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女性心血管疾病患者心脏康复的研究进展
中国心血管杂志, 2023,28(2) : 179-183. DOI: 10.3969/j.issn.1007-5410.2023.02.017
摘要

心脏康复作为目前女性心血管患者治疗指南的ⅠA类二级预防项目，以安全、个性化、结构化的运动康复为基础，辅以心理咨询、家庭教育、健康行为的建立以及疾病危险因素的控制，其核心组成部分包括病人评估、风险因素修正、压力管理和心理状况审查。既往研究显示女性患者入组困难，且具有较高的失访率，致使此类研究中普遍存在选择性偏移。女性心脏康复，是指内容适应女性需求和偏好的心脏康复。本研究对女性心血管疾病患者心脏康复的研究进展进行综述。

引用本文: 葛里格, 郭航, 胡博, 等.  女性心血管疾病患者心脏康复的研究进展 [J] . 中国心血管杂志, 2023, 28(2) : 179-183. DOI: 10.3969/j.issn.1007-5410.2023.02.017.
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除非特别声明，本刊刊出的所有文章不代表本刊编辑委员会的观点。

心脏康复(cardiac rehabilitation，CR)是一种标准化二级预防保健模式，以风险因素管理、结构化锻炼、患者教育和社会心理咨询为主体构成，其主要目标包括改善风险因素、提高功能储备和峰值耗氧量VO2、改善平衡和灵活性[1]。美国心脏学会(American Heart Association，AHA)指南建议将CR列为女性心血管疾病患者治疗指南ⅠA类推荐的二级预防项目[2]。现有研究结果表明，传统以康复科/中心为基础的CR可显著降低罹患心血管疾病患者的发病率、再住院率和死亡率，提高患者的生活质量，降低治疗成本[3,4,5]。数据观测显示，CR的效果具有剂量效应，即：达到一定康复时程(一般大于3个月)后，康复效果逐渐显现；随着康复时间的延长，疾病发展程度能够显著放缓，临床症状得以减轻[6,7]。CR通过刺激患者适应心血管缺血环境，提升心肌机械效能与运动耐力，延缓动脉粥样斑块的发展，防止冠状动脉血栓形成[8,9]。同时，CR还可以预防心室肌自律性过度活跃以减少心室颤动的发生，并提升骨骼肌摄取氧能力以改善外周肌力[10,11]。不仅如此，CR还可以显著提高患者的生活质量[12,13]。患者接受强化健康教育，能够提高对自身健康的认知，减少或去除心血管疾病的危险因素，增加有益于心脏健康的行为和改善药物治疗的依从性。参与运动亦可改善女性患者的更年期症状，有效减少抑郁和(或)焦虑情绪，提高患者生活质量，改善医患关系。尽管现有研究显示男性患者CR的效果优于女性患者[14,15]，但从完整参与CR的患者长期随访数据可以发现，女性患者死亡率较男性更低[16,17]。女性患者有必要及早进行安全、有效的CR[18]。目前，混合性别康复研究中存在女性患者入组困难、较高的失访率等问题，致使此类研究中普遍存在选择性偏移[19]。研究人员对造成CR利用率差异的原因展开分析，并对传统CR进行了大量改良试验[20]，以期提高女性患者的参与度。2022年6月，国际心血管预防和康复委员会(International Council of Cardiovascular Prevention and Rehabilitation，ICCPR)根据《研究和评估指南评估(AGREE II)》、医学研究所诚信标准和《医疗保健实践指南报告项目(RIGHT)》制定了首个女性CR临床实践指南[21]。指南回顾了研究人员的研究成果并总结出14条建议，指出切实落实相应措施将显著提高女性患者的生活质量，降低公共卫生资源消耗[12]。

1　心血管疾病的性别差异
1.1　生理心理学差异

从生理心理学层面上看，相较于男性，女性存在如下特点：(1)左心室相对较小，射血分数低[22]；(2)左心室舒张顺应性较低[23]；(3)肥胖人群所占比例更高[24]；(4)血红蛋白含量较低，更容易缺铁[25]；(5)对烟草更加敏感[26]；(6)可受到避孕药副作用的影响[27]；(7)抑郁症及焦虑症的发病率更高[28]；(8)冠状动脉血管弥漫性病变合并心肌梗死的发生率更高，预后较差[12]；(9)自发性冠状动脉夹层病变发生率更高[10]。

1.2　临床诊断与预后

女性患者容易出现无症状，或合并非典型心血管疾病(如射血分数保留的心力衰竭、非阻塞性冠状动脉的心肌梗死、冠状动脉夹层和血管痉挛等)症状，故漏诊发生率高[29]。起到血管保护作用的雌激素在女性绝经后分泌量会相应减少，导致胰岛素抵抗增加及血脂代谢紊乱，使中老年女性发生心血管疾病的风险明显增加[30]，伴有更多的并发症[31]。研究发现，外周血管病变所致的行走困难可能被诊断为髋关节或膝关节炎以及椎管狭窄[32]。女性患者在心血管疾病初期的漏诊和误诊导致其预后通常较差，包括高致残率、住院率及致死率[33]。并发症的存在增加CR难度，影响常规CR措施的施行[34]。有研究将峰值摄氧量等反映心肺功能的测量指标和不良预后之间的关系进行量化[35]，发现女性组患者峰值运动负荷、无氧阈运动负荷、峰值氧脉搏、峰值耗氧量VO2等均低于男性患者组，提示女性CR患者的心肺功能普遍较男性低。

1.3　以康复科/中心为基础的CR利用率的性别差异

女性患者CR转诊率较男性低(39%比49%)[19]。即使转诊至康复科后，女性患者CR的参与率仍较男性低(38.5%比45.0%)[36]，坚持完成CR的患者比例更少(64.2%比68.6%)[37]。国内有学者对各阶段阻碍女性急性冠状动脉综合征患者利用CR的原因进行了研究，归纳出医疗经费限制、运动恐慌、疼痛、交通障碍、家庭责任和缺乏适宜锻炼方式等患者自身因素，以及包括医疗服务人员相关因素和环境因素在内的外在因素[31]。需要特别指出的是，女性的运动偏好有别于男性，更关注隐私保护[38]。多数女性参与者对传统CR常规运动方式、拥挤的测试环境和体重的数据采集较为抵触运动疲劳或疼痛是阻碍女性患者参与CR的重要因素[39]。女性在运动过程中报告疼痛(如骨骼肌肉问题)和疲劳的次数更高[40]。与此同时女性心血管疾病患者可能在运动过程出现的并发症加剧了患者的抵触情绪[10]，包括合并尿失禁患者可能出现尿液渗漏，合并骨质疏松症患者可能发生意外骨折，合并糖尿病患者可能发生低血糖现象。康复方案的安全性通常是患者的关注重点。体现人文关怀的康复方案与运动过程中的实时监控与指导使患者感到安全[41]。此外某些地区的地域文化是女性心脏康复得不到保障的重要因素[39,42]。

2　女性CR

女性CR是指其内容适应女性需求和偏好的CR，又被称为以女性为重点或性别定制的CR[43,44]。纳入标准包括：(1)至少某一环节有半数以上女性参与(例如"仅限女性"的CR或设计以女性为重点的访谈环节)；(2)具有满足女性患者需求或偏好的措施(例如尊重隐私、全面的心理社会筛查和规划、教育内容和锻炼形式)；(3)给予患者充分选择权(解决女性常见的交通障碍及与照顾责任相关的时间限制)；(4)跨专业工作人员应具有CR领域深度知识(例如风险因素管理、运动处方和患有CVD的女性的心理健康方面的专业知识)，并具有与女性患者有效合作的敏感性和方法[40]。根据ICCPR提供的数据，目前共45个国家提供了总计686个女性CR项目，占提供CR的国家/地区总体的41%[20]。近十年来，以Beckie团队为代表的研究人员基于传统依赖康复科的CR进行了调整，开展了一系列女性CR研究[45,46,47,48,49,50,51]。2022年6月，ICCPR根据《研究和评估指南评估(AGREE II)》、医学研究所诚信标准和《医疗保健实践指南报告项目(RIGHT)》拟定了首份以女性为中心的CR临床实践指南[21]。草案中每项建议经ICCPR审计确定的通讯作者所组成的德尔菲小组(Delphi panel)进行了Likert评分，于专家组网络会议中审查修订，后经民意调查达成共识。该临床指南肯定了女性CR在提升生活质量和经济效益方面的作用，并指出女性CR在利用率上的效果还需要更多研究验证。

3　人员构成调整

既往参与到CR的工作人员往往以男性为主导，女性构成比例偏低[52]。以女性为重点的CR应提供具备足够数量的女性专业人员[53]，配备至少一名受心理保健专业人员以应对心血管疾病伴发的抑郁、焦虑障碍[54]。由于目前开展的仅限女性参与的CR研究较为有限，对于调整患者性别构成比例是否有助于女性心血管疾病患者利用CR服务的问题尚无定论。部分研究显示仅限女性参与的CR组患者出勤率优于混合性别组，在炎症标志物、抑郁症状、生活质量和健康观念方面较混合性别组有明显改善[46,47,48,49,50,51,55] 。另一些研究则表明参加传统混合性别CR的女性患者依从性更好[56,57,58]。

4　康复场地调整——家庭CR与远程CR

一些研究表明，女性可能需要更灵活地安排锻炼时间，家庭CR及远程CR是两种较为可行的方案[12,59]。家庭CR是以患者自身住所为康复场地的CR。由于家庭CR医疗费用不能被医疗保险所涵盖，且康复过程中的监测手段受限，使其不如传统康复科/中心康复应用广泛[60,61]。但随着COVID-19疫情影响，家庭CR有望成为CR的主流[62]。鉴于女性在参与传统以康复中心为基础的CR计划障碍较多且负担较高，推广较低成本的家庭CR可能有助于提高女性患者获取CR的机会。一项综合研究显示家庭康复对比传统CR计划完成率存在优势[63]。但是，该研究中只有19%的参与者是女性，涉及的23项研究中有4项没有女性患者参与。而另一项随机研究则显示家庭CR无法改善患者的依从性[64]。目前尚不能确定家庭CR可以缩小或消除CR参与方面的性别差距，但值得肯定的是家庭CR在减轻交通障碍负担上的积极作用。远程医疗CR是另一种传统CR的替代方法，医务人员可以通过网络视频、佩戴穿戴设施等手段指导并监测心血管患者执行康复计划，但受到技术和医疗人员数量等因素的限制，目前远程医疗CR的应用并不普遍[38]。目前有限研究表明远程CR可以增加参与者的有效参与率，并能够提高体力活动的整体水平，与传统CR带来的效益相近[65,66]。

5　模式调整

由于女性心血管疾病患者心肺功能与男性患者存在一定差异，建立独立的监测系统指导患者在确定的有氧运动强度和(或)阻抗负荷进行训练是女性CR安全有效的关键[9,35,67]。医务人员应明确并发症的预防措施并向患者说明相关不良事件的低风险性，鼓励患者充分享受运动的益处，询问并记录患者感知疲劳和疼痛程度[68]。近年来CR领域愈加关注运动形式的多样化及个体化，瑜伽、舞蹈、八段锦等新型运动模式逐渐融入康复方案，安全性与有效性被逐步证实[69,70,71,72,73] 。研究显示不同模式的CR可能有助于增加女性参与率[74]。此外，应用自动转诊评估进行CR护理CR益处的宣教以及经济上的激励措施，均可以显著提高CR的参与率与依从性[75,76,77]。

6　总结与展望

CR是一种多模式的干预，性别因素是影响康复效果的因素之一。女性CR为女性心血管疾病患者提供了更多选择，推动了个性化医疗康复的进程，充分彰显医学的人文情怀。然而，目前的女性CR有关研究尚处于起步阶段，主要存在以下问题：(1)缺乏大样本量随机对照试验；(2)大多数干预措施仅在单一环境中进行了短期测试；(3)能够获取到的长期随访数据较少，女性CR的长期收效有待观察。目前，女性CR能否有助于提高女性患者参与率及康复水平，亟待更多的临床试验来验证。

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