275.3 🏥 內科專科考前版

275.3.1 Mechanistic Deep Dive

275.3.1.1 Physiological Adaptations to Exercise

  • ↑ VO₂ peak via central (CO) + peripheral (a-v O₂ extraction)
  • ↑ stroke volume (cardiac remodeling)
  • ↓ resting HR (vagal tone)
  • ↑ capillary density, mitochondrial biogenesis
  • ↓ peripheral resistance
  • ↑ insulin sensitivity
  • Anti-inflammatory (↓ CRP, IL-6)
  • ↑ endothelial NO production

275.3.1.2 Exercise + Anti-Atherosclerotic Mechanisms

  • ↑ HDL, ↓ TG (less LDL change)
  • ↓ plaque burden (small effect)
  • ↑ endothelial function (FMD studies)
  • ↓ platelet aggregation
  • ↑ fibrinolysis
  • ↑ collateral vessel formation in chronic ischemia

275.3.2 Recent Trials & Updates

275.3.2.1 REHAB-HF (2021)

  • N = 349 acute decompensated HF (HFrEF + HFpEF)
  • 12-week CR within 4 weeks of discharge
  • ↑ SPPB (physical function), ↓ depression
  • ↓ 6-month rehospitalization rate
  • HFpEF benefit clearly shown

275.3.2.2 OPTIMEX-CLIN (2021)

  • HFpEF exercise training (HIIT vs MICT)
  • Both effective, MICT slightly better
  • Stamps HFpEF as exercise-responsive

275.3.2.3 HYCARET (2021)

  • Hybrid CR (home + center) non-inferior to traditional center-based
  • Lower dropout, higher completion
  • Cost-effective

275.3.2.4 TELEREH-HF (2023)

  • Tele-rehab for HF non-inferior to standard center-based
  • Wearable + video coaching
  • Promising for low-access populations

275.3.2.5 Heart Failure Exercise Trials Beyond HF-ACTION

  • ExTraMATCH 2 meta-analysis (2019): mortality benefit in stable HFrEF
  • HOLISTIC-HF: cognitive + behavioral integration with exercise

275.3.2.6 Wearable Tech + Mobile CR

  • Apple Watch + Fitbit + Garmin integration with CR programs
  • Real-time feedback
  • ECG, HR, activity tracking
  • Cardiac event detection (AF, fall)
  • Adherence monitoring

275.3.3 High-Yield Specialist Points

275.3.3.1 CR in Specific Conditions

LVAD Patients: - VO₂ peak limited despite circulatory support - Exercise improves QOL, may reduce HF symptoms - Bridge to transplant patients especially benefit

Heart Transplant: - Cardiac autonomic denervation → blunted HR response - Use RPE for intensity, not HR - Long-term: re-innervation in 6-12 months in some

TAVR: - Patients often elderly, frail - Pre-TAVR pre-habilitation increasingly recognized - Post-TAVR CR improves outcomes (TARC 2020)

HCM: - 2024 ACC/AHA: moderate-intensity exercise SAFE in stable HCM - High-intensity competitive sport individualized assessment - LIVE-HCM registry (2023): exercise safe

ICD Recipients: - Exercise safe with appropriate HR programming - Avoid exceeding ICD trigger threshold

Pulmonary HTN: - Pulmonary rehab improves capacity (RHC-confirmed PAH) - Use saturation + RPE

275.3.3.2 Quality Metrics

  • DEPACT (door-to-enrollment-to-PCI/ACS to CR < 21-28 days)
  • MIRACLE registry (US)
  • EuroAspire registry (Europe)

275.3.3.3 Recent Policy Developments

  • Medicare coverage for home-based CR expanded post-COVID
  • AHA Get With The Guidelines integration
  • Class I referral standards being mandated

275.3.3.4 Emerging Areas

  • Cancer cardiology (cardio-oncology) rehab
  • COVID-19 cardiac rehab (post-acute sequelae)
  • Pre-habilitation before cardiac surgery

275.3.3.5 Frailty + CR

  • Pre-CR frailty assessment (clinical frailty scale, SPPB)
  • Tailored program for frail (lower intensity, longer duration)
  • Sarcopenia + cachexia screening
  • Nutritional support, vitamin D, protein

275.3.4 Pearls

  • CR Class I post-ACS, post-PCI/CABG, HF (both r and pEF), valve, transplant, LVAD, PAD, HCM
  • Underutilization is the biggest problem — referral, enrollment, completion all suboptimal
  • Hybrid / tele-rehab is the future — equivalent outcomes with better access
  • HIIT safe + effective in stable CAD (SAINTEX-CAD)
  • REHAB-HF + REHAB-HFpEF established CR benefit in HFpEF
  • Smoking cessation alone reduces post-MI mortality by 36% — single biggest intervention