Aptidão Física e seu valor prognóstico no pós-operatório de cirurgia de revascularização do miocárdio
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Data
2010
Autores
Bueno, Flávia Regina [UNIFESP]
Orientadores
Dourado, Victor Zuniga [UNIFESP]
Tipo
Trabalho de conclusão de curso de graduação
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Introdução: A doença arterial coronariana (DAC) consiste na doença cardíaca causada
pelo desequilíbrio entre o aporte e a demanda do oxigênio ao miocárdio. O incremental shuttle
walk teste (ISWT) e o teste de caminhada de seis minutos (TC6) são testes de caminhada de campo
desenvolvidos para avaliar a aptidão física de pacientes com doenças cardiorrespiratórias. Embora
os testes sejam ferramentas estabelecidas, o seu valor prognóstico em pacientes submetidos a
cirurgia revascularização do miocárdio (CRM) não foi investigada suficientemente. Objetivos:
Avaliar a aptidão física de indivíduos com DAC e comparar com a aptidão física de indivíduos
saudáveis; avaliar o valor prognóstico da aptidão física e comparar o valor prognóstico do ISWT ao
do TC6 no pós-operatório de CRM; e, secundariamente, avaliar o efeito aprendizado e a
reprodutibilidade dos dois testes nessa população. Indivíduos e Métodos: Foram avaliados 21
pacientes com DAC aguardando CRM eletiva e 29 adulto/idosos saudáveis que compuseram o
grupo I (GI) e 21 indivíduos com DAC aguardando cirurgia de revascularização do miocárdio
(CRM) e esses por sua vez foram divididos, posteriormente em dois subgrupos: grupo
complicações (C) (n=11) e grupo sem complicações (SC) (n=10), segundo o seu prognóstico no
pós-operatório. O prontuário médico de cada paciente foi analisado para registro das variáveis:
tabagismo, tipo de cirurgia que será realizada, fração de ejeção do ventrículo esquerdo (FEVE),
cirurgia prévia, doença vascular periférica, hipertensão arterial sistêmica, diabetes mellitus, DPOC,
obesidade, insuficiência cardíaca e respiratória, entre outros. O ISWT foi realizado com intervalo
de aproximadamente 30 min entre eles. O teste consiste em caminhar, em corredor de 10 m, em
velocidade progressiva imposta por sinais sonoros. Os sinais impõem aumento de 0,17 m/s a cada
minuto até a exaustão e/ou a presença de sintomas. O TC6 consiste em caminhar num corredor de
30m por 6m, com incentivo verbal a cada minuto.Antes de depois de cada teste foram avaliados a
pressão arterial, a freqüência cardíaca a dispnéia e a fadiga de MMII através da Escala de Borg. A
dinamometria foi utilizada para avaliar a força de preensão manual em Kg/F. Resultados: Os
pacientes apresentaram FPM significativamente inferior quando considerados os valores em
percentuais do previsto (78,4 ± 16,3 vs. 97,2 ± 15; p = 0,0001). Os pacientes caminharam
significativamente menos no TC6 em valores absolutos (412 ± 79,77 vs. 601 ± 7; p = 0,0001) e em
percentuais dos valores previstos (72 ±13,5 vs. 110 ± 11; p = 0,0001). O mesmo resultado foi
observado para o ISWT (257 ± 90 vs. 517 ± 138; p=0,0001) em valores absolutos e (53 ± 16 vs.
108 ± 16; p=0,0001) em valores percentuais.O grupo C foi composto por 11 pacientes e o grupo SC
por 10 pacientes. A idade influenciou de maneira significante no prognóstico desses pacientes,
apresentando valores significativamente maiores no grupo C (57 ± 6 vs. 71 ± 7; p=0,0001). A FPM
apresentou valores significativamente superiores no grupo SC (41 ± 9 vs. 33 ± 6 ; p=0,04). As
distâncias percorridas no ISWT, em valores absolutos (311 ± 66 vs. 208 ± 81;p=0,05 ). Com
relação ao TC6, não encontramos diferenças estatísticamente significantes. Contudo, houve uma
tendência de pior desempenho do grupo C quando considerados os valores absolutos . Após análise
de regressão logística incluindo o ISWT e o TC6 em valores absolutos como variáveis
independentes, o ISWT foi selecionado como determinante para o prognóstico dos pacientes (Odds
ratio = 0,981 - CI5%=0,9; CI95%=0,9p=0,04)- ). Conclusão: Os pacientes com DAC e espera de
CRM eletiva apresentam significativa redução da aptidão física, a qual, por sua vez, influenciou de
maneira significativa o prognóstico pós-operatório dos pacientes. Dentre os testes de caminhada
utilizados, o ISWT apresentou valor prognóstico significativo e mais determinante quando
comparado ao TC6, discriminando os pacientes do grupo C daqueles do grupo SC. O ISWT
apresentou boa confiabilidade, sendo necessária a realização de apenas um teste para avaliar a
aptidão cardiorrespiratória. Nossos resultados sugerem a necessidade de intervenções não
farmacológicas capazes de aprimorar tais índices de aptidão física no pré-operatório para que a
prevalência de complicações, sobretudos as complicações pulmonares, seja menor no pósoperatório.
Introduction: The DAC consists of heart disease caused by an imbalance between supply and demand of oxygen to the myocardium. The 6MWT and the ISWT are field walking tests developed 11 to assess the physical fitness of patients with cardiorespiratory diseases. Although these tests form an established tool, their prognostic values in patients undergoing coronary artery bypass surgery (CABG) have not been investigated sufficiently. Objectives: To evaluate the influence of distance obtained by 6MWT and by ISWT over the postoperative prognosis of patients with CAD undergoing CABG. To evaluate the fitness of those individuals and compare it with the physical fitness of healthy adults. To evaluate the learning and the reproducibility of walk tests in this population. Subjects and Methods: 29 healthy adults / seniors were evaluated and made up the group I (GI) and 21 subjects with CAD awaiting coronary artery bypass graft (CABG) and these in turn were divided further into two subgroups: group complications (C ) (n = 11) and the group without complications (SC) (n = 10), according to their prognosis after surgery. The medical records of each patient were analyzed to record the variables of smoking, type of surgery to be performed, ejection fraction (LVEF), previous surgery, peripheral vascular disease, hypertension, diabetes mellitus, COPD, obesity, cardiac and respiratory failure, among others. The ISWT was conducted with a range of approximately 30 min between them. The test consists of walking in 10 m corridor in progressive speed imposed by sound signals. The signals require an increase of 0.17 m / s every minute until exhaustion and / or the presence of symptoms. The 6MWT consists of walking in a corridor of 30m by 6m, with verbal encouragement every minute. Before and after each test, were evaluated blood pressure, heart rate, dyspnea and fatigue of lower limbs by Borg Scale. The dynamometry was used to assess grip strength in kg / F. Results: In GI the average age was 65 years and 63 years in the IGI, in subgroup C was 71 years and 57 years at SC. The average BMI numbers for GI, GII, SC and C were, respectively, 27.7 Kg/m², 27,5 kg/m², 28,5 Kg/m²d 27 Kg/m². The average LVEF was 47%. The IGI showed the expected percentage of FPM significantly higher than the GII, and SC subgroup showed significantly better values of FPM both in absolute and in percentage of predicted compared to group C. The distance traveled in ISWT and 6MWT were significantly higher both in absolute and in percentage of predicted when comparing GI with GII, and when GC and GSC are compared, it is seen that those with worse prognosis walked significantly less in both tests. There was a learning effect in the 6MWT, as patients walked significantly more in the second test than the first, although the same can not be said about the ISWT because in this test the patients walked significantly less. The ISWT had a prognostic value for CAD and only one test proved to be necessary to assess the fitness of these patients. Conclusion: We conclude that patients with CAD have poorer cardiorespiratory fitness, and that only one ISWT test is able to evaluate the fitness of these patients and that this test has prognostic value in this population and that there was a learning effect in the 6MWT.
Introduction: The DAC consists of heart disease caused by an imbalance between supply and demand of oxygen to the myocardium. The 6MWT and the ISWT are field walking tests developed 11 to assess the physical fitness of patients with cardiorespiratory diseases. Although these tests form an established tool, their prognostic values in patients undergoing coronary artery bypass surgery (CABG) have not been investigated sufficiently. Objectives: To evaluate the influence of distance obtained by 6MWT and by ISWT over the postoperative prognosis of patients with CAD undergoing CABG. To evaluate the fitness of those individuals and compare it with the physical fitness of healthy adults. To evaluate the learning and the reproducibility of walk tests in this population. Subjects and Methods: 29 healthy adults / seniors were evaluated and made up the group I (GI) and 21 subjects with CAD awaiting coronary artery bypass graft (CABG) and these in turn were divided further into two subgroups: group complications (C ) (n = 11) and the group without complications (SC) (n = 10), according to their prognosis after surgery. The medical records of each patient were analyzed to record the variables of smoking, type of surgery to be performed, ejection fraction (LVEF), previous surgery, peripheral vascular disease, hypertension, diabetes mellitus, COPD, obesity, cardiac and respiratory failure, among others. The ISWT was conducted with a range of approximately 30 min between them. The test consists of walking in 10 m corridor in progressive speed imposed by sound signals. The signals require an increase of 0.17 m / s every minute until exhaustion and / or the presence of symptoms. The 6MWT consists of walking in a corridor of 30m by 6m, with verbal encouragement every minute. Before and after each test, were evaluated blood pressure, heart rate, dyspnea and fatigue of lower limbs by Borg Scale. The dynamometry was used to assess grip strength in kg / F. Results: In GI the average age was 65 years and 63 years in the IGI, in subgroup C was 71 years and 57 years at SC. The average BMI numbers for GI, GII, SC and C were, respectively, 27.7 Kg/m², 27,5 kg/m², 28,5 Kg/m²d 27 Kg/m². The average LVEF was 47%. The IGI showed the expected percentage of FPM significantly higher than the GII, and SC subgroup showed significantly better values of FPM both in absolute and in percentage of predicted compared to group C. The distance traveled in ISWT and 6MWT were significantly higher both in absolute and in percentage of predicted when comparing GI with GII, and when GC and GSC are compared, it is seen that those with worse prognosis walked significantly less in both tests. There was a learning effect in the 6MWT, as patients walked significantly more in the second test than the first, although the same can not be said about the ISWT because in this test the patients walked significantly less. The ISWT had a prognostic value for CAD and only one test proved to be necessary to assess the fitness of these patients. Conclusion: We conclude that patients with CAD have poorer cardiorespiratory fitness, and that only one ISWT test is able to evaluate the fitness of these patients and that this test has prognostic value in this population and that there was a learning effect in the 6MWT.
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Citação
BUENO, Flávia Regina. Aptidão Física e seu valor prognóstico no pós-operatório de cirurgia de revascularização do miocárdio. 2010. 36 f. Trabalho de conclusão de curso de graduação (Fisioterapia) - Instituto de Saúde e Sociedade (ISS), Universidade Federal de São Paulo (UNIFESP), Santos, 2010.