Паллиативная медицинская помощь при хронической сердечной недостаточности: немедикаментозные методы облегчения основных симптомов

Хроническая сердечная недостаточность является одной из основных причин роста смертности и инвалидизации населения по всему миру. На конечных стадиях хронической сердечной недостаточности, когда изнуряющие пациентов симптомы уже не поддаются лечению, встает вопрос об оказании паллиативной медицинской помощи. На сегодняшний день в актуальных клинических рекомендациях и руководствах отсутствуют данные о проведении паллиативных мероприятий в отношении данной категории пациентов. В таких условиях врачи часто не понимают, какую тактику ведения им необходимо избрать. Потому возрастает важность интеграции паллиативной медицинской помощи в лечение хронической сердечной недостаточности. Множество симптомов, сопряженных с терминальными стадиями хронической сердечной недостаточности, оказывают негативное влияние на общее состояние и качество жизни пациентов. Основными из них выступают одышка, боль, проявления астении, а также расстройства тревожно-депрессивного характера. В целях максимально возможного улучшения качества жизни таких пациентов паллиативная медицинская помощь должна быть комплексной: регулярная фармакотерапия, назначенная в соответствии с актуальными клиническими рекомендациями и сочетающаяся с различными немедикаментозными методами купирования основных симптомов. В качестве методов могут рассматриваться основные мероприятия кардиореабилитации, включающие регулярные физические тренировки, обучение соблюдению режима лечения, методикам управления стрессом, психологическую поддержку. Важное значение в организации паллиативной медицинской помощи имеют взаимоотношения пациентов и лиц, обеспечивающих уход, с медицинскими работниками. Адекватная и своевременная коммуникация необходима для улучшения самоконтроля и соблюдения медикаментозного лечения, предотвращения незапланированной госпитализации, информирования о принятии решений и в конечном счете обеспечения благополучной смерти. В статье рассматриваются основные концепции организации и оказания паллиативной
медицинской помощи пациентам с хронической сердечной недостаточностью, а также немедикаментозные паллиативные
мероприятия, предложенные европейскими, американскими и российскими специалистами.

1. Поляков ДС, Фомин ИВ, Беленков ЮН, Мареев ВЮ, Агеев ФТ, Артемьева ЕГ и др. Хроническая сердечная недостаточность в Российской Федерации: что изменилось за 20 лет наблюдения? Результаты исследования ЭПОХА-ХСН. Кардиология. 2021;61(4):4–14. https://doi.org/10.18087/cardio.2021.4.n1628.

2. Riley JP, Beattie JM. Palliative care in heart failure: facts and numbers. ESC Heart Fail. 2017;4(2):81–87. https://doi.org/10.1002/ehf2.12125.

3. Терещенко СН, Галявич АС, Агеев ФТ, Арутюнов ГП, Беграмбекова ЮЛ, Беленков ЮН и др. Хроническая сердечная недостаточность: клинические рекомендации. М.; 2020. 155 с. Режим доступа: https://cr.minzdrav.gov.ru/recomend/156_1.

4. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):1810–1852. https://doi.org/10.1161/CIR.0b013e31829e8807.

5. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. https://doi.org/10.1093/eurheartj/ehab368.

6. Jaarsma T, Beattie JM, Ryder M, Rutten FH, McDonagh T, Mohacsi P et al. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2009;11(5):433–443. https://doi.org/10.1093/eurjhf/hfp041.

7. Новиков ГА (ред.). Курс лекций по паллиативной медицине. М.: Российская ассоциация паллиативной медицины; 2017. 776 с. Режим доступа: https://www.msmsu.ru/upload/medialibrary/c72/c72093f5771c9b1558e0d512f63edb19.pdf.

8. Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs. 2005;4(3):198–206. https://doi.org/10.1016/j.ejcnurse.2005.03.010.

9. Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL. Symptom distress and quality of life in patients with advanced congestive heart failure. J Pain Symptom Manage. 2008;35(6):594–603. https://doi.org/10.1016/j.jpainsymman.2007.06.007.

10. Lokker ME, Gwyther L, Riley JP, van Zuylen L, van der Heide A, Harding R. The Prevalence and Associated Distress of Physical and Psychological Symptoms in Patients With Advanced Heart Failure Attending a South African Medical Center. J Cardiovasc Nurs. 2016;31(4):313–322. https://doi.org/10.1097/JCN.0000000000000256.

11. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263–e421. https://doi.org/10.1016/j.jacc.2021.12.012.

12. Piepoli MF, Conraads V, Corrà U, Dickstein K, Francis DP, Jaarsma T et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail. 2011;13(4):347–357. https://doi.org/10.1093/eurjhf/hfr017.

13. Remawi BN, Gadoud A, Preston N. The experiences of patients with advanced heart failure, family carers, and health professionals with palliative care services: a secondary reflexive thematic analysis of longitudinal interview data. BMC Palliat Care. 2023;22(1):115. https://doi.org/10.1186/s12904-023-01241-1.

14. Pandey A, Parashar A, Kumbhani D, Agarwal S, Garg J, Kitzman 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(1):33–40. https://doi.org/10.1161/CIRCHEARTFAILURE.114.001615.

15. Maddox TM, Januzzi JL Jr, Allen LA, Breathett K, Butler J, Davis LL et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021;77(6):772–810. https://doi.org/10.1016/j.jacc.2020.11.022.

16. Wisløff U, Støylen A, Loennechen JP, Bruvold M, Rognmo Ø, Haram PM et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation. 2007;115(24):3086–3094. https://doi.org/10.1161/CIRCULATIONAHA.106.675041.

17. Adams V, Reich B, Uhlemann M, Niebauer J. Molecular effects of exercise training in patients with cardiovascular disease: focus on skeletal muscle, endothelium, and myocardium. Am J Physiol Heart Circ Physiol. 2017;313(1):H72–H88. https://doi.org/10.1152/ajpheart.00470.2016.

18. O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439–1450. https://doi.org/10.1001/jama.2009.454.

19. Myers J. Principles of exercise prescription for patients with chronic heart failure. Heart Fail Rev. 2008;13(1):61–68. https://doi.org/10.1007/s10741-007-9051-0.

20. Taylor JL, Myers J, Bonikowske AR. Practical guidelines for exercise prescription in patients with chronic heart failure. Heart Fail Rev. 2023;28(6):1285–1296. https://doi.org/10.1007/s10741-023-10310-9.

21. Smart NA, Dieberg G, Giallauria F. Functional electrical stimulation for chronic heart failure: a meta-analysis. Int J Cardiol. 2013;167(1):80–86. https://doi.org/10.1016/j.ijcard.2011.12.019.

22. Kadoglou NP, Mandila C, Karavidas A, Farmakis D, Matzaraki V, Varounis C et al. Effect of functional electrical stimulation on cardiovascular outcomes in patients with chronic heart failure. Eur J Prev Cardiol. 2017;24(8):833–839. https://doi.org/10.1177/2047487316687428.

23. Haykowsky MJ, Daniel KM, Bhella PS, Sarma S, Kitzman DW. Heart Failure: Exercise-Based Cardiac Rehabilitation: Who, When, and How Intense? Can J Cardiol. 2016;32(10 Suppl. 2):S382–S387. https://doi.org/10.1016/j.cjca.2016.06.001.

24. Carvalho VO, Mezzani A. Aerobic exercise training intensity in patients with chronic heart failure: principles of assessment and prescription. Eur J Cardiovasc Prev Rehabil. 2011;18(1):5–14. https://doi.org/10.1097/HJR.0b013e32833a9c63.

25. Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244–1253. https://doi.org/10.1016/S0140-6736(11)60749-6.

26. Saeidifard F, Medina-Inojosa JR, West CP, Olson TP, Somers VK, Bonikowske AR et al. The association of resistance training with mortality: A systematic review and meta-analysis. Eur J Prev Cardiol. 2019;26(15):1647–1665. https://doi.org/10.1177/2047487319850718.

27. Cornelissen VA, Fagard RH, Coeckelberghs E, Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials. Hypertension. 2011;58(5):950–958. https://doi.org/10.1161/HYPERTENSIONAHA.111.177071.

28. Bjarnason-Wehrens B, Mayer-Berger W, Meister ER, Baum K, Hambrecht R, Gielen S et al. German Federation for Cardiovascular Prevention and Rehabilitation. Recommendations for resistance exercise in cardiac rehabilitation. Recommendations of the German Federation for Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2004;11(4):352–361. https://doi.org/10.1097/01.hjr.0000137692.36013.27.

29. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(5):572–584. https://doi.org/10.1161/CIRCULATIONAHA.107.185214.

30. Taylor JL, Bonikowske AR, Olson TP. Optimizing Outcomes in Cardiac Rehabilitation: The Importance of Exercise Intensity. Front Cardiovasc Med. 2021;8:734278. https://doi.org/10.3389/fcvm.2021.734278.

31. Hansen D, Abreu A, Ambrosetti M, Cornelissen V, Gevaert A, Kemps H et al. Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol. 2022;29(1):230–245. https://doi.org/10.1093/eurjpc/zwab007.

32. Savage PA, Shaw AO, Miller MS, VanBuren P, LeWinter MM, Ades PA, Toth MJ. Effect of resistance training on physical disability in chronic heart failure. Med Sci Sports Exerc. 2011;43(8):1379–1386. https://doi.org/10.1249/MSS.0b013e31820eeea1.

33. Sadek Z, Salami A, Joumaa WH, Awada C, Ahmaidi S, Ramadan W. Best mode of inspiratory muscle training in heart failure patients: a systematic review and meta-analysis. Eur J Prev Cardiol. 2018;25(16):1691–1701. https://doi.org/10.1177/2047487318792315.

34. Machado AC, Vianna LC, Gomes EAC, Teixeira JAC, Ribeiro ML, Villacorta H et al. Carotid chemoreflex and muscle metaboreflex interact to the regulation of ventilation in patients with heart failure with reduced ejection fraction. Physiol Rep. 2020;8(3):e14361. https://doi.org/10.14814/phy2.14361.

35. Palau P, Domínguez E, López L, Ramón JM, Heredia R, González J et al. Inspiratory Muscle Training and Functional Electrical Stimulation for Treatment of Heart Failure With Preserved Ejection Fraction: The TRAINING-HF Trial. Rev Esp Cardiol (Engl Ed). 2019;72(4):288–297. https://doi.org/10.1016/j.rec.2018.01.010.

36. Giallauria F, Piccioli L, Vitale G, Sarullo FM. Exercise training in patients with chronic heart failure: A new challenge for Cardiac Rehabilitation Community. Monaldi Arch Chest Dis. 2018;88(3):987. https://doi.org/10.4081/monaldi.2018.987.

37. Piepoli MF, Coats AJ. The ‘skeletal muscle hypothesis in heart failure’ revised. Eur Heart J. 2013;34(7):486–488. https://doi.org/10.1093/eurheartj/ehs463.

38. Piepoli MF, Guazzi M, Boriani G, Cicoira M, Corrà U, Dalla Libera L et al. Exercise intolerance in chronic heart failure: mechanisms and therapies. Part II. Eur J Cardiovasc Prev Rehabil. 2010;17(6):643–648. https://doi.org/10.1097/HJR.0b013e32833f3aa5.

39. Rehn TA, Munkvik M, Lunde PK, Sjaastad I, Sejersted OM. Intrinsic skeletal muscle alterations in chronic heart failure patients: a disease-specific myopathy or a result of deconditioning? Heart Fail Rev. 2012;17(3):421–436. https://doi.org/10.1007/s10741-011-9289-4.

40. Mancini DM, Henson D, La Manca J, Donchez L, Levine S. Benefit of selective respiratory muscle training on exercise capacity in patients with chronic congestive heart failure. Circulation. 1995;91(2):320–329. https://doi.org/10.1161/01.cir.91.2.320.

41. Cahalin LP, Arena RA. Breathing exercises and inspiratory muscle training in heart failure. Heart Fail Clin. 2015;11(1):149–172. https://doi.org/10.1016/j.hfc.2014.09.002.

42. Lan NSR, Lam K, Naylor LH, Green DJ, Minaee NS, Dias P, Maiorana AJ. The Impact of Distinct Exercise Training Modalities on Echocardiographic Measurements in Patients with Heart Failure with Reduced Ejection Fraction. J Am Soc Echocardiogr. 2020;33(2):148–156. https://doi.org/10.1016/j.echo.2019.09.012.

43. Munch GW, Rosenmeier JB, Petersen M, Rinnov AR, Iepsen UW, Pedersen BK, Mortensen SP. Comparative Effectiveness of Low-Volume Time-Efficient Resistance Training Versus Endurance Training in Patients With Heart Failure. J Cardiopulm Rehabil Prev. 2018;38(3):175–181. https://doi.org/10.1097/HCR.0000000000000304.

44. Пуховская МН, Цуцаева МВ, Климкина ДА, Булычев РЮ, Бодров ИМ, Рожаева КН и др. Дыхательные техники для улучшения спортивных результатов. М.: РЭУ им. Г.В. Плеханова; 2022. 123 с. Режим доступа: https://www.rea.ru/ru/org/cathedries/Kafedra-fizicheskogo-vospitanija/PublishingImages/Pages/studymaterials/Учебное%20пособие%20Дыхательные%20техники.pdf.

45. Spruit MA, Eterman RM, Hellwig VA, Janssen PP, Wouters EF, Uszko-Lencer NH. Effects of moderate-to-high intensity resistance training in patients with chronic heart failure. Heart. 2009;95(17):1399–408. https://doi.org/10.1136/hrt.2008.159582.

46. Bektas S, Franssen FME, van Empel V, Uszko-Lencer N, Boyne J, Knackstedt C, Brunner-La Rocca HP. Impact of airflow limitation in chronic heart failure. Neth Heart J. 2017;25(5):335–342. https://doi.org/10.1007/s12471-017-0965-4.

47. Ambrosino N, Cigni P. Non invasive ventilation as an additional tool for exercise training. Multidiscip Respir Med. 2015;10(1):14. https://doi.org/10.1186/s40248-015-0008-1.

48. Ito S. High-intensity interval training for health benefits and care of cardiac diseases – The key to an efficient exercise protocol. World J Cardiol. 2019;11(7):171–188. https://doi.org/10.4330/wjc.v11.i7.171.

49. Laohachai K, Winlaw D, Selvadurai H, Gnanappa GK, d’Udekem Y, Celermajer D, Ayer J. Inspiratory Muscle Training Is Associated With Improved Inspiratory Muscle Strength, Resting Cardiac Output, and the Ventilatory Efficiency of Exercise in Patients With a Fontan Circulation. J Am Heart Assoc. 2017;6(8):e005750. https://doi.org/10.1161/JAHA.117.005750.

50. Hägglund E, Hagerman I, Dencker K, Strömberg A. Effects of yoga versus hydrotherapy training on health-related quality of life and exercise capacity in patients with heart failure: A randomized controlled study. Eur J Cardiovasc Nurs. 2017;16(5):381–389. https://doi.org/10.1177/1474515117690297.

51. Yeh GY, Wood MJ, Wayne PM, Quilty MT, Stevenson LW, Davis RB et al. Tai chi in patients with heart failure with preserved ejection fraction. Congest Heart Fail. 2013;19(2):77–84. https://doi.org/10.1111/chf.12005.

52. Khatib MN, Kirubakaran R, Gaidhane S, Shankar A, Quazi Syed Z. Yoga for improving functional capacity, quality of life and cardiovascular outcomes in people with heart failure. Cochrane Database Syst Rev. 2016;(1):CD012015. https://doi.org/10.1002/14651858.CD012015.

53. Wang MH, Yeh ML. Respiratory training interventions improve health status of heart failure patients: A systematic review and network meta-analysis of randomized controlled trials. World J Clin Cases. 2019;7(18):2760–2775. https://doi.org/10.12998/wjcc.v7.i18.2760.

54. Беграмбекова ЮЛ, Каранадзе НА, Мареев ВЮ, Колесникова ЕА, Орлова ЯА. Комплексные тренировки дыхательной и скелетной мускулатуры у пациентов с хронической сердечной недостаточностью III–V функционального класса и низкой и промежуточной фракцией выброса левого желудочка. Дизайн и обоснование. Сибирский журнал клинической и экспериментальной медицины. 2020;35(2):123–130. https://doi.org/10.29001/2073-8552-2020-35-2-123-130.

55. Laoutaris ID, Adamopoulos S, Manginas A, Panagiotakos DB, Kallistratos MS, Doulaptsis C et al. Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study. Int J Cardiol. 2013;167(5):1967–1972. https://doi.org/10.1016/j.ijcard.2012.05.019.

56. Adamopoulos S, Schmid JP, Dendale P, Poerschke D, Hansen D, Dritsas A et al. Combined aerobic/inspiratory muscle training vs. aerobic training in patients with chronic heart failure: The Vent-HeFT trial: a European prospective multicentre randomized trial. Eur J Heart Fail. 2014;16(5):574–582. https://doi.org/10.1002/ejhf.70.

57. Таранина ОН, Тестова СГ, Алехина АВ. Способы коррекции тревожнодепрессивных расстройств на фоне хронической сердечной недостаточности у пациентов старших возрастных групп. Инновационная наука. 2020;(9):79–80. Режим доступа: https://aeterna-ufa.ru/sbornik/IN-2020-09.pdf.

58. Yu DS, Lee DT, Woo J, Hui E. Non-pharmacological interventions in older people with heart failure: effects of exercise training and relaxation therapy. Gerontology. 2007;53(2):74–81. https://doi.org/10.1159/000096427.

59. Gok Metin Z, Ejem D, Dionne-Odom JN, Turkman Y, Salvador C, Pamboukian S, Bakitas M. Mind-Body Interventions for Individuals With Heart Failure: A Systematic Review of Randomized Trials. J Card Fail. 2018;24(3):186–201. https://doi.org/10.1016/j.cardfail.2017.09.008.

60. Chang BH, Hendricks A, Zhao Y, Rothendler JA, LoCastro JS, Slawsky MT. A relaxation response randomized trial on patients with chronic heart failure. J Cardiopulm Rehabil. 2005;25(3):149–157. https://doi.org/10.1097/00008483-200505000-00005.

61. Yu DS, Lee DT, Woo J. Improving health-related quality of life of patients with chronic heart failure: effects of relaxation therapy. J Adv Nurs. 2010;66(2):392–403. https://doi.org/10.1111/j.1365-2648.2009.05198.x.

62. Yu DS, Lee DT, Woo J. Effects of relaxation therapy on psychologic distress and symptom status in older Chinese patients with heart failure. J Psychosom Res. 2007;62(4):427–437. https://doi.org/10.1016/j.jpsychores.2006.10.012.

63. Rogers AE, Addington-Hall JM, Abery AJ, McCoy AS, Bulpitt C, Coats AJ, Gibbs JS. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. BMJ. 2000;321(7261):605–607. https://doi.org/10.1136/bmj.321.7261.605.

64. Horne G, Payne S. Removing the boundaries: palliative care for patients with heart failure. Palliat Med. 2004;18(4):291–296. https://doi.org/10.1191/0269216304pm893oa.

65. Harding R, Selman L, Beynon T, Hodson F, Coady E, Read C et al. Meeting the communication and information needs of chronic heart failure patients. J Pain Symptom Manage. 2008;36(2):149–156. https://doi.org/10.1016/j.jpainsymman.2007.09.012.

66. Boyd KJ, Murray SA, Kendall M, Worth A, Frederick Benton T, Clausen H. Living with advanced heart failure: a prospective, community based study of patients and their carers. Eur J Heart Fail. 2004;6(5):585–591. https://doi.org/10.1016/j.ejheart.2003.11.018.

67. Zickmund SL, Blasiole JA, Brase V, Arnold RM. Congestive heart failure patients report conflict with their physicians. J Card Fail. 2006;12(7):546–553. https://doi.org/10.1016/j.cardfail.2006.03.008.

68. Zapka JG, Hennessy W, Carter RE, Amella EJ. End-of-life communication and hospital nurses: an educational pilot. J Cardiovasc Nurs. 2006;21(3):223–231. https://doi.org/10.1097/00005082-200605000-00011.