重症心力衰竭患者运动病理生理学特征的临床研究*

目的: 通过症状限制性极限运动心肺运动试验（CPET）,从整体整合角度研究慢性心力衰竭患者（CHF）的运动病理生理学特征。方法: 选2016年10月至2017年10月就诊于中国医学科学院阜外医院签署知情同意书后的CHF 83例,并选同期12例正常人作为对照。在严格定标、规范化操作下按照美国加州大学洛杉矶分校医学中心标准完成连续递增功率方案的症状限制性CPET,并检测运动中呼吸循环代谢等功能指标。结果: CHF病人CPET核心指标中峰值摄氧量为（14.33±2.69） ml/（min·kg）, （44.25±14.74）%pred显著低于正常对照组（29.42±5.46） ml/（min·kg）, （83.88±6.28）%pred。此外,CHF组患者的无氧阈（AT）、峰值氧脉搏、摄氧通气效率峰值平台（OUEP）、二氧化碳通气当量最小值（Lowest VE/VCO₂）、二氧化碳通气当量斜率（VE/VCO₂ Slope）均与正常对照组有显著统计学差异（P<0.01）;CHF肺功能核心指标一秒用力呼气容积（FEV₁）、用力肺活量（FVC）、一秒率（FEV₁/FVC）、肺一氧化碳弥散量（DLCO）百分预计值均显著低于正常对照组（P<0.01）。CHF组收缩压的5个功能状态均显著低于正常对照组（P<0.05）,舒张压无统计学差异,心率在无氧阈、峰值和恢复2 min时均显著低于正常对照组（P<0.01）。分钟通气量、潮气量和呼吸频率在静息和热身状态下显著高于正常对照组（P<0.05）,在运动极限时显著低于正常对照组（P<0.05）,潮气量在恢复期显著高于正常对照组（P<0.05）。摄氧量在无氧阈、峰值和恢复2 min显著高于正常对照组（P<0.01）;氧脉搏在无氧阈、峰值显著高于正常对照组（P<0.01）;脉搏氧饱和在5个功能状态均显著低于正常对照组（P<0.01）。结论: 心源性疾病导致的CHF患者整体功能下降主要源于循环受限,同时呼吸和代谢也有受限。

Clinical study on the characteristics of exercise pathophysiological in patients with severe heart failure

Objective: The cardiopulmonary function of patients with chronic heart failure (CHF) was severely limited, but the holistic integrative exercise pathophysiology is still unclear. Methods: After signed the consent form, Eighty three patients with severe CHF from October 2016 to October 2017 in Fuwai Hospital were performed Ramp incremental loading program CardioPulmonary Exercise Testing (CPET), and 12 normal subjects served as control. CPET were performed according to standard of Harbor-UCLA MC and the circulatory, respiratory and metabolic parameters during CPET were measured and analyzed. Results: Peak oxygen uptake (Peak VO₂) in CHF (14.33±2.69) ml/(min·kg), (44.25±14.74)%pred was significantly lower than control ((29.42±5.46) ml/(min·kg), (83.88±6.28)%pred). Other core parameters of CPET such as anaerobic threshold (AT), peak oxygen pulse, oxygen uptake efficiency platform (OUEP), the lowest of carbon dioxide output ventilation ratio (Lowest VE/VCO₂), and carbon dioxide output ventilation slope (VE/VCO₂ Slope) in CHF were significantly different with the control group(P<0.01). The core parameters of lung function, such as forced expiratory volume in the first second (FEV₁), forced vital capacity (FVC), FEV₁/FVC, and carbon monoxide diffusion (DLCO) were significantly decreased (P<0.01). Systolic blood pressure during all stages of CPET in CHF was significantly lower than control group (P<0.05); Heart rate at AT, peak and recovery stages were significantly lower than control (P<0.01). Minute ventilation, tidal volume and respiratory frequency at rest, warm-up were significantly higher than control (P<0.05). Tidal volume at recovery was significantly higher than control (P<0.05). VO₂ at AT, peak and recovery stages in CHF were significantly higher than control (P<0.01). Oxygen pulse at AT and peak were significantly higher than control (P<0.01). Pulse oxygen saturation during all stages of CPET in CHF were significantly lower than control (P<0.01). Conclusion: The decreased holistic functional capacity of cardiogenic CHF dominantly due to circulatory limitation, and secondly due to respiratory and metabolic limitation.