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1、心脏病人非心脏手术术前评估与术中管理,江苏省苏北人民医院麻醉科 杨柳青,2009 ESC/ESA 指南,本文档由医学百事通高端医生网专家制作在线咨询医生,Impact Factor 9.275,The Preamble,Guidelines and recommendations should help physicians and other healthcare providers to make decisions in their daily practice.However,the physician in charge of his/her care must make the u
2、ltimate judgement regarding the care of an individual patient,Introduction,The present guidelines focus on the cardiological management of patients undergoing non-cardiac surgery,i.e.patients where heart disease is a potential source of complications during surgery major non-cardiac surgery is assoc
3、iated with an incidence of cardiac death of between 0.5 and 1.5%,and of major cardiac complications of between 2.0 and 3.5%,Impact of the ageing population,It is estimated that elderly people require surgery four times more often than the rest of the population,Pre-operative evaluation,Surgical risk
4、 for cardiac events:the urgency,magnitude,type,and duration of the procedure,as well as the change in body core temperature,blood loss,and fluid shifts,Functional capacity,Functional capacity is measured in metabolic equivalents(METs)Exercise testing provides an objective assessment of functional ca
5、pacity Without testing,functional capacity can be estimated by the ability to perform the activities of daily living,4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events,Risk indices,Goldman(1977),Detsky(1986),Lee(1999)The Lee index,
6、to be the best currently available cardiac risk prediction index in non-cardiac surgery,Six independent clinical determinants(The Lee index),a history of IHD a history of cerebrovascular diseaseheart failure insulin-dependent diabetes mellitus impaired renal functionHigh-risk type of surgery,The Lee
7、 index,All factors contribute equally to the index(with 1 point each)the incidence of major cardiac complications is estimated at 0.4,0.9,7,and 11%in patients with an index of 0,1,2,and 3 points,respectively,Biomarkers,Cardiac troponins T and I(cTnT and cTnI)are the preferredmarkers for the diagnosi
8、s of MI because they demonstrate sensitivity and tissue specificity superior to other available biomarkers,Plasma BNP and NT-proBNP,important prognostic indicators in patients with heart failure additional prognostic value for long-term mortality and for cardiac events,Non-invasive testing,three car
9、diac risk markers:LV dysfunction myocardial ischaemia heart valve abnormalities,Echocardiography,A meta-analysis of the available data demonstrated that an LV ejection fraction of 35%had a sensitivity of 50%and a specificity of 91%for prediction of perioperative non-fatal MI or cardiac death,a well-
10、established invasive diagnostic procedure rarely indicated to assess the risk of noncardiac surgery,Angiography,Risk reduction strategiesPharmacological,Besides specific risk reduction strategies adapted to patient characteristics and the type of surgery,preoperative evaluation is an opportunity to
11、check and optimize the control of all cardiovascular risk factors,b-blockers,The dose of b-blockers should be titrated,which requires that treatment be initiated optimally between 30 days and at least 1 week before surgery.treatment start with a daily dose of 2.5 mg of bisoprolol or 50 mg of metopro
12、lol succinate which should then be adjustedbefore surgery to achieve a resting heart rate of between 60 and 70 bpm with SBP 100 mmHg,Nitrates:Nitroglycerin,Diuretics,Aspirin,Anticoagulant therapy,Revascularization,Specific diseases,Arterial hypertensionValvular heart diseaseAortic stenosisMitral ste
13、nosisAR and MRprosthetic valve(s),Arterial hypertension,antihypertensive medications should be continued during the perioperative period.In patients with grade 3 hypertension(systolic blood pressure 180 mmHg and/or diastolic blood pressure 110 mmHg),the potential benefits of delaying surgery to opti
14、mize the pharmacological therapy should be weighed against the risk of delaying the surgical procedure,Valvular heart disease,higher risk Echocardiography should be performed,Aortic stenosis,Severe AS:aortic valve area 1 cm2 0.6 cm2/m2 body surface area),Mitral stenosis,relatively lowrisk:non-signif
15、icant mitral stenosis(MS)(valve area 1.5 cm2)and in asymptomatic patients with significant MS(valve area 1.5 cm2)and systolic pulmonary artery pressure 50 mmHg control of heart rate Strict control of fluid overload anticoagulation AF,AR and MR,Non-significant AR and MR(low risk)asymptomatic patients
16、 with severe AR and MR and preserved LV function(low risk)Symptomatic patients and LV EF30%(High risk,only if necessary,optimization of pharmacological therapy),prosthetic valve(s),no evidence of valve or ventricular dysfunction(without additional risk)endocarditis prophylaxis anticoagulation regime
17、n modification,Bradyarrhythmias,Temporary cardiac pacing is rarely required,even in the presence of pre-operative asymptomatic bifascicular block or CLBBB The indications for temporary pacemakers are generally the same as those for permanent pacemakers,Pacemaker/implantable cardioverter defibrillato
18、r,unipolar electrocautery represents a significant risk be avoided by positioning the ground plate Keeping the electrocautery device away from the pacemaker,giving only briefbursts and using the lowest possible amplitude,The implantable cardioverter defibrillator should be turned off during surgery
19、and switched on in the recovery phase before discharge to the ward,Perioperative monitoring,V5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)Continuous automated ST trending monitors(sensitivity and specificity of 74 and 73%),ECG,Transesophageal echocardiography,Right heart catherization,both a large observa
20、tional study and a randomized multicentre clinical trial did not show a benefit associated with the use of right heart catheterization no difference in mortality and hospital duration/a higher incidence of pulmonary embolism,Disturbed glucose metabolism,promotes atherosclerosis,endothelial dysfuncti
21、on,and activation of platelets and proinflammatory cytokines,Intraoperative anaesthetic management,proper organ perfusion pressureSpinal and epidural anaesthesia(T4)One meta-analysis reported significantly improved survival and reduced incidence of post-operative thromboembolic,cardiac and pulmonary
22、 complications with neuraxial blockade compared with general anaesthesia,Putting the puzzle together,患者和外科特殊因素决定治疗策略，不需进一步心脏检查和治疗，请求会诊以加强术中管理，监测心脏事件和拟定长期药物治疗方案,多学科会诊以决定最佳治疗方案，如能推迟手术则可进行CABG、球囊成形术、支架植入术,明确危险因素、进行手术治疗、提供正确的生活方式和适当的药物治疗，以改善术后长期生存质量,明确心功能状态、进行手术治疗、适当的术前药物治疗（他汀类，受体阻滞剂）,适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）、进行手术治疗、围术期ECG监测,适当的术前药物治疗（他汀类，受体阻滞剂）、左室收缩功能障碍者（ACE-inhibitors）,non-invasive stress test,Revascularization,bridging therapy,
