MOBILISATION BEI PATIENTEN MIT FRISCHEM MYOKARDINFARKT

Numerous publications reporting clinical experience and the results of controlled studies indicate that early mobilization after acute myocardial infarction, as compared with the conservative bedrest regimen, exerts no adverse effect on short or long-term prognosis. Unsettled, however, are the prerequisite criteria for time of initiation of mobilization, the type and the desired clinical degree of mobilization. Selection of the patients and different functional monitoring during mobilization generally do not permit accurate evaluation of treatment risk. To assess the feasibility and therapeutic results of early mobilization, all patients admitted to our clinic with acute myocardial infarction were entered into a mobilization program, according to WHO guidelines, which was standardized with respect to indication, physical therapy and functional monitoring. The results accumulated over a 5-year period were analyzed and compared with established prognostic criteria. The study group consisted of 502 patients documented to have acute myocardial infarction. Early mortality (prior to any form of mobilization) was 27.9%. Mobilization was not performed in a further 5.4% due to non-cardiac compromise of physical condition and in 2.4% due to inadequate cooperation. Severe impairment of cardiac function precluded mobilization in only 1%. In the remaining 320 patients (63.7%) mobilization was initiated after an average of 9.0±5.6 days from the onset of the acute event. The time of initiation correlated weakly with the CPI (coronary prognostic index, according to Norris et al.) and the maximal initial levels of CK and LDH. Only 75% of the patients completed the entire program. An uncomplicated course permitted early discharge in 6.3%. Mobilization was terminated in 8.4% due to congestive heart failure and severe arrhythmias and in 6.2% due to noncardiac causes. During the observation period, 4.1% died, apparently not directly related to mobilization procedures. Cardiovascular complications necessitating modification of the program were observed in 49.1%, the most frequent of which were threatening arrhythmias detected by ECG-telemetry (21.6%) and angina pectoris during exercise (12.8%). The rate of complication increased substantially in those with initial CPI values greater than 6.0, and initial maximal levels of CK, GOT and LDH in excess of 250 U/l, and 40 U/l and 480 U/l respectively. Similarly, an increased rate of complications was found in those with more than 1 or 2 humoral pathologic factors or elevation of the ST segments of more than 0.2 mV at the time of initiation of mobilization. The average duration for the entire mobilization was 22.8±8.2 days. The results of this study indicate that mobilization can be carried out in all patients with acute myocardial infarction provided that the indication for therapeutic measures are based on consideration of the severity of disease in the individual case. Careful observation under continuous monitoring is of particular importance during the first 2 days. For all practical clinical purposes, the contraindications, as recommended by the WHO, retain validity. Prior to initiation of mobilization the serum enzyme activity, in particular those of CK and CK-MB, should have returned to near-normal and ST-segment elevation should not exceed 0.2 mV. The rate of complication is determined primarily by the extent of the disease. Thus, the program should be tailored to the patient's needs with the amount of physical activity incremented stepwise accordingly. This procedure permits prospective application of a pre-determined mobilization program. Detailed functional monitoring plays a decisive role in determining the exercise capacity of the patient to enable the shortest but necessarily most effective duration of in-hospital management.