Körperliche Aktivität in der Rehabilitation nach Myokardinfarkt

In der Therapie nach einem Herzinfarkt verbessert körperliche Aktivität die Prognose und senkt die Mortalität. Doch worauf beruht dieser Effekt, wann soll ein Sporttraining in welchem Umfang und mit welcher Intensität angefangen, wie lange soll es fortgeführt und wie soll es kontrolliert werden? Darauf gibt der vorliegende Beitrag Antworten und praktische Empfehlungen.

Kernaussagen

• Nach einem Myokardinfarkt ist die leitliniengerechte pharmakologische Intervention die Basis der Therapiestrategie, ergänzend sind Lebensstilmaßnahmen als gleichwertige Therapie essenziell.

• Lebensstilmaßnahmen beinhalten eine Sporttherapie mit regelmäßiger körperlicher Alltagsaktivität ergänzt durch ein gezieltes Training, eine „herzgesunde Ernährung“, ein Stressmanagement und die Raucherentwöhnung.

• Körperliche Aktivität verbessert die Prognose und senkt sowohl die Gesamtmortalität als auch die kardiovaskuläre Mortalität nach einem Myokardinfarkt.

• Je belastbarer der Patient ist, desto besser ist seine Prognose.

• Patienten sollen so früh wie möglich wieder körperlich aktiv werden.

• Jeder Patient soll individuelle Belastungsempfehlungen bezüglich Intensität und Umfang der körperlichen Aktivität erhalten.

• Mehrmalige Aktivität pro Tag mit geringem Umfang und Intensität wird für wenig belastbare Patienten gerade zu Beginn empfohlen.

• Erst wird der Umfang, dann die Intensität gesteigert.

• Die Intensität des Trainings sollte über individuelle Herzfrequenzempfehlungen gesteuert werden.

• Ein strukturiertes Training sollte im Rahmen der Rehabilitationsphase II bereits beginnen und die Sporttherapie lebenslang durchgeführt werden.

Schlüsselwörter

Sporttherapie - kardiovaskuläre Risikofaktoren - Myokardinfarkt - individuelle Belastungsempfehlungen - kardiale Rehabilitation

• Literatur

• 1 OʼConnor GT, Buring JE, Yusuf S. et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80: 234-244
• 2 Oldridge NB, Guyatt GH, Fischer ME. et al. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA 1988; 260: 945-950
• 3 Kavanagh T, Mertens DJ, Hamm LF. et al. Prediction of long–term prognosis in 12 169 men referred for cardiac rehabilitation. Circulation 2002; 106: 666-671
• 4 Swift DL, Lavie CJ, Johannsen NM. et al. Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention. Circ J 2013; 77: 281-292
• 5 Lassale C, Tzoulaki I, Moons KGM. et al. Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis. Eur Heart J 2018; 39: 397-406 doi:10.1093/eurheartj/ehx448
• 6 De Schutter A, Lavie CJ, Milani RV. The impact of obesity on risk factors and prevalence and prognosis of coronary heart disease–the obesity paradox. Prog Cardiovasc Dis 2014; 56: 401-408 doi:10.1016/j.pcad.2013.08.003
• 7 Romero-Corral A, Montori VM, Somers VK. et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 2006; 368: 666-678 doi:10.1016/S0140-6736(06)69251-9
• 8 Stanford KI, Goodyear LJ. Exercise and type 2 diabetes: molecular mechanisms regulating glucose uptake in skeletal muscle. Adv Physiol Educ 2014; 38: 308-314 doi:10.1152/advan.00080.2014
• 9 Umpierre D, Ribeiro PA, Kramer CK. et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011; 305: 1790-1799 doi:10.1001/jama.2011.576
• 10 Look AHEAD Research Group. Wing RR, Bolin P. et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369: 145-154 doi:10.1056/NEJMoa1212914
• 11 Look AHEAD Research Group. Effect of a long-term behavioural weight loss intervention on nephropathy in overweight or obese adults with type 2 diabetes: a secondary analysis of the Look AHEAD randomised clinical trial. Lancet Diabetes Endocrinol 2014; 2: 801-809 doi:10.1016/S2213-8587(14)70156-1
• 12 Fikenzer K, Fikenzer S, Laufs U. et al. Effects of endurance training on serum lipids. Vascul Pharmacol 2018; 101: 9-20 doi:10.1016/j.vph.2017.11.005
• 13 Kelley GA, Kelley KS, Vu Tran Z. Aerobic exercise, lipids and lipoproteins in overweight and obese adults: a meta-analysis of randomized controlled trials. Int J Obes (Lond) 2005; 29: 881-893 doi:10.1038/sj.ijo.0802959
• 14 Kraus WE, Houmard JA, Duscha BD. et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002; 347: 1483-1492 doi:10.1056/NEJMoa020194
• 15 NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants. Lancet 2017; 389: 37-55 doi:10.1016/S0140-6736(16)31919-5
• 16 Cornelissen VA, Fagard RH. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension 2005; 46: 667-675 doi:10.1161/01.HYP.0000184225.05629.51
• 17 Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc 2013; 2: e004473 doi:10.1161/JAHA.112.004473
• 18 Kavanagh T, Mertens DJ, Hamm LF. et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol 2003; 42: 2139-2143
• 19 Anderson L, Oldridge N, Thompson DR. et al. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol 2016; 67: 1-12 doi:10.1016/j.jacc.2015.10.044
• 20 De Schutter A, Kachur S, Lavie CJ. et al. Cardiac rehabilitation fitness changes and subsequent survival. Eur Heart J Qual Care Clin Outcomes 2018; 4: 173-179 doi:10.1093/ehjqcco/qcy018
• 21 Hannan AL, Hing W, Simas V. et al. High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis. Open Access J Sports Med 2018; 9: 1-17 doi:10.2147/OAJSM.S150596
• 22 Conraads VM, Pattyn N, De Maeyer C. et al. Aerobic interval training and continuous training equally improve aerobic exercise capacity in patients with coronary artery disease: the SAINTEX-CAD study. Int J Cardiol 2015; 179: 203-210 doi:10.1016/j.ijcard.2014.10.155
• 23 Pattyn N, Vanhees L, Cornelissen VA. et al. The long-term effects of a randomized trial comparing aerobic interval versus continuous training in coronary artery disease patients: 1-year data from the SAINTEX-CAD study. Eur J Prev Cardiol 2016; 23: 1154-1164 doi:10.1177/2047487316631200
• 24 Elliott AD, Rajopadhyaya K, Bentley DJ. et al. Interval training versus continuous exercise in patients with coronary artery disease: a meta-analysis. Heart Lung Circ 2015; 24: 149-157 doi:10.1016/j.hlc.2014.09.001
• 25 Pattyn N, Coeckelberghs E, Buys R. et al. Aerobic interval training vs. moderate continuous training in coronary artery disease patients: a systematic review and meta-analysis. Sports Med 2014; 44: 687-700 doi:10.1007/s40279-014-0158-x
• 26 Liou K, Ho S, Fildes J. et al. High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease: A Meta-analysis of Physiological and Clinical Parameters. Heart Lung Circ 2016; 25: 166-174 doi:10.1016/j.hlc.2015.06.828
• 27 Stewart RAH, Held C, Hadziosmanovic N. et al. Physical Activity and Mortality in Patients With Stable Coronary Heart Disease. J Am Coll Cardiol 2017; 70: 1689-1700 doi:10.1016/j.jacc.2017.08.017
• 28 White HD, Norris RM, Brown MA. et al. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987; 76: 44-51
• 29 Haykowsky M, Scott J, Esch B. et al. A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling. Trials 2011; 12: 92 doi:10.1186/1745-6215-12-92
• 30 Andersen MJ, Borlaug BA. Heart failure with preserved ejection fraction: current understandings and challenges. Curr Cardiol Rep 2014; 16: 501 doi:10.1007/s11886-014-0501-8
• 31 Ponikowski P, Voors AA, Anker SD. et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37: 2129-2200 doi:10.1093/eurheartj/ehw128
• 32 McMurray JJ, Adamopoulos S, Anker SD. et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787-1847 doi:10.1093/eurheartj/ehs104
• 33 Taylor RS, Sagar VA, Davies EJ. et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014; (04) CD003331 DOI: 10.1002/14651858.CD003331.pub4.
• 34 Gomes Neto M, Duraes AR, Conceicao LSR. et al. High intensity interval training versus moderate intensity continuous training on exercise capacity and quality of life in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis. Int J Cardiol 2018; 261: 134-141 doi:10.1016/j.ijcard.2018.02.076
• 35 Ellingsen O, Halle M, Conraads V. et al. High-Intensity Interval Training in Patients With Heart Failure With Reduced Ejection Fraction. Circulation 2017; 135: 839-849 doi:10.1161/CIRCULATIONAHA.116.022924
• 36 Pandey A, Parashar A, Kumbhani D. et al. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. Circ Heart Fail 2015; 8: 33-40 doi:10.1161/CIRCHEARTFAILURE.114.001615
• 37 Angadi SS, Mookadam F, Lee CD. et al. High-intensity interval training vs. moderate-intensity continuous exercise training in heart failure with preserved ejection fraction: a pilot study. J Appl Physiol (1985) 2015; 119: 753-758 doi:10.1152/japplphysiol.00518.2014
• 38 Isaksen K, Morken IM, Munk PS. et al. Exercise training and cardiac rehabilitation in patients with implantable cardioverter defibrillators: a review of current literature focusing on safety, effects of exercise training, and the psychological impact of programme participation. Eur J Prev Cardiol 2012; 19: 804-812
• 39 Dougherty CM, Glenny RW, Burr RL. et al. Prospective randomized trial of moderately strenuous aerobic exercise after an implantable cardioverter defibrillator. Circulation 2015; 131: 1835-1842 doi:10.1161/CIRCULATIONAHA.114.014444
• 40 Ibanez B, James S, Agewall S. et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39: 119-177 doi:10.1093/eurheartj/ehx393
• 41 Laufs U, Scharnagl H, Halle M. et al. Treatment Options for Statin-Associated Muscle Symptoms. Dtsch Arztebl Int 2015; 112: 748-755 doi:10.3238/arztebl.2015.0748
• 42 Zhang H, Plutzky J, Turchin A. Discontinuation of statins in routine care settings. Ann Intern Med 2013; 159: 75-76 doi:10.7326/0003-4819-159-1-201307020-00022
• 43 Laszlo R, Lesevic H, Enders K. et al. Sport unter oraler Antikoagulation bei Vorhofflimmern. Deutsche Zeitschrift für Sportmedizin 2017; DOI: 10.5960/dzsm.2017.286.
• 44 Siegrist M, Freiberger E, Geilhof B. et al. Fall Prevention in a Primary Care Setting. Dtsch Arztebl Int 2016; 113: 365-372 doi:10.3238/arztebl.2016.0365
• 45 Frey PM, Mean M, Limacher A. et al. Physical activity and risk of bleeding in elderly patients taking anticoagulants. J Thromb Haemost 2015; 13: 197-205 doi:10.1111/jth.12793
• 46 Shendre A, Beasley TM, Brown TM. et al. Influence of regular physical activity on warfarin dose and risk of hemorrhagic complications. Pharmacotherapy 2014; 34: 545-554
• 47 Borjesson M, Dellborg M, Niebauer J. et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2018; DOI: 10.1093/eurheartj/ehy408.
• 48 Mezzani A, Hamm LF, Jones AM. et al. Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2012; 32: 327-350 doi:10.1097/HCR.0b013e3182757050
• 49 Scherr J, Wolfarth B, Christle JW. et al. Associations between Borgʼs rating of perceived exertion and physiological measures of exercise intensity. Eur J Appl Physiol 2013; 113: 147-155 doi:10.1007/s00421-012-2421-x
• 50 Fihn SD, Gardin JM, Abrams J. et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012; 60: 2564-2603 doi:10.1016/j.jacc.2012.07.012
• 51 Laufs U, Banzhoff ND, Haasenritter J. Nationale VersorgungsLeitlinie Chronische KHK. Langfassung. 4. Aufl. 2016
• 52 [Anonym] Deutsche Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen e. V. Im Internet: https://www.dgpr.de/herzgruppen.html Stand: 15.05.2019