réadaptation et insuffisance cardiaque€¦ · *week intervals shown are goals and may vary for...
TRANSCRIPT
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Réadaptation et Insuffisance Réadaptation et Insuffisance Cardiaque Cardiaque
Dr Marie Christine IliouService de Réadaptation Cardiaque
Hôpital Broussais - Paris
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Interactions physiopathologiques dans l’IC Interactions physiopathologiques dans l’IC
Dysfonction VGDysfonction VGDysfonction VGDysfonction VG
Diminution du débit cardiaque
Stimulation neurohormonaleVasoconstriction
MuscleMuscleMuscleMuscleFatigue,Fatigue,
DéconditionnementDéconditionnement
ReinReinReinReinRétention HRétention H22O, NaO, Na
CongestionCongestion
CerveauCerveauCerveauCerveau
ConfusionConfusion
PoumonPoumonPoumonPoumon DyspnéeDyspnée
Autres Autres organesorganesAutres Autres organesorganes
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Pronostic IC (50 ans)
+ 1,5 ans
+ 15 %
Levy D, et al . N Engl J Med 2002;347:1397-402
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Pourquoi?• Améliorer capacités d’effort• Améliorer qualité de vie• Améliorer connaissance physiopathologique
de l’insuffisance cardiaque• Limiter mortalité, morbidité et ré-admissions
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Pour Qui ?Indications
• Insuffisance cardiaque stable durant 3 mois• Classe fonctionnelle II et III• Précautions pour classe IV• FE < 40 %• Traitement médical optimisé• Patients motivés pour programmes longs
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Insuffisance CardiaqueInsuffisance Cardiaque
Reduction of Reduction of physical activityphysical activity
(Dyspnea)(Dyspnea) FatigueFatigue
Muscles Deconditionning
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Comparaison sujet sain et insuffisant cardiaque en IRM musculaire
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MMusclesuscles and CHF and CHF
NormalNormal Heart failureHeart failure
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Épreuve d’effort avec mesure de VO2
Pic VO2, % de VO2/NormeParamètres sous maximaux : SAV, VE/VCO2
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Valeur du pic de VO2 pour l’évaluation pronostique des patients en insuffisance cardiaque
DM. Mancini et al, Circulation 1991; 83: 778-86DM. Mancini et al, Circulation 1991; 83: 778-86
*
* p < 0.05
0
25
50
75
100
0 3 6 9 12Mois
Surv
ie (%
)
> 18 ml/kg/min> 14, < 18 ml/kg/min< 14, > 10 ml/ kg/ min< 10 ml/kg/min
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Relation entre les capacités d’effort et Relation entre les capacités d’effort et la fonction systolique VGla fonction systolique VG
45
5
10
15
20
25
30
35
40
Pic
VOPi
c VO
2 (m
l/kg/
mn)
2 (m
l/kg/
mn)
5 10 15 20 25 30 35 40 45 50
FE VG isotopique (%)FE VG isotopique (%)
n = 124r = 0,12
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Revue littérature• 1996-2000 : 31 études
• 14 rand, 2 non randomisées, 8 cross-over, 7 pré-post test• 20 études < 25patients, 7 : 26 à 50 pts, 4 : 51 à 150 pts• Age <65 ans dans 21 études• Effets montrés sur
– Capacité d’effort : 27– Qualité de vie : 11– Mortalité : 1– Réadmissions : 1
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Auteur année n FE(%)
Intensité(%)
Durée(sem)
pic VO2
(%)p
Coats 1992 17 2020 70-80 12 + 18 <0.01Koch 1992 25 26 Fc <115 12 + 34+ 34 <0.0001Kayanakis 1994 48 30 50 33 + 16 <0.05Belardinelli 1995 27 30 4040 8 + 17 <0.001Hambrecht 1995 22 26 70 24 + 33 <0.01Keteyan 1996 29 21 60-80 24 + 16 <0.01Wilson 1996 27 23 60-70 12 + 8.5 NSKilavuori 1996 27 25 50-60 24 +12 NSMeyer 1996 18 21 50 3 + 20 <0.01Demopoulos 1997 16 21 <50 12 + 30 <0.05Dubach 1997 25 33 70-8070-80 8 +29 <0.05Hambrecht 1998 20 24 60 26 + 26 <0.05Piepoli 1998 134 25 70-80 6-16 + 13 <0.01Wielenga 1999 80 29 60 12 + 10 NSBelardinelli 1999 99 28 60 5252 + 18 <0.001McKelvie 2002 181 <40 60-70 12 + 10+ 10 <0.01
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Effets sur VO2 au maximum de l’effort et au seuil d’adaptation ventilatoire
Exercice Control
Dubach P, JACC 1997;29:1591
(ml/kg/min)
8
13
18
23
28
1 2 3
* *Max
* *SAV
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Amélioration du seuil d’adaptation ventilatoire
MJ. Sullivan et al, Circulation 1989;79:324-29
8
12
16
20
Pre training Post training
VO
2 (m
l/Kg/
min
) at t
heve
ntila
tory
ana
erob
ic th
resh
old
p = 0.01
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Effets de l’entraînement sur les symptômes
Kayanakis J, Presse Med, 1994; 23 : 121
1
2
3
4
Before 3 weeks 3 months
NYH
A
Control group Training group
* p < 0.05
** NS
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Effets de l’entraînement sur la fréquence cardiaque
Coats A, Circulation 1992 ; 85 : 2119-31
70
80
90
100
110
120
130
140
0 25 50 75 100 125
Load (Watts)
Hea
rt r
ate
RestTraining
***
*
*
* p < 0.05*** p < 0.001
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Effets de l’entraînement sur le débit cardiaque
Coats A et al, Circulation, 1992 ; 85 : 2119-31
4
4,5
5
5,5
6
6,5
7
7,5
0 25 50 75 100Load (Watts)
Card
iac ou
tput (
l/min)
RestTraining
**
* p < 0.05
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Effets hémodynamiques au maximum de l’effort
Dubach P, JACC 1997;29:1591
Débit cardiaque D AV PAPo
Exercice (n=12) Control (n=13)
* *
9
10
11
12
13
14
15
1 312
12,5
13
13,5
14
14,5
15
1 38
10
12
14
16
18
20
1 3
(l/min) (ml/dl) (mmHg)
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ELVD - CHFELVD - CHF
Giannuzzi P et al. Circulation 2003;108:554-559Giannuzzi P et al. Circulation 2003;108:554-559
80
100
120
140
160
180
200
Vol TD Vol TS
(ml/m2)
*
*
0
5
10
15
20
25
30
35
40
F Ey
(%)
*
n = 456 months ETTraining Control
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Effets sur remodelage Ciné-IRM
80
85
90
95
100
105
Ex Avant Ex Apres C Avant C Apres
Vol TD VG Masse VG
NS NS
Dubach P, J Am Coll Cardiol 1997;29:1591Groupe Entraîné Groupe Contrôle
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Effets sur la vitesse de relaxation Ciné-IRM (n=24 CMD)
0
5
10
15
20
25
Exercise Control
Pre Post
(degré/sec)p<0.05 NS
Dubach P, AHA 2001Dubach P, AHA 2001
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Improvement of muscular Improvement of muscular metabolismmetabolism
S. Adamopoulos et al, JACC, 1993 ; 21 : 1101-06S. Adamopoulos et al, JACC, 1993 ; 21 : 1101-06
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
Rest 2 4 peak
TrainedDetrainedControls
PCr/
(PC
r +
Pi)
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Effets de l’entraînement sur la ventilation
0
10
20
30
40
50
60
Rest 25 W 50 W Peak
Min
ute
vent
ilatio
n (l/
min
)
RestTraining
Coats A et al,Circulation 1992;85:2119
**
* p < 0.05
(17 pts)
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Effets de l’entraînement sur la fonction endothéliale
B Hornig et al,Circulation, 1995;1996:210B Hornig et al,Circulation, 1995;1996:210
* * *
Normals CHF CHF training
p<0.05 p<0.05
0
5
10
15
20Pe
rcen
t cha
nge
in d
iam
eter Before L-
NMMAAfter L-NMMA
NO synthase
L-arginine NOL-NMMA
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Effets sur le système nerveux autonome
AJS. Coats et al, Circulation 1992; 85: 2119-31AJS. Coats et al, Circulation 1992; 85: 2119-31
HRV PSA-HF
PSA-LF NE rest NE ex
Vag
al
Sym
path
etic Detraining
Training
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Effet immuno-modulateur
0123456789
Baselin
e
Training
Detrain
ing0123456789
10
Baselin
e
Training
Detrain
ing
TNF- Il-6(pg/ml) (pg/ml)
p<0.001p<0.001 p<0.001p<0.001 p<0.001p<0.001p<0.001p<0.001
Adamopoulos S, J Am Coll Cardiol 2002; 39:653
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Passino et al. JACC 06
TNF, IL6 etc …
Exercise Training in Heart Failure:Exercise Training in Heart Failure: Improved Autonomic Function and neurohormonesImproved Autonomic Function and neurohormones
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Effets de l’entraînement sur le pronostic
Belardinelli et al, Circulation,1999 : 1173Belardinelli et al, Circulation,1999 : 1173
p = 0,01
(n = 50)
(n = 49)
R
NR
Mortalité cardiaque (-22,8 %)Mortalité cardiaque (-22,8 %)
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Belardinelli et al, Circulation, 1999 : 1173Belardinelli et al, Circulation, 1999 : 1173
p = 0,006(n = 50)
(n = 49)
R
NR
Effets de l’entraînement sur le pronostic Evénements cardio-vasculaires (- 42 %)
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Effets de l’entraînement sur le pronostic
Belardinelli et al, Circulation, 1999 : 1173Belardinelli et al, Circulation, 1999 : 1173
p = 0,02(n = 50)
(n = 49)
R
NR
Hospitalisations pour Ins Cardiaque (-19%)Hospitalisations pour Ins Cardiaque (-19%)
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EXERT study6 min walk test
McKelvie R, Am Heart J 2002;144:23-30
300
350
400
450
500
Avant 3 mois 1 an
Exercise Control
(m)NS NSNS
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EXERT study
McKelvie R, Am Heart J 2002;144:23-30
0
200
400
600
800
1000
1200
1400
Avant 3 mois 1 an
Exercise Control
(ml/min)
Pic VO2
***
**
90 91 83 7580 64
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EXERT studyQualité de vie (Minnesota)
McKelvie R, Am Heart J 2002;144:23-30
05
10152025303540
Avant 3 mois 1 an
Exercise Control
NS NSNS
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McKelvie RS et al. Am Heart J. 2002;144:23-30
EXERT study : pas effet sur mortalité
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EXERT study : pas effet sur les rehospitalisations
McKelvie RS et al. McKelvie RS et al. Am Heart JAm Heart J. 2002;144:23-30. 2002;144:23-30
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Effets sur le pronostic
Belardinelli(n=99)
Mc Kelvie(n=181)
Mortalité cardiaqueMortalité cardiaque -23 %(p=0.002)(p=0.002)
NS
Hospitalisations ICHospitalisations IC -19 %(0.02)(0.02)
NS
Adhésion Adhésion programmeprogramme
89 % < 70 %
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ExTraMATCH Meta-Analysis
ExTraMATCH Colloborators, BMJ Online First, bmj.com; 2004ExTraMATCH Colloborators, BMJ Online First, bmj.com; 2004
HR 0.72
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ExtraMATCH meta analysis 9 studies (1997-2002) Training
(n=395)Control(n=406)
Age (years) 60.5 59.7Males (%) 88.4 87.2IHD (%) 59.7 58.7LVEF (%) 28 ± 8 27 ± 8Peak VO2 (ml/kg/min) 15.4 ± 4 15.2 ± 4
2 years mortality 22.2 % *22.2 % *(15.4 – 25.8)
25.8 %25.8 %(20.7 – 31.8)
2 years hospitalisations
34.0 % *34.0 % * 42.3 %42.3 %13 patients needed to treat to prevent 1 hospitalization at 2 years
Piepoli M . BMJ 2004:1-7Piepoli M . BMJ 2004:1-7
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Efficacy and Safety of Exercise Training as a Treatment Modality in Patients With Chronic
Heart Failure: Results of A Randomized Controlled Trial Investigating Outcomes of Exercise TraiNing
(HF-ACTION)
David J. Whellan, MD, MHSJefferson Medical College, Philadelphia, PA
Christopher M. O’Connor, MDDuke University Medical Center, Durham, NC
Funded by NHLBIAncillary studies funded by GE Healthcare and Roche Diagnostics
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Exercise Training Program
*Week intervals shown are goals and may vary for individual participants.
Training Phase
Location Week* Sessions/ week
Aerobicminutes
Intensity(% HR reserve)
TrainingMode
Initial Supervised
Clinic 1-2 3 15-30 60% Walk/Cycle
Supervised Clinic 3-6 3 30-35 70% Walk/Cycle
Supervised & Home
Clinic & Home
7-12 3 & 2 30-35 70% Walk/Cycle
Maintenance Home 13-end 5 40 60-70% Walk/Cycle
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Baseline Medications and Devices
0%
25%
50%
75%
100%
ACEI or A
RB
Beta block
er
Aldostero
ne antag
Loop diuret
ic
Digoxin ICD
BiV pacer
Perc
ent o
f Pat
ient
s Usual CareExercise Training
92% 95%76%
43% 45% 40%
18%
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Median Change in 6-Minute Walk and Cardiopulmonary Exercise (CPX) Tests
UsualCare
ExerciseTraining
P-value
6-minute walk distance (m) 5 20 <0.0001CPX exercise duration (min.) 0.3 1.5 <0.0001Peak VO2 (mL/min/kg) 0.2 0.6 <0.0001
* Complete case analysis
Baseline to 3 months*
UsualCare
ExerciseTraining
P-value
6-minute walk distance (m) 12 13 0.26CPX exercise duration (min.) 0.2 1.5 <0.0001Peak VO2 (mL/min/kg) 0.1 0.7 <0.0001
Baseline to 12 months*
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0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0 0.5 1 1.5 2 2.5 3
Eve
nt R
ate
Years from Randomization
Usual CareExercise
All-Cause Mortality or All-Cause Hospitalization
(Primary) HR 0.93 (95% CI: 0.84, 1.02), P = 0.13*Adjusted HR 0.89 (95% CI: 0.81, 0.99), P = 0.03
* Adjusted for key prognostic factors* Adjusted for key prognostic factors
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CV Mortality or CV Hospitalization
HR 0.93 (95% CI 0.84, 1.02, P=0.13)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0 0.5 1 1.5 2 2.5 3
Eve
nt R
ate
Years from Randomization
Usual CareExercise
HR 0.92 (95% CI: 0.83, 1.03), P = 0.14*Adjusted HR 0.91 (95% CI: 0.82, 1.01), P = 0.09
* Adjusted for key prognostic factors* Adjusted for key prognostic factors
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0
0.1
0.2
0.3
0.4
0 0.5 1 1.5 2 2.5 3
Eve
nt R
ate
Years from Randomization
Usual CareExercise
CV Mortality or HF Hospitalization
HR 0.87 (95% CI: 0.75, 1.00), P = 0.06*Adjusted HR 0.85 (95% CI: 0.74, 0.99), P = 0.03
* Adjusted for key prognostic factors* Adjusted for key prognostic factors
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>70
Subject Group Interaction P-valueN HRAll SubjectsAge70
SexFemaleMale
Etiology of HFIschemicNon-ischemic
2331 0.930.69
1896435
0.920.96
0.176611670
0.830.97
0.7311971134
0.940.91
Exercise Better Usual Care Better0.5 1.0 2.0
>25
Baseline NYHA Class
LVEF25
History of MINoYes
On ACE-inhibitorNoYes
1477 0.95
0.6812171110
0.940.91
0.60
0.12979
1352
5951736
0.910.96
0.810.97
IIIII/IV 854 0.85
0.27
Subgroup Analysis
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Exercise Training: Minutes Per Week
Goal
Goal
Mean : 50 min0
20
40
60
80
100
120
140
160
180
200
1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 25-36Study Months
Med
ian
(25t
h, 7
5th)
Exe
rcis
e Ti
me
(min
/wk)
30%
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Serious Adverse EventsUsual Care
N=1172Ex Training
N=1159At least one CV event * 40% 37%At least one ICD firing 23% 22%Hospitalized after physical activity 2% 3%Hospitalized for fracture of hip/pelvis 0.6% 0.3%Deaths identified as possibly occurring within 3 hours of physical activity
0.4% 0.4%
* Worsening HF, MI, unstable angina, serious adverse arrhythmia, stroke, TIA
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Training in CHF
Aspects pratiquesAspects pratiques
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Entraînement en endurance
• Idéal : bicyclette ergométrique : • entraînement à très faible charge possible• reproductibilité• surveillance (télémétrie, PA...)• Possibilité de choisir le type d'exercice :
– exercice continu ou en intervalles
• Tapis : complémentaire, mais :• chutes• surveillance plus difficile
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Réadaptation segmentaire
• Entraînement à 25 à 50% de la force musculaire maximale
• Tous groupes musculaires• 3x10 contractions-relaxations par muscle et par
séance
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En pratique
• Entraînement à 25 à 50% de la force musculaire maximale
• Tous groupes musculaires• 3x10 contractions-relaxations par muscle et
par séance
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Muscular electro -stimulationMuscular electro -stimulation• CI : pacing • Quadriceps• Good local and cardiovascular tolerance
• Improvement of symptoms, increase in muscular strengh and in exercise capacity. Maillefert et al , J Cardiopulm Rehab 1998Maillefert et al , J Cardiopulm Rehab 1998
• Significant improvement of submaximal parameters (6’ walk test).Harris et al, Eur Heart J 2003Harris et al, Eur Heart J 2003
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Résultats BroussaisRésultats Broussais 1997-2004
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PopulationN = 262
Age (ans) 54 ± 12Sexe Masculin 230 (88%)Ischémiques 164 (87%)CM Dilatées 98 (13%)Rythme sinusal 216 (82%)FE VG (%) 27,8 ± 8,2VO2 (ml/kg/min) 15,6 ± 5,0
SAV (ml/kg/min) 10,6 ± 3,5IEC/ARA II 255 (97%)bloquants 159 (61%)Diurétiques 207 (79%)Antialdostérone 101 (39 %)
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Traitements
n %
IEC 194 94
Diurétiques 161 78
B Bloquants 121 58
Digoxine 38 18
Spironolactone 65 31
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Échocardiographie
DTD VG (mm) 63.5 ± 8.1
DTS VG (mm) 50.5 ± 10.1
Onde E (cm) 0.82 ± 0.33
Onde A (cm) 0.58 ± 0.27
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Réadaptation• 21 ± 10 séances• Adhérence au programme : 85 ± 14 %
(ml/kg/min)
0
5
10
15
20
Pic VO2 SAV
Avant Apres
* *
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Événements cardiaques en fonction SDNN > ou < 20 %
Iliou et al, ESC 2001
SDNN > 20 %SDNN < 20 %
0
,2
,4
,6
,8
1
0 2 4 6 8 10 12 14
p < 0,05
months
Surv
Car
diac
Eve
nts F
ree
57 patients
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Changes on NT-proBNP levels after exercise training
0500
1000150020002500300035004000
LVEF < 35 % LVEF > 35%
Before ETAfter ET
(pg/ml)
NSNS
p = 0.04p = 0.04
Iliou, AHA 2003
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Après re-synchronisation
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Peak VO2
9,5
13,214,6
5
7
9
11
13
15
17
19
Before PM After PM After Training
39
53,3
62,4
20
30
40
50
60
70
80
Before PM After PM After Training
0.09<0.05 NS<0.05
<0.05<0.05
% theor VO% theor VO22(ml/kg/min) (%)
+ 49 % + 11 %
Iliou , EJCPR 2004Iliou , EJCPR 2004
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0
5
10
15
20
25
I II III
peak VO2
**
0
20
40
60
80
100
I II III
Compliance
*
Facteurs prédictifs réponse à l’entraînement
I : gain VO2 > 10 % II : gain VO2 0 - 10 % III : aggravation VO2 < 10 %
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Facteurs prédictifs réponse à l’entraînement
Baseline peak VO2
Peak
VO
2 (a
fter-b
asel
ine)
/bas
elin
e
-0,6
-0,4
-0,2
0,0
0,2
0,4
0,6
0,8
1,0
1,2
5 10 15 20 25 30 35 40 45
r = -0.3214p <0.05
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Effets de la réadaptation Effets de la réadaptation
AJS. Coats et al, Circulation 1992 ; 85 : 2119AJS. Coats et al, Circulation 1992 ; 85 : 2119
Baseline Training Rest0
5
10
15
20Exercise duration (min)
p < 0.001
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Adhérence au programme et tolérance à l’effort
Coats A et al, Circulation 1990;85:2119-31
-10-20-30-40
0 20 40 60 80 100 120Compliance (%)
010
20
30
40
50
60
70
% increase in exercise time
r = 0.74, p< 0.01
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Risques de l’entraînement physique
(16 essais, 659 patients)
47
313
19
280
0%10%20%30%40%50%60%70%80%90%
100%
Exercice Control
Pas d'événements Evénements
(13%) (6.4 %)
Événements Entraînement(n = 360)
Contrôle(n = 299)
Décès 1111 4Ins. cardiaque 77 4Greffe 3 1Fatigue 5 0Refus 9 3Tr. rythme 55 1Autres 7 6Total 47 19
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Contre-indications• Absolues
– Aggravation progressive de dyspnée au repos ou dans les 3-5 js– Ischémie à faible niveau (<2 METs, < 50 watts)– Diabète mal équilibré– EP ou phlébite récente– Péricardite ou myocardite active– Insuffisance valvulaire nécessitant correction chirurgicale , RA
modéré ou sévère– IDM < 3 semaines– FA récente
• Relatives– Prise > 2 kg dans les 3 js précédents– Classe IV– Traitement continu ou intermittent par Dobutamine– Troubles du rythme ventriculaires sevères au repos ou à l’effort– FC repos > 100 b/min– Co-morbidités
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Entraînement endurance : 3 à 5 fois par semaine
• Endurance en continu • échauffement 5 mn• effort stable : 20-30 mn• récupération 5 mn
• Efficace : protocoles utilisés dans toutes les études :
• Amélioration fonctionnelle• Morbi-mortalité
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"Interval Training"• But :
• obtenir un exercice musculaire plus intense sans majorer le "stress" cardiaque :
» en restant "aérobique"» prouvé par la mesure du taux de lactates et du rapport
VCO2/VO2
• Encore peu utilisé• En développement grâce à la programmation des
cycloergomètres
Meyer K. Am J Cardiol 1998; 82 : 1382-87
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Interval training• Résultats : Comparables à l'entraînement classique mais :
• Plus rapidement obtenus• Effort plus intenses maintenus sur de très courte durée =
– Probable amélioration de la qualité de vie
• Technique : "créneaux" : • travail : 30 secondes :
– 50% du travail maximal sur EE abrupte ( 25 w/10sec après 3 mn d'échauffement) : soit 70 à 100 watts
– (90% de la VO2 ?)• récupération : 60 sec 10-15 w
Meyer K.Med Sci Sports Exerc 1997; 29(3) : 306-12
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Myers et al, AmJ Cardiol 1996Myers et al, AmJ Cardiol 1996
Protocole Intervalles
Amélioration des capacités physiques, de la tolérance à l’effort
2-3 fois par semaine
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Protocole Intervalles
0
2
4
6
8
10
12
14
16
Pic VO20
100
200
300
400
500
600
BNP
Kreulich K et al, ESC 2001Kreulich K et al, ESC 2001
Réadaptation n= 17Contrôle n= 17
* ns ns*
ml/kg/min pg/ml
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Entraînement en résistance = « musculation »
• Objectifs : – Gagner en masse musculaire plus rapidement
pour :• Débuter la réadaptation chez des sujets très
déconditionnés• Parfaire le reconditionnement de l’ensemble des
patients
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Techniques utilisées
• Banc de Koch
• Haltères
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Réadaptation segmentaire
0
5
10
15
20
25
30
FEI Durée EE Force Musc pic VO2 SAV
AVANT APRES
Chevallier et al, Arch Mal Cœur 1996 Chevallier et al, Arch Mal Cœur 1996
P <0.01P <0.01
P <0.01P <0.01
nsns
nsnsnsns
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• Natation1: déconseillée dans sa forme classique
– conséquences de l'immersion :• augmentation du retour veineux (+ 700 ml),• dilatation ventriculaire gauche, • élévation de la Pcp (de 9 à 21 mmhg au repos chez
les coronariens à bon VG)– Natation lente : 25m/mn :
• Elevation de Fc, lactates et VO2 équivalente à un effort de 100 à 150 watts
(1) Meyer K. Exercise training in heart failure : recommendations.Med Sci Sports Exerc 2001; 33 : 525-31
L'Entraînement "aérobie"
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• centrée sur le patient• processus d’adaptation du patient à la maladie, les représentations de la
santé et de la maladie, les aspects socioculturels, les besoins objectifs et subjectifs,
• intégrée au traitement et aux soins• concerne la vie quotidienne du patient et doit impliquer autant que
possible son entourage proche• processus continu, adapté en permanence à l’évolution de la maladie et
fait partie de la prise en charge au long cours• structurée, organisée et proposée systématiquement à tous les patients• moyens et des méthodes variés d’éducation et d’apprentissage• pluridisciplinaire et nécessite un travail en réseau• évaluation du processus d’apprentissage et de ses effets• réalisée par des professionnels de santé formés à cet effet
Éducation thérapeutique : Critères OMS
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Effets d’un programme d’éducation
0
10
20
30
40
50
60
70
80
90
100
Réadmission Réadm IC >1 readm js hospit
ControlEducation
(n)
Rich M, N Engl J Med 1995;333:1190-5
p = 0.02
p = 0.04
p = 0.01
p = 0.04
282 patients ICC > 70 ans suivi 90 jours
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DIAL study
AHA Nov 2002
51 centres en Argentine, suivi 457 jours par des Infirmières
26,5
31
16,8
22,3
34,3
39,1
15,316,1
0
5
10
15
20
25
30
35
40
DC ou Hospit IC Hospit IC Hospit Mortal totale
Téléphone (n=760)Contrôles (n= 758)
- 20 %20 %(0.026)
- 29 %29 %(0.005)
- 15 %15 %(0.05)
- 5 %(0.69)
(%)
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Effets sur la survie106 patients (sur 1964 patients)
1 visite 2-3 semaines/épisode aigu
Strömberg A, Eur Heart J 2003;24:1014-1023
0
10
20
30
40
50
60
70
80
90
100
0 80 160 240 320
InterventionControl
surv
ie
p = 0.005
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Programme d’éducation Ins Cardiaque
• Cours : – Maladie– Diététique– Équivalents sel– Traitements– Vie quotidienne– Exercice et activités physiques– Signes de décompensation
• Atelier « courses »
• Évaluation • Clinique• Connaissances• Réajustements
• Film
• Brochures
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Atelier « courses »
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(Dialogue, mardi 10h35):
La secrétaire hospitalière (anxieuse): il faut reprendre M. Lapoissequi est aux urgences en arythmie….
La surveillante ( résignée) : pas de lit … je vais voire l’interne
L’interne (conciliant): • soit: M. Leglu attend la convalo depuis 1 semaine: finalement il peut sortir: je vais voir ça avec lui( il sort…et n’ira pas en réadaptation initialement prévue)
• soit: M. Limite est un peu juste pour rentrer chez lui allez voir où en est la demande de convalo !( il prend la place du précédent et se retrouve en réadaptationsans l’avoir demandé)
La réadaptation vue par les équipes hospitalières:
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La réadaptation vue par les malades….
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En vrai….
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Conclusions
• Améliorations de la tolérance à l ’effort
• Réduction de la mortalité ( à confirmer : HF-ACTION)
• Nécessite programmes personnalisés
• Fait partie du traitement de l’IC