拒絕心力衰竭 打造強健心臟之路

Maurice Cloutier has chronic heart failure. He and his doctor credit his regular attendance at a cardiac rehabilitation program with keeping him out of the hospital.
莫里斯·克盧捷(Maurice Cloutier)患有慢性心力衰竭。他和他的醫生將其不用住院的原因歸功於定期參加心臟康復計劃。

Such rehabilitation programs are opening up to more people with chronic heart failure, one of medicine's most debilitating and costly illnesses, following a recent change in Medicare reimbursement rules. After nearly a decade of deliberation, Medicare officials decided to cover cardiac rehabilitation for these patients, clearing a big obstacle to supervised exercise and counseling programs for hundreds of thousands of people.
如何應對心力衰竭？慢性心力衰竭是醫學中最易使人衰弱、治療成本最高的疾病之一。在“醫療保險計劃”（Medicare）報銷規定近期發生變化之後，此類康復計劃開始向更多這類患者開放。經過近10年的仔細考慮後，“醫療保險計劃”官員決定爲這些患者償付心臟康復費用，從而清除了數十萬人進行有看護的鍛鍊及加入諮詢計劃的一大障礙。

'This takes the most disabled heart patients and gives them a chance to improve their functional capacity and quality of life,' said Philip Ades, medical director of cardiac rehabilitation at Fletcher Allen Health Care in Burlington, Vt., and Mr. Cloutier's doctor. 'Twenty years ago we told them to go sit in an arm chair. Now we can hand you back part of your life.'
佛蒙特州伯靈頓弗萊徹艾倫醫療中心(Fletcher Allen Health Care)心臟康復醫務主任菲利普·埃茲(Philip Ades)說：“它囊括了行動最不便的心臟病患者，爲他們提供了提高身體機能和改善生活質量的機會。在20年前我們會讓他們在扶手椅中靜坐，現在我們能讓你恢復一部分正常生活。”

Heart failure is a chronic condition in which the heart can't pump a sufficient supply of blood to deliver oxygen to other organs in the body. It results in shortness of breath, fatigue and edema, a buildup of fluids in the lungs and extremities such as the ankles. Some 6.5 million Americans are living with heart failure. An additional 650,000 new cases are diagnosed each year, according to the American Heart Association, though Medicare data suggest the number is higher. Heart failure is the most common reason Medicare beneficiaries end up in the hospital. Though Medicare has long covered cardiac rehab for patients recovering from a heart attack or heart surgery, the burgeoning population of heart-failure patients has largely been left out.
心力衰竭是一種慢性疾病，病因是心臟無法泵出足夠的血液爲其他身體器官提供氧氣。它會引發呼吸短促、疲勞和水腫（即液體積聚在肺部和腳踝等手足部位）等症狀。美國約有650萬人患有心力衰竭。美國心臟協會(American Heart Association，簡稱“AHA”)的數據顯示，每年還有65萬人被新診斷出患上該疾病。不過“醫療保險計劃”的數據顯示，新患者的數目比這個數字更高。心力衰竭是“醫療保險計劃”受益者住院最常見的原因。儘管“醫療保險計劃”早就爲因心臟病發作或心臟病手術而實施心臟康復的患者償付費用，但隊伍不斷壯大的心力衰竭患者中的多數人都被排除在外。

A big factor in Medicare's decision was a 2,300-patient study called HF-Action, published five years ago. It found three weekly exercise sessions over 12 weeks were associated, after certain adjustments, with a modest 11% reduction in death and hospitalizations among patients with heart failure.
美國“醫療保險計劃”的官員之所以決定擴大償付範圍，一個重要因素是五年前發表的一項名爲“HF-Action”的研究。它對2,300名患者展開了研究，結果發現經過某些調節後，每週三次、共持續12周的鍛鍊計劃與心力衰竭患者的死亡率和住院率溫和下降11%存在關聯。

Dr. Ades, who is also a professor at University of Vermont College of Medicine, and other experts for the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology, AHA and the Heart Failure Society of America, used the HF-Action data and other recent research as the basis of their argument to Medicare to extend coverage for cardiac rehab.
埃茲醫生也是佛蒙特大學(University of Vermont)醫學院的教授，他與來自美國心血管與肺康復協會(American Association of Cardiovascular and Pulmonary Rehabilitation)、美國心臟病學會(American College of Cardiology)、AHA、美國心力衰竭學會(Heart Failure Society of America)的其他專家運用了HF-Action的數據及其他的最新研究，將它們作爲說服“醫療保險計劃”官員擴大心臟康復報銷範圍的理據基礎。

Medicare officials were persuaded by the quality of the study, the benefit of a physician-supervised exercise program, and the counseling component to guide lifestyle and other changes. 'When you look at the big picture, it was a positive step forward' to extend coverage, said Tamara Syrek-Jensen, acting director for the coverage and analysis group at the Centers for Medicare and Medicaid Services, which administers the Medicare program.
醫療保險計劃的官員被該研究的質量、醫生看護鍛鍊計劃的好處，以及指導生活方式及其他變化的諮詢計劃所說服。醫療保險計劃管理方——醫療保險與醫療救助服務中心(Centers for Medicare and Medicaid Services)負責償付與分析的代理主任塔瑪拉·希賴克-詹森(Tamara Syrek-Jensen)說：“從全局來看，（擴大償付範圍）是個積極的進步。”

Patients and clinicians hope increased access to a structured exercise program will not only improve and prolong patients' lives but reduce hospital admissions -- and readmissions. An estimated 17% of the 42 million elderly beneficiaries of Medicare have a heart-failure diagnosis and account for about 800,000 hospital admissions a year.
患者與醫生希望，提供更多的機會供患者參加有組織的鍛鍊計劃，不僅會改善患者的生活，延長他們的壽命，還能降低住院以及再次住院的數量。醫療保險計劃的4,200萬名早期受益者中估計有17%的人被診斷患有心力衰竭，每年因此住院的數量爲80萬人次。

But patients with heart failure are often frailand much sicker than the type of patients most cardiac-rehab programs are used to working with. 'They have low confidence in what they can do physically,' said Randal Thomas, preventive cardiologist at the Mayo Clinic in Rochester, Minn. 'To convince people they can benefit is going to be a bit of a challenge.'
但是，心力衰竭患者往往比過去大多數心臟康復計劃服務的患者更虛弱，病情更嚴重。明尼蘇達州羅徹斯特梅約醫院(Mayo Clinic)的心臟病預防醫生蘭德爾·托馬斯(Randal Thomas)說：“他們對自己能從事什麼體力活動信心不足，讓他們相信他們能從中獲益會有一定難度。”

Many heart-failure patients struggle to climb a flight of stairs, go grocery shopping or perform other routine daily activities. They commonly have other medical problems as well that complicate their treatment. Fifty percent of people diagnosed with heart failure die within five years.
許多心力衰竭患者爬一段樓梯、購買食品雜貨或者做些其他日常活動時非常費力。他們通常還患有其他病症，這讓他們的治療變得更爲複雜。被診斷患有心力衰竭的患者有50%的人在五年內去世。

Although patients recovering from a heart attack or open heart surgery are routinely urged to get on their feet and exercise as soon as they are stable, patients and doctors alike have been skeptical that it would be safe for people with heart failure to engage in strenuous activity. But 'the safety in the HF-Action trial was very significant,' said Nancy Houston Miller, associate director of the Stanford Cardiac Rehabilitation Program, Palo Alto, Calif., and an investigator on the study.
心臟病發作或接受心臟手術的患者在恢復過程中常被敦促要站起來，一旦病情穩定就要馬上開始鍛鍊，但患者與醫生一直對心力衰竭患者參與激烈活動是否安全均持懷疑態度。加州帕洛阿託斯坦福(Stanford)心臟康復計劃的副主任南希·休斯頓·米勒(Nancy Houston Miller)說：“HF-Action實驗中的安全性是非常顯著的。”她也是HF-Action研究的調研者之一。

Mr. Cloutier, a 77-year-old retiree who says heart problems run in his family, has been in a cardiac-rehab program off and on since he suffered a heart attack in 1985 at age 48. Lately he has been paying about $100 every three months for exercise sessions but now it is possible he will be covered for a course of treatment under Medicare.
今年77歲的克盧捷是一名退休人員，他說他的家族有心臟病史。自從在1985年48歲心臟病發作以來，他斷斷續續參加過心臟康復計劃。不久之前他每三個月爲鍛鍊計劃支付約100美元，現在他的療程費用有可能在“醫療保險計劃”下得到報銷。Mr. Cloutier had quadruple bypass surgery in 2000. He also had a defibrillator implanted in 2003 and a pacemaker put in three years ago. Since then, he has avoided being admitted to the hospital, an accomplishment he and Dr. Ades attribute to his regular physical activity. Until recently, Mr. Cloutier, a nonsmoker, organized regular 20-to-40-mile bicycle trips in the Vermont countryside. Last year, though, his heart-failure symptoms caught up with him and he said he was able to ride only 3 miles. He's hoping to get that to 5 to 10 miles weekly this summer. And he keeps up his rehab regimen, currently 20-minute treadmill sessions at 3 miles an hour and using a weight machine two to three times a week. On other days, he goes on 1 mile walks.
克盧捷在2000年實施了冠狀動脈搭橋術，後在2003年植入了一個心臟除顫器，三年前他又安了一個心臟起搏器。自那以後，他一直沒有住過院，他和埃茲醫生將這一成績歸功於定期的體育鍛煉。直到不久前，不吸菸的克盧捷還一直定期組織在佛蒙特鄉村騎自行車，每次騎20至40英里。然而，去年他出現了心力衰竭症狀，他說他只能騎三英里了。他希望在今年夏天實現每週騎行五至10英里的目標。此外，他還堅持進行心臟康復治療，目前是以每小時三英里的速度在跑步機上跑20分鐘，並使用力量訓練器械進行鍛鍊，頻率爲每週兩到三次。在其他日子裏，他會散一英里的步。

'The heart is a muscle,' he said. 'If you don't exercise it and keep it in reasonable shape then it's going to deteriorate and give you problems. That's why I keep going back.'
克盧捷說：“心臟是一團肌肉，如果你不鍛鍊它，使它一直處於良好的狀況，接下來它就會變衰弱，給你帶來麻煩。那就是我一直參加鍛鍊的原因。”

The Medicare decision extends coverage to patients whose heart-pumping function is compromised to a specific level and who have certain heart-failure symptoms despite being on an optimal drug therapy for at least six weeks. It offers one course of 36 sessions for up to 36 weeks, though two- or three-times-a-week sessions are optimal. Patients could apply for a second course of rehab, but generally, they would have to pay out of pocket after completing the first course.
“醫療保險計劃”的新規定將償付範圍擴大到心臟泵血功能減弱到某個水平，在進行了至少六週最佳藥物治療後仍出現某些心力衰竭症狀的患者。它提供一個包含36次康復訓練的療程，最長可持續36周，但每週兩到三次訓練的療程最佳。患者可申請報銷第二個康復療程的費用，但一般說來在完成第一個療程後他們得自己掏腰包。

The new decision affects about 50% of patients with chronic heart failure. Medicare officials said more data are need to determine whether cardiac rehab will benefit the others, who have a different form of the condition.
新規定影響了50%左右的心力衰竭患者。“醫療保險計劃”官員稱，其餘的患者病症不同，要確定心臟康復是否有利於這些患者，還需研究更多數據。

Doctors expect the trigger for coverage for many patients will be their first hospital admission for heart failure. At that time, doctors would discuss starting an exercise program with a patient after six weeks on medications.
醫生預計，許多患者因心力衰竭第一次住院治療時，就有可能納入康復報銷計劃。在那時，醫生會在六週的藥物治療後與患者討論開始鍛鍊計劃。

The first episode 'is your teachable moment,' said Mariell Jessup, a heart failure doctor at University of Pennsylvania and president of the American Heart Association. Upon hearing the diagnosis, people think it is a death sentence. 'We say, 'you're not going to die. We're going to work on you living.'
賓夕法尼亞大學(University of Pennsylvania)心力衰竭醫生、AHA主席瑪麗埃爾·傑瑟普(Mariell Jessup)稱，第一階段“是你可施教的時機。”一聽到診斷結果後，人們就會覺得自己被判了死刑。傑瑟普說：“我們會告訴他們，‘你不會死的，我們會努力讓你活下去。”