Effectiveness of Sanatorium-and-Spa Rehabilitation of Patients with Coronary Heart Disease after Surgical Myocardial Revascularization

The dissertation is devoted to assessing the effectiveness of sanatorium-and-spa rehabilitation of patients with coronary heart disease who have undergone surgical myocardial revascularization. The study examines the initial functional state of the vascular endothelium, indicators of the lipid spectrum and cytokine profile of blood plasma, as well as clinical and hemodynamic parameters in this category of patients on admission to the sanatorium stage of restorative treatment. The work analyses the influence of the combined use of dry carbon dioxide baths and dosed physical training on the vasoregulatory function of the endothelium, the lipid and cytokine profile, the clinical course of the disease, the quality of life, and the psychoemotional status of patients. Based on the results obtained, methodological recommendations are developed for the optimisation of restorative treatment at the sanatorium stage.

RELEVANCE OF THE TOPIC

Surgical myocardial revascularization has become the method of choice in the treatment of patients with coronary heart disease (CHD) due to its wide prevalence and the insufficient effectiveness of drug therapy [5, 34, 45, 76, 83, 84, 85]. Despite the great advances achieved in the surgical treatment of CHD, its effectiveness is directly related to the quality of postoperative rehabilitation [257]. Even successfully performed myocardial revascularization does not prevent further progression of atherosclerosis, which makes the problem of secondary prevention of CHD even more relevant for this category of patients [17, 111, 154, 195, 243]. The effectiveness of restorative treatment depends to a significant extent on the completeness of the complexes of rehabilitation measures and on strict continuity between the stages of rehabilitation.

In the practice of domestic public health there exists a system of staged rehabilitation of CHD patients who have undergone surgical myocardial revascularization [13, 19, 32, 59, 60, 61, 157]. At the stage of sanatorium rehabilitation, along with drug therapy, physical training, preformed physical factors, physiotherapeutic and balneological methods, and psychotherapy are used, which have shown their definite effectiveness in patients who have suffered myocardial infarction and in those with chronic CHD. The use of physical factors in the complex therapy of patients after surgical myocardial revascularization has not been fully studied [196].

One of the accessible methods applied in sanatorium rehabilitation complexes is dosed physical training and dry carbon dioxide baths (DCB) [22, 40, 77, 88, 94, 95, 113, 128]. Despite their wide application, the mechanisms and specific features of their effect on patients after surgical myocardial revascularization remain not fully clarified.

There are no data on their influence on the functional state of the endothelium and on clinical parameters in patients after surgical myocardial revascularization. The effects of sanatorium treatment on hemodynamic indices and on patients' quality of life also remain unstudied. Meanwhile, effective rehabilitation of this category of patients determines the further course and prognosis of the disease [14, 18, 44, 47, 74, 176].

AIM OF THE STUDY

To assess the influence of complex rehabilitation including dry carbon dioxide baths and dosed physical training on the functional state of the endothelium, the cytokine profile, and clinical and hemodynamic parameters in CHD patients after surgical myocardial revascularization at the sanatorium stage.

OBJECTIVES OF THE STUDY

1. To investigate the specific features of the functional state of the vascular endothelium, the cytokine profile, and clinical and hemodynamic parameters in CHD patients who have undergone surgical myocardial revascularization, on admission to the sanatorium depending on the extent of the surgical intervention.

2. To study the influence of dosed physical training and dry carbon dioxide baths on the functional state of the endothelium and the lipid spectrum of blood plasma in CHD patients after surgical myocardial revascularization within complex sanatorium rehabilitation.

3. To evaluate the effect of dry carbon dioxide baths and dosed physical training on the cytokine profile of blood in CHD patients who have undergone surgical myocardial revascularization at the stages of rehabilitation.

4. To analyse the influence of complex sanatorium-and-spa rehabilitation using dry carbon dioxide baths and dosed physical training on clinical and hemodynamic parameters and the psychoemotional status of CHD patients after surgical myocardial revascularization.

5. To develop methodological recommendations for optimising restorative treatment in CHD patients after surgical myocardial revascularization at the stages of rehabilitation.

SCIENTIFIC NOVELTY

The work provides scientific substantiation of the clinical and functional effectiveness of the complex of rehabilitation measures including dry carbon dioxide baths and dosed physical training in the rehabilitation of patients with coronary heart disease after surgical myocardial revascularization.

For the first time it has been established that the use of dry carbon dioxide baths in combination with dosed physical training contributes to an increase in physical working capacity and improvement of clinical and hemodynamic indices in CHD patients who have undergone surgical myocardial revascularization.

It has been revealed that the combined use of dry carbon dioxide baths and dosed physical training exerts a substantial influence on the vasoregulatory function of the endothelium, manifested as an improvement of endothelium-dependent (EDVD) and endothelium-independent (EIVD) vasodilation and a decrease in the levels of von Willebrand factor, P-selectin, and endothelin-1 against the background of positive changes in lipid metabolism.

It has been demonstrated that against the background of complex sanatorium-and-spa rehabilitation including dry carbon dioxide baths and dosed physical training, an improvement of the cytokine profile is observed, with a decrease in pro-inflammatory and an increase in the level of anti-inflammatory cytokines. It has been established that the results of sanatorium rehabilitation of CHD patients after surgical myocardial revascularization have a positive effect on the psychoemotional status of patients and persist for three months.

PRACTICAL SIGNIFICANCE

The studies carried out have demonstrated the expediency of a comprehensive assessment of the initial state of the vascular endothelium and of the cytokine and lipid profile of blood plasma in patients with coronary heart disease after surgical myocardial revascularization admitted to the sanatorium stage of rehabilitation, for the purpose of differentiated and individualised selection of rehabilitation programmes.

It has been shown that for the optimisation of the sanatorium stage of rehabilitation of patients with coronary heart disease after surgical myocardial revascularization, the complex application of dry carbon dioxide baths and dosed physical training, which promote improvement of the functional state of the vascular endothelium and of the cytokine and lipid profile of blood plasma, is expedient.

The combined application of dry carbon dioxide baths and physical training increases the effectiveness of the rehabilitation measures carried out and has a beneficial effect on the clinical and functional state and the psychoemotional status of patients.

MAIN PROPOSITIONS SUBMITTED FOR DEFENCE

1. In CHD patients who have undergone surgical myocardial revascularization, on admission to the sanatorium stage of rehabilitation there is endothelial dysfunction manifested as a decrease in its vasodilator properties and an increased level of von Willebrand factor, P-selectin, and endothelin-1, an elevated content of pro-inflammatory cytokines, and a reduced level of anti-inflammatory cytokines.

2. The inclusion of dry carbon dioxide baths and dosed physical training in the complex programme of sanatorium rehabilitation of CHD patients after surgical myocardial revascularization contributes to the improvement of the vasoregulatory function of the endothelium, has a favourable effect on the lipid spectrum of blood plasma, and regulates cytokine status.

3. Complex sanatorium-and-spa rehabilitation of CHD patients who have undergone surgical myocardial revascularization, with the use of physical training and DCB, contributes to the improvement of clinical and hemodynamic parameters and the psychoemotional status of patients and produces long-term results.