心血管康复的特色技术-体外反搏介绍.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,心血管康复的特色技术：体外反搏,卫生部辅助循环重点实验室,A Novel Modality of Cardiovascular Rehabilitation:Enhanced External Counterpulsation,2,伍贵富,美国哈佛大学医学院博士后、博士生,导师,中山大学第一附属医院心内科教授,深圳市福田区人民医院 院长,中国体外反搏专业委员会副主任委员,卫生部辅助循环重点实验室主任,国际体外反搏领域核心专家之一,“国际体外反搏项目工作组”中国区总,负责人,2010-2030,中国,CVD,事件将发生警报性增长（,50%,),WHO,疾病负担项目,Circulation.2011;124:314-323.,Circulation.2011;124:278-279.,中国心脑血管病防治面临挑战更为严峻！,脑卒中死亡率,冠心病死亡率,4,体外反搏技术的概念与发展,心脏康复与体外反搏,血管康复与体外反搏,体外反搏技术的未来发展,主要内容,5,体外反搏是如何工作的？,D/S,比值,1.2,执行机构,电池阀（,开,/,关,）,管道（气体传输）,主机系统,D,S,囊套（充气,/,排气）,效果监测,信息反馈,D/S,比值,心电图,调节气泵压力,增强型体外反搏工作原理,Enhanced External Counterpulsation,EECP,7,美国：,1960,年代,研制成功,液压驱动,的体外反搏装置（未推广普及）,体外反搏概念的提出与技术发展,中国：中山大学领衔的课题组,1970,年代,研制成功,气动式四肢序贯式,体外反搏装置并在国内推广应用（,ECP,）,中国：,1980,年代,研制成功增强型体外反搏装置并在国内推广应用（,EECP,）,时 间,体外反搏发展的重要事件,1980,年代初,增强型体外反搏装置（,EECP,）诞生并进入临床应用,1990,年代初,EECP,装置获美国,FDA,批准，进入美国并经此进入世界其他国家和地区,1995-1997,年,美国第一个体外反搏,RCT,（,MUST-EECP,）：哈佛大学、耶鲁大学、哥伦比亚大学、纽约州立大学及加州州立大学等联合攻关,1998,年,第一个,“,国际,EECP,病人登记中心（,IEPR,）,”,（美国匹兹堡大学）,2002,年,美国,ACC/AHA,冠心病稳定型心绞痛治疗指南,2006,年,欧洲心脏病协会（,ESC,）冠心病心绞痛治疗指南,中华医学会心血管病分会冠心病心绞痛治疗指南,2009,年,在中国老年学会的支持下，中国体外反搏专业委员会,(EAC),成立,各国指南对体外反搏的推荐,10,国外媒体给予体外反搏积极和正面的报道,Bypassing the surgeon(,不需要外科的,“,心脏搭桥,”,！,),11,中东地区于,2001,年初开始引进体外反搏疗法,12,体外反搏技术的概念与发展,心脏康复与体外反搏,血管康复与体外反搏,体外反搏技术的未来发展,主要内容,13,增强型体外反搏工作原理,Enhanced External Counterpulsation,EECP,增加心输出量,Duplex echocardiography Descending Aorta,Lawson,Hui:J of Critical Illness 2000;5:629-636,Control,EECP,降低收缩期阻力负荷,舒张期主动脉根部血流增加,增加,CO,增加静脉回心血流,增加心室舒张期充盈,收缩期,舒张期,降低收缩期阻力负荷,增加冠脉血流,体外反搏对心脏血流的影响,15,Bhavananda T.Reddy,Andrew D.Michaels,Journal of Geriatric Cardiology 2010;7(2):67,体外反搏与,IABP,比较的血流动力学差异,舒张压,主动脉平均压,收缩压,冠脉平均流速,舒张期冠脉流速,Health Volunteer,Atherosclerotic,10,20,30,10,20,0,Change of blood velocity(%),收缩期流速,舒张期,平均流速,-6.0%,-19.3%*,9.6%,13.7%*,3.2%,23.6%*,*p0.05,*p0.01,体外反搏对其它重要脏器的影响,-,眼底动脉血流,Werner D,et al:Graefes Arch Clin Exp Ophthalmol.239:599-6-2,健康志愿者,动脉粥样硬化,颈动脉,(n=35),肾动脉,(n=18),Applebaum RM,et al:Am Heart J 1997;133:611-5.,10,20,30,0,22%,19%,p=0.001,(%),p=0.0001,血流速度积分变化率,20,40,60,0,56,40,(cm/sec),舒张期平均流速,体外反搏对其它重要脏器的影响,-,颈动脉、肾动脉,1990,年,1991,年,1992,年,2,年内,7,次,PCI,2,次搭桥手术,病例介绍,Nat Clin Pract Cardiovasc Med 2006;3(11):623-32,Change in Angina Functional Class from IEPR-1,Baseline CCS anginal Class Distribution,1-year CCS anginal Class Distribution,86%in Class III/IV,25%in Class III/IV,27,19,30,19,6,0,10,20,30,40,50,60,No,Angina,I,II,III,IV,%of patients in each CCS Class,76%maintained at least 1 CCS class improvement,0,10,20,30,40,50,60,I,II,III,IV,%of patients in each CCS Class,N=4,565,29.7,18.4,27.8,17.9,6.2,0,10,20,30,40,50,60,No,angina,I,II,III,IV,2-year CCS anginal Class Distribution,24%in Class III/IV,Am Journal of Cardiol 2004;93:461-464,3-year CCS anginal Class Distribution,0,10,20,30,40,50,60,No Angina,I,II,III,IV,21%in Class III/IV,5%,16%,24.8%,19.3%,34.9%,Clin.Cardiol 2008;31,4:159-164,Changes in patients with Left Ventricular Dysfunction,With diabetes mellitus(DM,n=36)versus non-diabetes(Non-DM,n=27),6-minute Walk,NYHA Classification,2.7,1.1,2.9,1.3,p0.001,p0.001,p0.001,p0.001,Increase 37%,Increase 30%,No significant difference in the increase in both group,Pre-EECP,Post-EECP,747,873,1,025,1,137,(ft),AHA 2008,Changes in patients with Left Ventricular Dysfunction,With diabetes mellitus(DM,n=36)versus non-diabetes(Non-DM,n=27),Cardiac,Output,3.1,3.9,3.3,4.1,p0.001,p0.001,Pre-EECP,Post-EECP,0,5,10,15,20,25,30,35,40,DM,Non-DM,Ejection Fraction,p0.001,p0.001,Increase 21%,Increase 20%,No significant difference in the increase in both group,29.8,29.9,36.2,35.9,(%),(l/min),Increase 25%,Increase 22%,No significant difference in the increase in both group,AHA 2008,Cost effectiveness,Potential Cost Savings Scenario,#HF pts,Total#Hospital Visits,Average Cost per Hospital Visit,Total Cost to Healthcare System/1,000 pts,Before ECP,1,000,3,000*,$5,456,$16,368,000,After ECP,1,000,500*,$5,456,$2,728,000,Reduction in hospitalization costs after treated with ECP,$13,640,000,Cost to treat with ECP,$3,640,000,Annual savings to healthcare,$10,000,000,Saving per patient,$10,000,*Average#of hospital visits before ECP over 12 months is 3.6,*Average#of hospital visits after ECP over 12 months is 0.5,(Reduction in average cost of hospitalizations),EECP,reduced,ER Visits&Hospitalizations in Patients with LVD,Hospitalizations,CHF 2007;13:36-40,0,0.2,0.4,0.6,0.8,1,1.2,1.4,86%,83%,6-months,Pre-EECP,6-months,Post-EECP,p0.001,p0.001,ER Visits,6-months,Pre-EECP,6-months,Post-EECP,3.5,3.0,2.5,2.0,1.5,1.0,0.5,0,体外反搏技术的概念与发展,心脏康复与体外反搏,血管康复与体外反搏,体外反搏技术的未来发展,主要内容,24,Evolution of Cardiovascular Diseases,Risk Factors,Hypertension,Atherogenic Dyslipidemia,Diabetes Mellitus,Abdominal Obesity,Prothrombotic state,Proinflammatory state,Genetics,Ethnic Predisposition,Aging,Hormonal imbalance,Physical inactivity,Smoking,Common Factors,Exercise capacity,Arterial wall thickening,Vascular Stiffness Atherosclerosis,LV-contractility,LV-relaxation,Endothelial Dysfunction,Inflammation,Catabolism,Atrophy,Early fatigue,Skeletal Muscle Dysfunction,Ventilatory Abnormalities,Neurohormonal activation,Renal,Single organ dysfunction,Angina,Heart Attack,Stroke,Silent Ischemia,Multiple organs dysfunction,Heart failure,Renal Failure,Cerebral,Pulmonary,Disease Progression,Complex factors that determine the rate of progression from risk to organ failure,Linking risk factors to cardiovascular disease is endothelial dysfunction,血流切应力与血管内皮保护,生理状态的切应力,低切应力状态,低血流切应力和湍流区域,是动脉粥样硬化斑块高发区域,血流切应力与冠心病的临床联系,Zhang Y,et al:,Circulation 2007,116:526-34,流 速,切应力,体外反搏对猪颈总动脉内的血液流速和切应力变化,30,体外反搏治疗对实验性动脉粥样硬化猪冠脉内膜的影响,Zhang Y,et al:Circulation 2007,116:526-34,Confidential,x400,x40,正常组,动脉硬化组,动脉硬化组体外反搏,体外反搏保护血管内膜促进,冠状动脉,血管重构,HE,染色,弹力纤微染色,Zhang Y,et al:Circulation 2007,116:526-34,32,体外反搏降低冠脉前降支,CRP,和补体,C3a,表达,Zhang Y,et al:ATVB 2010,Cardiology 2008;110:160-166,Circulating Endothelial Progenitor Cells(,C,EPC),in patients with Angina Pectoris,Baseline,Post-treatment,Assessed by flow activated cell sorter,per 10,5,peripheral blood mononuclear cells,Number of CD34+/KDR+Cells,p=0.430,p=0.049,p=0.557,p=0.010,CEPC Colony Forming Unit,per well,Arterial Stiffness and Myocardial Oxygen Demand,Results of a randomized sham control study,Am J Cardiol 2011;107(10):1466-1472,Aortic Augmentation Index(Alx),Change in Alx (%),*p0.01,p0.05,p0.05,*,*,*,Wasted Left Ventricular Energy,Ew(dynes cm,2,sec),p0.05,p0.05,EECP,(N=28),Sham Control(N=14),Pulse-Wave Velocity,Carotid Femoral,Carotid-Femoral(m/sec),*p0.05,p0.05,p0.05,*,*,Changes in Exercise Capacity,Results of a randomized sham control study,Am J Cardiol 2011;107(10):1466-1472,EECP(N=28),Sham Control(N=14),Exercise Time,Treadmill Exercise Time(sec),*p0.05,p0.001,p0.01,*,*,*,Modified Naughton protocol,Peak Time to Angina,Peak Time to Angina(sec),*,p0.05,p0.001,p0.01,*,*,*,Peak Oxygen Uptake,Peak Oxygen Uptake(ml/kg/min),*p0.05,p0.001,p0.01,*,*,*,EECP improves endothelial function,A randomized sham-controlled study,Braith:Circulation 2010;122:1612-1620,Effects on Vasomotor,Flow-Mediated Dilation:Brachial Artery,Percent Change(%),p0.01,Sham N=14,EECP N=28,Pre-EECP,Post-EECP,2%,51%,Percent Change(%),Flow-Mediated Dilation:Femoral Artery,p0.01,3%,30%,Change in Plasma NOx,p0.01,mol/L,2%,36%,Change in Prostaglandin 6-keto-PGF,1,p0.01,pg/mL,1%,71%,Change in Endothelin-1,p0.01,pg/mL,5%,25%,EECP improves endothelial function,A randomized sham-controlled study,Braith:Circulation 2010;122:1612-1620,Inflammatory Cytokines and Adhesion Molecules,Tumor Necrosis Factor-,Sham N=14,EECP N=28,Pre-EECP,Post-EECP,Soluble Vascular Cell Adhesion Molecule,p0.01,1%,6%,*,ng/mL,High-sensitivity C-reactive Protein,p0.01,5%,32%,*,mg/L,p0.01,12%,16%,*,pg/mL,Monocyte chemoattractant Protein-1,p0.01,0.2%,13%,pg/mL,*,EECP improves endothelial function,A randomized sham-controlled study,Pre-EECP,Post-EECP,Sham N=14,EECP N=28,Braith:Circulation 2010;122:1612-1620,Functional and Exercise Capacity,CCS Functional Class,p0.001,*,Angina Episodes per day,p0.01,*,Daily Nitrate Usage,p0.01,*,1.0,1.0,0.9,0.2,Peak Time to angina,p0.01,*,sec,406,449,471,645,p0.001,Peak Exercise Duration,*,sec,Peak Oxygen Consumption,p0.001,*,mL/kg/minute,体外反搏研究：逐步占领学术的至高点,（心血管领域）,Michaels AD,et al:,Circulation 2002;106;1237-1242;,通过,有创检查,证实体外反搏的即时血流动力学效果,Zhang Y,et al:Circulation 2007;116;526-534;,通过,慢性动物试验,论证体外反搏保护血管内皮,Braith RW,et al:,Circulation.2010;122:1612-16.,通过,临床随机研究,论证体外反搏通过抑制炎症因子保护血管内皮,Yang DY,WU GF.Int J Cardiol.2012 May 3.Epub ahead of print,全面,综述,体外反搏机制研究的国内外进展，重点阐述体外反搏的细胞与分子机制与动脉粥样硬化病变的关系,Martin JS,et al:Appl Physiol.2012;112(5):868-76,目的：研究体外反搏对糖耐量异常患者动脉血管功能、糖耐量和肌肉形态组织学研究,治疗方案：,7 wks(35 1-h sessions)EECP,或标准疗法,结 果：,FMD,肱动脉 增加,27%,腘动脉增加,52%,空腹血糖下降,16.9 5.4 mg/dl,，,2,小时血糖下降,28.3 7.3 mg/dl,胰岛素抵抗降低,31%,股外侧肌活检：毛细血管密度增加,结 论：,体外反搏治疗可以改善糖耐量异常患者的血糖耐量和外周动脉血管的功能,体外反搏与糖尿病治疗,Stroke.2012;43:00-00,DOI:10.1161/STROKEAHA.112.659144,Stroke 2008;39;1340-1343;,Conclusion,EECP provides a new method of cerebral blood flow augmentation in ischemic stroke by elevation of blood pressure.Flow augmentation induced by ECP suggests the improvement of cerebral perfusion and collateral supply from infarct ipsilateral and contralateral sides,体外反搏与,脑血管病防治,AS,进展期,斑块破裂,破裂斑块修复,体外反搏,-,从动脉粥样硬化病变的早期开始介入,Peter Libby,Circulation 2001;104;365-372,斑块形成,体外反搏,47,血管内皮,切应力,“,血管内皮”：体外反搏作用的新靶点,中国专家的观点,加速动脉血流速度，提高血管内皮的血流切应力刺激,改善血管内皮功能，促进内皮修复,抑制内膜增生,抑制动脉粥样硬化病变及相关基因表达,Circulation,2007,116:526-534,ATVB,2010;30(4):773-780.,AJP-Heart Circ Physiol.,2006;290(1):H248-54,Am J Cardiol.,2006;98:28-30.,Chin Med J(Engl).,2009;122(10):1188-94.,Circulation.,2010;122:1612-20,JACC,2003,41:1761-1768.,JACC,2006,48:1208-1214,Am J Cardiol.,2006;98:28-30.,Cardiology,2008,110:160-166.,体外反搏,血流速度,动脉粥样硬化,冠心病,国际同行的论证,体外反搏与血管康复：从血管内皮保护开始,48,冠心病、心绞痛的治疗,Guidelines:AHA/ACC(2002),ESC(2006),中国冠心病指南（,2006,）,慢性脑血管疾病的康复,Han JH,et al:Stroke 2008;39:1340,冠心病高危人群预防（血糖、血脂、血压、吸烟等）,Barsheshet A,et al:Cardiology,2008,110:160-166.,Nichols WW,et al:J Am Coll Cardiol,2006,48:1208-1214.,Zhang Y,et al:Circulation,2007,116:526-534,Zhang Y,et al:Arterioscl Thromb Vasc Biol.2010;30(4):773-780,亚健康人群,McCullough PA,et al:Am Heart J 2006;151(1):139,体外反搏的临床应用范围和目标人群,体外反搏的目标人群,残留心肌缺血,1.,心绞痛，伴或不伴左室功能障碍,2.,静息性心肌缺血,药物疗效差的心绞痛,不适合接受,PCI/CABG,者,血管重建术后（,PCI/CABG,）,代偿性心力衰竭？,其它：缺血性脑卒中，突发性耳聋,心血管疾病康复与亚健康状态等,体外反搏技术的概念与发展,心脏康复与体外反搏,血管康复与体外反搏,体外反搏技术的未来发展,主要内容,51,2009-7,重庆,2011,中国心血管病临床指南与专家共识,-,人民卫生出版社,两次国际体外反搏学术交流会均在中国成功举办,54,血管介入,外科搭桥,综合治疗,+,体外反搏,56,体外反搏技术应用与发展三步曲,慢性血管病防治和康复的新选择！,谢谢！,体外反搏,