抑郁对冠心病患者生存质量和运动耐力的影响

2014-04-01 07:49倪奕王乐民沈玉芹车琳张启萍李广
心脑血管病防治 2014年1期
关键词:生存质量抑郁

倪奕+王乐民+沈玉芹+车琳+张启萍+李广鹤

[摘 要] 目的 探讨抑郁对冠心病(CHD)患者生存质量?运动耐

力的影响程度?

方法 131例CHD患者由本人独立填写完成贝克抑郁自评量表(BDI)和简明

健康测量量表(SF_36)?根据BDI评分将患者分为抑郁组(n=34)?非抑郁组(n=97)并

分别行心肺运动试验(CPET)?

结果 (1)131例CHD患者SF_36各维度均低于中国常模,除社会功能外各

维度有显著差异(P<0.01),抑郁组CHD患者SF_36各维度得分均低于非抑郁组患者,

除生理功能?生理职能外各维度有显著差异(P<0.05,或P<0.01)?(2)抑

郁组CHD患者CPET结果中峰值氧耗量(VO2peak)?无氧代谢阈值氧耗量(VO2AT)?无氧代

谢阈值负荷(LoadAT)均低于非抑郁组,分别为VO2peak:(17.3±1.7)ml·kg-

1·m

in-1比(18.6±2.9)ml·kg-1·min-1,P<0.05;VO2AT:(12.

0±1.7)ml·kg-1·min-1比(13.2±2.2)ml·kg-1·min-1

P<0.01;LoadAT:(30.7±11.4)J·s-1比(36.0±13.9)J·s-1

,P<

0.05?(3)CHD患者SF_36与运动耐力有相关性(P<0.05);SF_36各维度得分

与BDI评分有显著负相关性(P<0.05);BDI评分与CPET结果中VO2peak?VO2AT?

LoadAT有显著负相关性(P<0.05)?

结论 合并抑郁的冠心病患者生存质量和运动耐力下降,抑郁与冠心病患

者生存质量和运动耐力密切相关?

[关键词] 冠状动脉疾病;抑郁;生存质量;运动耐力;心肺运动试

中图分类号:R541.4

文献标识码:A 文章编号:1009_816X

(2014)01_0005_04

doi:10.3969/j.issn.1009_816x.2014.01.03

Effects of Depression on Quality of Life and Exercise Tolerance in Patients with

Coronary Heart Disease.

NI Yi, WANG Le_min, SHEN Yu_qin, et al. Department of cardiology, Tingyi Hos

pital, Shanghai 200065,China

[Abstract] Objective To explore effects of depression on quali

ty of life and exercise toler

ance in patients with coronary heart disease (CHD).

Methods 131 patients with C

HD completed Beck Depression Inventory (BDI) and the MOS 36_ Item Short_From Hea

lth survey(SF_36)independently. According to the scores of BDI, the patients

were divided into depression group (n=34) and non_depression group (n=97). Both

groups were given cardiopulmonary exercise testing (CPET).

Results (1) Compared with Chinese norms, the scores on all subsc

ales of SF_ 36 in 131 patients with CHD were lower, and there were sign

ificant differences on all subscales of SF_36 except that related to social func

tion (P<0.01). Furthermore, the scores on all subscales of SF_36 in depr

ession

group were lower than non_depression group, there were significant differences

on all subscales of SF_36 except those related to physical function and physi

cal role (P<0.05, or P<0.01). (2) The peak oxygen consumption (VO

2peak:), thres

hold of oxygen consumption of anaerobic metabolism (VO2AT), threshold anaerobi

c metabolism load (LoadAT) in depression group were lower than those in no

n_depression. VO2peak:(17.3±1.7)ml·kg-1·min-1 vs. (18.6

±2.9)ml·kg-1·min-1, P<0.05; VO2AT:(12.0±1.7)ml·kg

-1·min-1 vs.(13.2±2.2)ml·kg-1·min-1,P<0.01;

LoadAT:(30.7±11.4)J·s-1 vs.(36.0±13.9)J·s-1,P<0

.05.(3)

In patients with CHD, the scores of SF_36 and exercise tolerance were significan

tly correlated (P<0.05); the scores on all subscales of SF_36 measured by B

DI were significantly negatively correlated (P<

0.05); the

scores measured by BDI and VO2peak, VO2AT, LoadAT during CPET were sig

nificantly negatively correlated (P<0.05).

Conclusions Quality of life and exercise toler

ance of patients with CHD complicating depression decreased severely, and qualit

y of life and exercise tolerance closely related to depression.

[Key words] Coronary heart disease; Depression; Quality of lif

e; Exercise tolerance; Cardiopulmonary exercise test

冠状动脉粥样硬化性心脏病(coronary heart disease,CHD),简称冠心病,是一种公

认的心身疾病,其发生?发展以及预后均和心理社会因素有着密切的联系[1~3]?

国外研究

发现,冠心病患者心血管系统功能易受精神因素的影响,抑郁?焦虑等负性情绪在冠心病患

者中普遍存在[4]?其中抑郁情绪自20年前开始就被认为是冠心病独立的危险因素

,近15年

来抑郁还被认为是导致冠心病死亡的危险因素[5]?本研究初步探究抑郁情绪对冠

心病患者生存质量?运动耐力的影响,为冠心病患者系统性康复提供依据?

1 资料与方法

1.1 一般资料:研究对象为2012年12月至2013年7月,在同济医院心内科接受治

疗并进行康复的131例冠心病患者,经心肌同位素检测?超声心动图,或冠状动脉造影确诊

为冠心病?心功能NYHA分级Ⅱ~Ⅲ级?患者无智力障碍,有认知能力,语言清晰,能较好地

进行语言沟通,并排除既往

有神经精神疾病史?严重认知功能障碍及检查不合作者?小学文化程度以下患者?131例患

者中男103人,女28人;年龄40~70(57.3±7.5)岁?患者一般资料构成情况见表1?

所有患者试验前均经介绍研究流程,签订知情同意书?本研究通过同济大学附属同济医院伦

理委员会审批,伦理委员会批件文号为LL(H)_08_13,并在中国临床试验中心注册?

1.2 方法:

1.2.1 调查方法:使用自制的调查表,由本研究第一作者对被调查者实施面访?调查内

容包括患者的基本情况:姓名?性别?出生年月?文化程度?职业?婚姻?诊断?病史及

BMI等?由患者本人在安静环境下独立填写完成贝克抑郁自评量表(BDI)[6]:BDI

对每个问题做出0到3的评分?总分为0~39分?总分

≤4分,无抑郁或极轻

微;5~13分,轻度抑郁;14~20分,中度抑郁;≥21分,重度抑郁?将131例患者中BDI评

分≥5分的34例定为抑郁组,<5分的97例定为无抑郁组?两组患者均独立填写完成由美国波

士顿健康研究所研制的简明健康测量量表(SF_36)[7]:包括36个条目,分为8个维度

,分别为生理功能(PF)?生理职能(RP)?躯体疼痛(BP)?总体健康(GH)?活力(VT)?社会功

能(SF)?情感职能(RE)和精神健康(MH)?生活质量各维度分值记分方法运用累加法

,按最后分值计算原始分数,再用标准公式计算转换分数为0~100的标准分?得分越高,

生存质量越好?

1.2.2 CPET:心肺运动试验(cardiopulmonary exercise test,CPET)包括心电图负荷

试验和运动时气体代谢分析?采用的仪器包括丹麦Innovision公司生产的气体再呼吸系统?

美国通用公司生产的运动测试系统负荷Ramp10方案,患者试验开始后的每一次呼出的气体均

被气体再呼吸系统连续监测?无氧代谢阈值氧耗量(VO2AT)用V_slope方法判定?所有受

试者均能耐受心肺运动试验,无1例出现明显的不良反应?

1.3 统计学处理:采用SPSS 21.0软件进行统计分析,计量资料均以(

3 讨论

冠心病是常见的心血管系统疾病,随着人们生活水平的提高和生活方式的改变,其发病率和

病死率呈迅速上升趋势,现已成为中国居民死因增速最快的疾病[9]?冠心病具有

迁延不愈?反复发作的特征,而抑郁作为冠心病独立的危险因素,不仅与冠心病的发生?发

展有着密切的联系,还会影响冠心病的预后,降低患者的生存时间和生存质量[10]

?

Belardinelli等[11]报道118例经皮冠状动脉介入(PCI)治疗的冠心病患者进

行为期6月的运动康复?术后血管再狭窄率没有受运动康复的影响,但训练组的患者峰值耗

氧量增加26%,生活质量参数提高27%?Swardfager等[12]报道366例冠心病康复患

者中

轻度抑郁占22.3%,明显抑郁占10.4%,6.3%的患者服用抗抑郁药?与抑郁积分的相关预

测因素为低VO2peak?低年龄?女性?低最大舒张压?心绞痛和服用抗抑郁药?

VO2peak和VO2AT是运动耐力最常用的指标,VO2pea

k的下降与氧传输(心排量?血液携氧能力)?肺通气效率?组织摄氧能力?肌肉骨骼功能

有关,VO2peak的减少说明运动耐力下降?在临床试验中,由于主?客观因素,导致患

者不能或不愿执行最大运动试验量,而VO2AT?VE/VCO2等指标可以从亚极量运动试验

中得出,因此VO2peak结合VO2AT?VE/VCO2评价

运动耐力更为客观?

本研究共纳入131例冠心病患者?研究发现,冠心病患者的生存质量下降,而且抑郁组冠心

病患者生存质量较非抑郁组患者进一步下降,通过相关分析证实冠心病患者生存质量与运动

耐力密切相关?在相关分析中我们同样证实,抑郁对冠心病患者的生存质量有重要影响,本

研究与国内外相关研究的结论

一致?我们还发现抑郁组冠心病患者运动耐力低于非抑郁组患者,并且通过相关分

析证实抑郁与冠心病患者运动耐力密切相关?本研究中,冠心病患者中抑郁的发

病率为26%,明显高于正常人群中抑郁的发病率,本研究结果也与国内外其他类似研究结果

相一致?

欧美发达国家在20世纪80?90年代已经率先开展以运动疗法为核心的心脏康复,心脏康复能

够明显改善患者运动耐力?降低心血管疾病死亡率?提高患者的生活质量[13]?国

内外学者

的很多研究也证实,以运动训练?心理干预和教育督导等方式为主的心脏康复可从多种途径

有效地改善冠心病患者的抑郁?焦虑情绪,从而使患者获得最大的治疗效益[14]?

以CPET为评估方法的心脏有氧运动康复,在我国刚刚起步,运动康复对于冠心病患者的负性

情绪?生存质量?运动耐力的改善,无疑为心脏病患者生活质量的提高带来福音?

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[7]Ware JE, Snow KK, Kosinski M. SF_36Health Survey: Manu_al and Interpretat

ion Guide[M]. Boston,MA: The Health Institute, New England Medical Center,

1993:5-224.

[8]王红妹,李鲁,沈毅.中文版SF_36量表用于杭州市区居民生命质量研究[J].中华预

防医学杂志,2001,35(6):428-430.

[9]Moran A, Zhao D, Gu D, et al. The future impact of population growth and

aging on comnar3,heart disease in China:projections from the Coronary Heart Di

sease Policy Model_China[J]. BMC Public Health,2008,8:394.

[10]Dudek D, Datka W, Iwek MS, et al. The quality of life related to depres

sive symptoms in coronary artery disease patients after successful coronary angi

oplasty: one_year follow up[J]. Psychiatr Pol,2007,41(2):229-242.

[11]Belardinelli R, Paolini I, Cianci G, et al. Exercise training intervention

after coronary angioplasty: the ETICA trial[J]. J Am Coll Cardiol,2001,37(

7):1891-1900.

[12]Swardfager W, Herrmann N, Dowiati Y, et al. Relationship between cardiop

ul_monary fitness and depressive symptoms in cardiac rehabilitation patients wit

h coronary artery disease[J]. J Rehabil Med,2008,40(3):213-218.

[13]Balady GJ, Williams MA, Ades PA, et al. Core components cardiac rehabil

itation/secondary prevention progams: 2007 update: a scientific statement form

the American Heart Association Exercise, Cardiac Rehabilitation, and Preventi

on Committee, the Council on Clinical Cardiology; the Councils on Cardiovascul

ar Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, a

nd Metabolism; and the American Association of Cardiovascular and Pulmonary Reh

abilitation Circulation[J].Circulation,2007,115(20):2675-2682.

[14]马跃文,刘畅.心脏康复对于冠心病患者抑郁?焦虑情绪改善的研究进展[J].中国

康复理论与实践,2012,18(2):141-143.

2396.

[5]Nader Monirpooraa, Mohammad Ali Besharatbb, Helen Khoosficc, et al. T

he role o

f illness perception in predicting post_CHD depression in patients under CABG an

d PCI[J]. Procedia_Social and Behavioral Sciences,2012,32:74-78.

[6]张明圆.精神科评定量表手册[M].第1版.长沙:湖南科学技术出版社,1998:35-133.

[7]Ware JE, Snow KK, Kosinski M. SF_36Health Survey: Manu_al and Interpretat

ion Guide[M]. Boston,MA: The Health Institute, New England Medical Center,

1993:5-224.

[8]王红妹,李鲁,沈毅.中文版SF_36量表用于杭州市区居民生命质量研究[J].中华预

防医学杂志,2001,35(6):428-430.

[9]Moran A, Zhao D, Gu D, et al. The future impact of population growth and

aging on comnar3,heart disease in China:projections from the Coronary Heart Di

sease Policy Model_China[J]. BMC Public Health,2008,8:394.

[10]Dudek D, Datka W, Iwek MS, et al. The quality of life related to depres

sive symptoms in coronary artery disease patients after successful coronary angi

oplasty: one_year follow up[J]. Psychiatr Pol,2007,41(2):229-242.

[11]Belardinelli R, Paolini I, Cianci G, et al. Exercise training intervention

after coronary angioplasty: the ETICA trial[J]. J Am Coll Cardiol,2001,37(

7):1891-1900.

[12]Swardfager W, Herrmann N, Dowiati Y, et al. Relationship between cardiop

ul_monary fitness and depressive symptoms in cardiac rehabilitation patients wit

h coronary artery disease[J]. J Rehabil Med,2008,40(3):213-218.

[13]Balady GJ, Williams MA, Ades PA, et al. Core components cardiac rehabil

itation/secondary prevention progams: 2007 update: a scientific statement form

the American Heart Association Exercise, Cardiac Rehabilitation, and Preventi

on Committee, the Council on Clinical Cardiology; the Councils on Cardiovascul

ar Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, a

nd Metabolism; and the American Association of Cardiovascular and Pulmonary Reh

abilitation Circulation[J].Circulation,2007,115(20):2675-2682.

[14]马跃文,刘畅.心脏康复对于冠心病患者抑郁?焦虑情绪改善的研究进展[J].中国

康复理论与实践,2012,18(2):141-143.

2396.

[5]Nader Monirpooraa, Mohammad Ali Besharatbb, Helen Khoosficc, et al. T

he role o

f illness perception in predicting post_CHD depression in patients under CABG an

d PCI[J]. Procedia_Social and Behavioral Sciences,2012,32:74-78.

[6]张明圆.精神科评定量表手册[M].第1版.长沙:湖南科学技术出版社,1998:35-133.

[7]Ware JE, Snow KK, Kosinski M. SF_36Health Survey: Manu_al and Interpretat

ion Guide[M]. Boston,MA: The Health Institute, New England Medical Center,

1993:5-224.

[8]王红妹,李鲁,沈毅.中文版SF_36量表用于杭州市区居民生命质量研究[J].中华预

防医学杂志,2001,35(6):428-430.

[9]Moran A, Zhao D, Gu D, et al. The future impact of population growth and

aging on comnar3,heart disease in China:projections from the Coronary Heart Di

sease Policy Model_China[J]. BMC Public Health,2008,8:394.

[10]Dudek D, Datka W, Iwek MS, et al. The quality of life related to depres

sive symptoms in coronary artery disease patients after successful coronary angi

oplasty: one_year follow up[J]. Psychiatr Pol,2007,41(2):229-242.

[11]Belardinelli R, Paolini I, Cianci G, et al. Exercise training intervention

after coronary angioplasty: the ETICA trial[J]. J Am Coll Cardiol,2001,37(

7):1891-1900.

[12]Swardfager W, Herrmann N, Dowiati Y, et al. Relationship between cardiop

ul_monary fitness and depressive symptoms in cardiac rehabilitation patients wit

h coronary artery disease[J]. J Rehabil Med,2008,40(3):213-218.

[13]Balady GJ, Williams MA, Ades PA, et al. Core components cardiac rehabil

itation/secondary prevention progams: 2007 update: a scientific statement form

the American Heart Association Exercise, Cardiac Rehabilitation, and Preventi

on Committee, the Council on Clinical Cardiology; the Councils on Cardiovascul

ar Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, a

nd Metabolism; and the American Association of Cardiovascular and Pulmonary Reh

abilitation Circulation[J].Circulation,2007,115(20):2675-2682.

[14]马跃文,刘畅.心脏康复对于冠心病患者抑郁?焦虑情绪改善的研究进展[J].中国

康复理论与实践,2012,18(2):141-143.

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