Rev Bras Fisiol Exerc 2020;19(1):65-74
10.33233/rbfe.v19i1.3986
CASE
REPORT
Cardiovascular
rehabilitation in discrete coronaropathy with reduction of functional capacity
1ACTUS CORDIOS
Cardiovascular, Respiratory and Musculoskeletal Rehabilitation, Salvador/BA,
Brazil, 2Specialization in Exercise Physiology, Centro Oeste Paulista College, Bauru/SP, Brazil, 3Bahia
Adventist College, Cachoeira/BA, Brazil, 4Bahiana
School of Medicine and Public Health, Salvador/BA, Brazil, 5Social
College of Bahia, Salvador, BA, Brazil
Correspondent author: Daniela Santos de
Jesus, Av. Anita Garibaldi, 1518 Ondina 40170-130 Salvador BA Brazil
Daniela Santos de Jesus:
daniela.reabilitacao@gmail.com
Jackeline Barbosa
Matias: jackmoreir25@gmail.com
Milena Cipriano Santos:
milenacipriano5@gmail.com
Lucas Mendes Santa
Cecília: lucas94.mendes@gmail.com
Marvyn de Santana do
Sacramento: marvynsantana@gmail.com
José Francisco dos
Santos: jfdossantos64@hotmail.com
Jefferson
Petto: gfpecba@bol.com.br
Abstract
Introduction: Pharmacological treatment to control the triggering factors of
coronary artery disease (CAD) is the initial front line. However, an adjuvant
option to pharmacological treatment is Cardiovascular Rehabilitation (CR).
Therefore, the aim of this study is to show the results of CR in improving the
quality of life and functionality of a patient with mild coronary artery
disease. Case description: Male, 52 years old, sedentary, former smoker
for 12 years, with clinical diagnosis of mild CAD, arrhythmia, systemic
arterial hypertension and dyslipidemia. The patient enters CR in August of
2017, complaining of shortness of breath, fatigue, difficulty climbing and
descending stairs, limitations to perform daily life and work activities. Results:
Decreased blood pressure 140/90 vs. 110/70 mmHg, increased VO2max 32
vs. 52 ml/kg.min, improved left ventricular ejection
fraction 50 vs. 68%, decreased concentric hypertrophy with LV posterior wall
diastolic thickness and 12 vs. 9 mm interventricular septum and left
ventricular mass reduction 299 vs. 213 g. He gets a
87% improvement in quality of life assessed by the Minnesota 72 vs. 9 points,
plus decrease and withdrawal of drugs. Conclusion: An individualized
Cardiovascular Rehabilitation program seems to promote improvement of quality
of life, functionality and clinical aspects of patients with mild coronary
artery disease.
Keywords: coronary obstruction; surgery; cardiac rehabilitation.
Resumo
Reabilitação
cardiovascular na coronariopatia discreta com
diminuição da capacidade funcional
Introdução: O tratamento
farmacológico para controle dos fatores desencadeantes da Doença Arterial Coronariana
(DAC) são a linha de frente inicial. No entanto, uma opção adjuvante ao
tratamento farmacológico é a Reabilitação Cardiovascular (RC). Portanto, o
objetivo deste estudo é mostrar os resultados da RC na melhora da qualidade de
vida e funcionalidade de um paciente com coronariopatia
discreta. Descrição do caso: Sexo masculino, 52 anos, sedentário,
ex-fumante há 12 anos, com diagnóstico clínico de DAC discreta, arritmia,
hipertensão arterial sistêmica e dislipidemia. Ingressa na RC em agosto de
2017, com queixas de falta de ar, fadiga, dificuldade ao subir e descer
escadas, limitações para realizar atividades de vida diárias e laborais. Resultados:
Diminuição da pressão arterial 140/90 vs. 110/70 mmHg, aumento do VO2máx
32 vs. 52 ml/kg.min, melhora da fração de ejeção do
ventrículo esquerdo 50 vs. 68%, diminuição da hipertrofia concêntrica com
espessura diastólica da parede posterior do VE e do septo interventricular
12vs. 9mm e redução da massa ventricular esquerda 299 vs. 213 g. Melhora de 87%
na qualidade de vida avaliada pelo Minnesota 72 vs. 9 pontos, além da
diminuição e retirada de fármacos. Conclusão: Um programa de
Reabilitação Cardiovascular individualizado parece promover melhora da
qualidade de vida, funcionalidade e dos aspectos clínicos do paciente com coronariopatia discreta.
Palavras-chave: doença das
coronárias; cirurgia; reabilitação cardíaca.
Introduction
Cardiovascular diseases (CVDs) are responsible for a high number of
deaths worldwide. In 2016, approximately 17.6 million people died from CVDs
[1]. In Brazil, that same year were 362 thousand deaths [2]. Among CVDs,
coronary artery disease (CAD) has the highest incidence and results in a high
rate of hospitalizations and high costs [3].
CAD becomes significant when ≥ 70% of the vessel diameter is
obstructed following larger epicardial arteries or when ≥ 50% stenosis in
the left coronary trunk diameter occurs [4]. According to Leaman's
score, 84% of the blood flow that irrigates the ventricles arrives through the
left coronary artery. Of this blood that reaches the left coronary artery, 66%
is directed to the anterior descending artery and 33% to the circumflex artery
[5].
In cases of chronic CAD, even without significant obstructions (mild
coronary artery disease), some patients may have heart failure (HF), with
classic clinical features of decreased functional capacity and negative impact
on performing activities of daily living. The pharmacological treatment to
control the triggering factors of CAD associated with the drugs used to reduce
the symptoms of HF is the initial front line. However, an adjuvant option to
pharmacological treatment is Cardiovascular Rehabilitation (CR).
Several studies indicate how much cost-benefit CR is superior than other
isolated treatments, such as pharmacological and myocardial revascularization
surgery or angioplasty [6]. However, the effect of CR associated with
pharmacological treatment in HF patients due to CAD with non-significant
obstructions is still poorly explored in the literature. Therefore, the aim of
this study is to describe the effect of CR on HF in a patient with CAD with
calcified plaques without significant obstructions
Case
description
JFS, male, sedentary, 52 years old, 1.75 m tall, 78 kg, waist
circumference 123 cm, Body Mass Index (BMI) 25.5 kg/m2, former
smoker for 12 years, diagnosed with systemic arterial hypertension, obstructive
sleep apnea and coronary artery disease with non-significant calcified plaques
(obstructions less than 50% in the circumflex and posterior descending artery)
determined by CT angiography. He was referred to the Cardiovascular
Rehabilitation service of the CORDIS Clinic in Salvador - BA / Brazil on August
17, 2017.
During the first evaluation, the patient reported that for about 4 to 5
months he had been feeling short of breath, fatigue, difficulty climbing and
descending stairs, difficulties in performing his work activities, as well as
decreased activity and sexual capacity. These data were compatible with the
clinical diagnosis of chronic heart failure.
The fasting laboratory test identified: 92 mg/dl glycemia, 245 mg/dl
triglycerides, 39 mg/dl high-density lipoprotein (HDL), 110 mg/dl low-density
lipoprotein (LDL), total cholesterol of 198 mg/dl, hemoglobin glycated (HbA1c)
6.1%, insulin 36 IU/ml. This led to a classic picture of ongoing insulin
resistance, even with fasting blood glucose values within normal limits.
In the ambulatory blood pressure monitoring report (ABPM) we observed
absent nocturnal fall (not Dipper). Doppler echocardiography revealed
alteration of grade I diastolic relaxation, slight increase in final systolic
diameter 43 mm (normal up to 39 mm), increase in final systolic and diastolic
volume respectively of 83 ml and 167 ml (normal up to 61 and 150 ml), increase
of left atrium 44 mm (normal up to 40 mm) slight increase in left ventricular
mass 299 g (normal up to 290 g), increase in septum and left ventricular
posterior wall thickness of 12 mm compatible with concentric hypertrophy and
borderline systolic function with 50% ejection fraction (below of the Brazilian
average for age which is 72%). Holter demonstrated the presence of single-focal
isolated bigeminated ventricular extrasystoles and
episodes of unsupported supraventricular tachycardia, ischemic T-wave, and left
anterior superior divisional block.
The patient underwent a maximal physical exercise test in which a
maximal heart rate (HRmax) of 119 bpm was reached,
the same heart rate (HR) as the ischemic threshold, determined by a depression
greater than 2mm associated with symptoms of typical angina pectoris. HRmax corresponded to 71% of predicted HRmax
for age by the Karvonen equation (220 - age). Blood pressure behaved
physiologically during the test. At the time of recovery and in the final
stage, monomorphic left ventricular outflow tract extrasystoles were observed. The drugs used by the patient were:
Carvedilol 25 mg at 07h and 19h; Enalapril 5 mg at 12h and 19h; Aldactone 25 mg
at 2pm and Acetylsalicylic Acid.
Given the evaluation and the clinical condition of the patient, the
objective of CR was to restore the patient's ability to perform daily life
activities without being tired. Moreover, we also aimed to improve functional
capacity and control the triggering factors of CAD such as hypertension and
insulin resistance, as well as containing arrhythmia. The prognosis of
treatment to achieve the goals was set at six months
Cardiovascular
rehabilitation program
The CR program was started in August 2017 and lasted six months, with
frequency of three weekly sessions. The exercises were monitored
electrocardiographically (ECAFIX multiparameter cardiac monitor, Active® model,
São Paulo, SP, Brazil). Before each session, remote ischemic preconditioning
(PCIR) was performed. As the systolic pressures between the arms was similar,
we chose to perform this procedure on the left arm. The RIPC was performed with
30 mmHg above the systolic blood pressure of the training day, with a 5-minute
occlusion for 5 minutes of reperfusion in three series.
The first month's fitness session is described in Box I. Importantly,
cyclic exercise (treadmill) was prescribed based on a conventional maximal
physical exercise test performed before the start of the program.
MMSS
= Superior Members; Lower limbs; TEFM = Maximum Physical Effort Test.
The IMT is prescribed to be done at home, however, we adopt as protocol
to perform the first three sessions in the clinic so that the patient learns
the procedure properly and to see if during the IMT there is no significant
increase in arrhythmia, typical angina or some hemodynamic decompensation. As
there was a significant increase in the number of unifocal ventricular
extrasystoles (more than 10% increase) during IMT compared to rest, in the
first month the patient performed this procedure only at the clinic under
electrocardiographic monitoring. To determine the load, an incremental
inspiratory muscle test was performed to determine the glycemic threshold load,
the load at which the training was performed.
After the adaptation period, the patient underwent two further
reassessments, one in September and one at the end of November and the CR
protocol was updated according to his progression to training. After the first
month the IMT was prescribed to be performed at home due to arrhythmia control.
The PCIR was still being held at the beginning of the CR session. After the
third month of CR the program began to be held three times a week. Box 2
details the protocols used in the other stages of CR.
We emphasize that although the treadmill prescription continued with the
same percentage values of effort intensity, the velocities corresponding to
these intensities were increased, since the patient had improved functional
capacity, which in turn caused the need to increase the speed to achieve the
same heart rates initially prescribed. In addition, in the last three months of
the program, stair training was included, and the treadmill was performed in
two days at high intensity interval, based on the Borg subjective perception
scale, and one day at moderate intensity continuously. The program was held
every other day.
This case report was submitted and approved by the Ethics and Research
Committee of Feira de Santana State University, Feira de Santana, BA, Brazil
under CAAE No. 0036.059.000-11.
Results
Graphic 1 shows the mean arterial pressure (BP) due to each month of
treatment. We observed that there was a reduction in the monthly average, from
the first month of intervention to the last, of systolic (121 mmHg vs. 110
mmHg) and diastolic (79 mmHg vs. 70 mmHg) blood pressure. Mean arterial
pressure at baseline was 93 mmHg vs. 83 mmHg reflecting an 11% improvement. In
the first evaluation the BP was 140/90 mmHg, characterizing borderline systemic
arterial hypertension and in the last evaluation the BP was 110/70 mmHg.
Graph
1 - Monthly mean systolic and diastolic resting
blood pressure during CR sessions.
Graphic 2 represents the average velocities (km/h) performed on the
treadmill of the heating and conditioning phase according to each month of CR.
At the beginning of treatment, in the conditioning phase the patient reached a
speed of 3.5 km/h. However, at the end of the CR program it reached a speed of
14.4 km/h, without showing signs or symptoms of typical angina pectoris. This
represented an improvement of 411%, demonstrating considerable improvement in
functional capacity and ischemic threshold. It is important to note that
throughout the program the patient's monomorphic ventricular extrasystoles,
which arose during exercise, completely withdraw.
Graphic 2 - Monthly average velocity
practiced in CR sessions.
In the new Doppler echocardiography performed by the same evaluator, no
change in volumes and diameters was observed, resulting in a 38% reduction in
final systolic volume (84 vs. 53 ml) and a 17% reduction in final diastolic
diameter (43 vs. 36 mm). Left ventricular mass decreased by 8% (299 vs. 213
mg), left ventricular posterior wall and interventricular septum thickness
decreased by 25% (12 vs. 9 mm). Diastolic dysfunction was no longer identified
and there was a 36% increase in left ventricular ejection fraction (50 vs. 68%).
No further laboratory examination was performed after the CR program.
Table I shows the results of pre and post RC MTEF. We noticed a clear
improvement in functional capacity, especially the increase in indirect VO2max,
chronotropic reserve, cardiac output and distance covered. We also point out
that no extrasystoles were seen at the peak of exertion and during the recovery
period, and no ST-segment depression and typical angina pectoris symptoms were
identified.
Table
I - Evolution of cardiovascular conditioning -
Comparison of exercise test results before and after CR.
HR
max = Maximum Heart Rate = MVO2 max: Maximum myocardial oxygen uptake; DBPmax = Maximum Diastolic Blood Pressure; PAS max =
Maximum Systolic Blood Pressure; VO2 max = Maximum oxygen volume.
When we evaluated the quality of life test (Minnesota) we initially
checked for a score of 72 points. In the last evaluation, six months later, the
score obtained was 9, showing an evolution of 87%, with improvement in the
aspects of sexual activity, sleep quality, leisure, sports, walking and
climbing stairs and the level of attention and concentration. In addition,
there were no more complaints of pain, tiredness and fatigue. Finally, all
improvements culminated in the patient's return to daily living and working
activities. Given the improvement in clinical and functional variables, the
attending physician, after six months of CR, reduced the dosage of carvedilol
from 25 mg to 12 mg and withdrew the use of aldactone.
Discussion
The results of this case report suggest that CR is a viable adjuvant
treatment for HF patients due to CAD with calcified plaques and non-significant
obstructions.
The basic pharmacological treatment of HF with borderline or decreased
ejection fraction aims to reduce HR, preload, afterload and promote coronary
vasodilation. Physical exercise was potentiating, or even, the protagonist
feature of the treatment objectives mentioned above. By analyzing BP behavior, we
observed a clear reduction in preload and afterload throughout treatment, with
an 11% reduction in mean resting blood pressure. We also identified BP
improvement at the peak of the effort in which, for a higher workload, there
was a 22% lower elevation in SBP. The impact of training on CF was also clear.
During the program, we found that the speed on the treadmill initially used for
conditioning was 4.5 km/h. At the end of the six months of rehabilitation, the
speed evolved to 14.4 km/h, without the patient showing any signs or symptoms
of cardiac discomfort. We also observed a 58% increase in chronotropic reserve
between the first and last TEFM. In conclusion, we highlight the effect of
exercise on the ischemic threshold identified in the first MTEF. As reported in
the results, in the second test no electrocardiographic signs or symptoms of
ischemia were seen, which reflects improved circulation in the ischemic area.
This probably occurred due to the opening of collateral circulation,
angiogenesis and even due to the increase in the size of coronary arteries [7].
The cardiac structural improvement observed in the comparison between
the first and last Doppler echocardiography is also noteworthy. Scientific
literature has long signaled the effect of reverse myocardial remodeling
produced by exercise, although it is still undervalued and discussed. In a
systematic review study with meta-analysis published in the JACC and conducted
by Haykowsky et al. [8], it was shown that
exercise can promote reverse myocardial remodeling in dilated or hypertrophic
heart disease. The study included 812 patients in the exercise group and 569 in
the control group, evidencing the positive response that exercise promotes.
In order to achieve the benefits mentioned above, the prescription of
physical exercise was based on four premises: biological and clinical
individuality; specificity of training; moments of reevaluation and
periodization; and idiosyncrasy caused by training. These principles make a
total difference in the magnitude of the effects and, therefore, we seek to
report them in detail in the case description section. The outcome of this
report points out that an approach that uses these principles may be the key to
obtaining results that are favorable or superior to those commonly reported in
the scientific literature, which use generalist prescriptions.
It is also imperative to report the pleiotropic benefits generated by
CR, ranging from decreasing drug intake (as reported in this case) to promoting
a deeper sense of responsibility for the times and days of pharmacological
treatment. In addition, more attention is paid to dietary reeducation, sleep
quality, more active lifestyles, better understanding of the disease [9-10], as
well as generating a quality emotional response to the challenges (reported in
the quality of life test).
In the same direction, with treatment we were able to achieve the
primary goals proposed with the CR program. We obtained 87% gain in the
patient's quality of life, who at the end of the program had already resumed
all their work and daily life activities. In addition, the limitations imposed
by cardiovascular disease interrupt the daily flow of work activities. Thus, it
is possible that there is a movement that refers to depressive aspects, and the
existence of deconstruction of patients' autonomy can be glimpsed [11].
However, although CR is a viable and cost-effective alternative, it is
still little explored by cardiologists. Because of this, it is necessary that
it is known and recognized by these professionals, to increase the number of
patients referred to these programs, because only 5 to 30% of patients with CVD
are referred to CR programs, and this percentage is likely to be even lower in
Brazil [12,13]. There is a need for constant efforts to publicize CR by public
health agencies and health professionals in this area. Reports such as this
should encourage professionals to refer this possibility of treatment to
patients with cardiovascular diseases. All health professionals, not just
cardiologists, cannot forget this responsibility, revealing to their patients
that full treatment has a much broader spectrum than just pharmacological
intervention.
Conclusion
An individualized Cardiovascular Rehabilitation program promoted
improved quality of life, reestablished functionality and generated significant
clinical improvements in a patient with chronic heart failure due to CAD with
calcified plaques. The description of this case highlights once again the
importance of health professionals offering this possibility of treatment to
their patients with cardiovascular diseases.
Authoral contribution
Conception and research design: Jesus DS, Petto
J. Data collection: Jesus DS, Matias JB, Santos MC, Cecília
LMS, Sacramento MS, Santos JF. Data analysis and interpretation: Jesus DS,
Matias JB, Petto J.
Writing of the manuscript: Jesus DS, Matias JB, Santos MC, Cecília LMS, Petto J. Critical
revision of the manuscript for important intellectual content: Petto J.
Academic
link
This study resulted in the conclusion of Daniela Santos de Jesus's
degree course by the Specialization in Physiology of Exercise Applied to
Rehabilitation at the Centro Oeste Paulista School,
Bauru, SP, Brazil, under the supervision of Professor Doctor Jefferson Petto.
Potential
conflict of interest
Part of the authors (Jesus DS, Matias JB, Sacramento MS and Petto J) make up the Cardiovascular Rehabilitation team
ACTUS CORDIOS Cardiovascular, Respiratory and Musculoskeletal Rehabilitation,
Salvador, BA, Brazil.
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