja vrednost peak VO2 iznosila (24,82 ± 5,77 ml/kgTT/min), dok je kod kontrolne grupe iznosila (21,21 ± 4,05 ml/kgTT/min). U kontrolnoj grupi ppVO2(%) se smanjio za (5,28 ± 14,39), a u ispitivanoj se povećao za (7,16 ± 18,51). U kontrolnoj grupi ppVO2(%) se nije značajno promenio (p = 0,058), dok se u osnovnoj grupi statistički značajno povećao (p = 0,005). Razlika srednjih vrednosti promena METs između osnovne i kontrolne grupe je bila statistički značajna (p < 0,0005). U kontrolnoj grupi METs se smanjio za (0,55 ± 1,12), a u osnovnoj se povećao za (0,58 ± 1,12). U kontrolnoj grupi METs se značajno smanjio (p = 0,013), a u osnovnoj grupi se značajno povećao (p < 0,0005). Zaključak: Program ambulantne sveobuhvatne kardijalne rehabilitacije, kod bolesnika nakon akutnog koronarnog sindroma, lečenih perkutanom koronarnom intervencijom, utiče na poboljšanje faktora rizika kardiovaskularnih bolesti, značajno utiče na poboljšanje stepena dijastolne disfunkcije leve komore i na poboljšanje funkcionalnog statusa pacijenata, u odnosu na početak istraživanja.sr
dc.description.abstractBackground: In modern world, coronary artery disease (CAD) is one of the leading cause of morbidity and mortality, and acute coronary syndrome (ACS) is one of its most common and most dangerous clinical manifestations. Left ventricle diastolic dysfunction (LVDD) is often associated with CAD and is possibly a contributing factor for poor clinical course and outcome. The question arises as to the extent to which the left ventricle diastolic dysfunction is associated with CAD and whether modern ambulatory comprehensive cardiac rehabilitation programs (ACCR) have an impact on a better prognosis of this group of cardiac patients. Despite the wide use of revascularization procedures in everyday clinical practice and numerous trials that have indicated the positive effects of the ACCR on the functional status of patients after ACS, there is still much controversy about the effects of physical training, and its impact on cardiac function and the improvement of functional capacity in patients with CAD and associated diastolic dysfunction. Objective: to examine the influence of supervised physical training programe as a part of ambulatory comprehensive cardiac rehabilitation (ACCR), on diastolic dysfunction and the functional capacity of patients after ACS resolved by percutaneous coronary intervention (PCI), and whether, on the other hand, the presence and the degree of diastolic dysfunction at the beginning of the study, affects the functional capacity and occurrence of unwanted cardiac events (MACE), in this group of patients within the ACCR program and without it. Methods: The study include a total of 85 subjects, both sexes, ages 18-65, who were treated as clinically proven ACS during the index hospitalization and in which some of the interventional coronary procedures were performed (pPCI; PCI; PTCA). After 4 weeks of hospitalization due to NSTEMI or APNS, or after 6 weeks of hospitalization due to STEMI, patients with LVEF ≥ 45%, without significant valvular and other disorders and with some degree of lef ventricle diastolic dysfunction, were candidates for participation in the study. All patients were subjected to an initial, “entrance”, echocardiographic examination (ECHO) in order to evaluate the left ventricle systolic function and the degree of diastolic dysfunction, as well as the initial, “entrance”, spiroergometry test (CPET) in orther to asses the functional capacity. The ACCR program include a total duration of 12 weeks, or 36 individual exercise training sessions, 3 times a week, with the duration of 30 minutes. The control group included a group of patients who did not live near ICVDV and who was not able to come regularly to the exercise training sessions as a part of ACCR. They determine the degree of exercise trainig on their own will after they performed initial EHO and the CPET examination, using the optimal medical treatment and other secondary prevention measures. After 3 months, both groups of patients were subjected to a new, "exit", ECHO and CPET examinations in order to compare with the results at the start of the study. Results: The study showed that after 3 months of supervised exercise training program, as a part of the ACCR, in patients following ACS treated with percutaneous coronary intervention, there is an improvement in the degree of left ventricular diastolic dysfunction, especially through changes in the echocardiographic parameters e'l and E / e 'l . In the control group e'l decreased by (0,003 ± 0,025), and in the base group it increased by (0,011 ± 0,021). In the control group, e'l did not change significantly (p = 0,515), while in the base group significantly increased (p <0,0005). At the beginning of the study in the base group e'l was (0,097 ± 0,027 m/sec), and at the end (0,108 ± 0,031 m/sec). E / e'l did not change significantly in the control group (p = 0,226), and in the base group significantly decreased (p = 0,002). At the beginning of the study in the base group E / e'l was (8,02 ± 2,98), and at the end (6,97 ± 2,17). It has also been established that after 3 months of supervised training within the ACCR program, the functional capacity of patients with CAD and left ventricular diastolic dysfunction is improved, by increasing in peak VO2, VO2 predict and METs. In the control group, peak VO2 decreased by (1,79 ± 3,84), and in the base group it increased by (1,67 ± 4,29). In the control group, peak VO2 decreased significantly (p = 0,018) and significantly increased in the base group (p = 0,005). At the start of the study in the control group, the mean peak VO2 was (23,01 ± 3,99 ml/ kgTT / min), and in the base group it was (23,15 ± 4,99 ml / kgTT / min). At the end of the study in the base group, the mean peak VO2 was (24,82 ± 5,77 ml/ kgTT / min), while the control group was (21,21 ± 4,05 ml / kgTT / min). In the control group ppVO2 (%) it decreased by (5,28 ± 14,39), and in the examined it increased by (7,16 ± 18,51). The control group ppVO2 (%) did not significantly change (p = 0,058), while in the base group it increased significantly (p = 0,005). The difference in mean values of MET changes between base and control group was statistically significant (p <0,0005). In the control group METs decreased by (0,55 ± 1,12), and in the base group it increased by (0,58 ± 1,12). METs significantly decreased in the control group (p = 0,013), while in the base group significantly increased (p <0,0005). Conclusions: The program of ambulatory comprehensive cardiac rehabilitation in patients following acute coronary syndrome, treated with percutaneous coronary intervention, has an positive effect on the improvement of the risk factors for cardiovascular diseases, significantly influencing the improvement of the degree of left ventricle diastolic dysfunction and the improvement of the functional capacity of patients.en
dc.languagesr (latin script)
dc.publisherУниверзитет у Новом Саду, Медицински факултетsr
dc.rightsopenAccessen
dc.sourceУниверзитет у Новом Садуsr
dc.subjectakutni koronarni sindromsr
dc.subjectAcute Coronary Syndromeen
dc.subjectLeften
dc.subjectCoronary Artery Diseaseen
dc.subjectVentricular Dysfunctionen
dc.subjectCardiac Rehabilitationen
dc.subjectRisk Factorsen
dc.subjectTreatment Outcomeen
dc.subjectkoronarna arterijska bolestsr
dc.subjectdisfunkcija leve komoresr
dc.subjectkardijalna rehabilitacijasr
dc.subjectfaktori rizikasr
dc.subjectishod terapijesr
dc.titleUticaj sveobuhvatne kardijalne rehabilitacije na dijastolnu disfunkciju i funkcionalni status pacijenata lečenih perkutanom koronarnom intervencijom nakon akutnog koronarnog događajasr
dc.title.alternativeThe impact of comprehensive cardiac rehabilitation on diastolic dysfunction and the functional status of patients treated with percutaneous coronary intervention after acute coronary eventen
dc.typedoctoralThesissr
dc.rights.licenseBY-NC
dc.identifier.fulltexthttp://nardus.mpn.gov.rs/bitstream/id/34041/IzvestajKomisije.pdf
dc.identifier.fulltexthttp://nardus.mpn.gov.rs/bitstream/id/34040/Disertacija.pdf


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