圍手術(shù)期心臟評價

1、內(nèi)科會診的原則內(nèi)科會診的原則(一一)1、內(nèi)科會診醫(yī)師應(yīng)意識到自己代表的是整個內(nèi)科、內(nèi)科會診醫(yī)師應(yīng)意識到自己代表的是整個內(nèi)科 2、電話里簡單詢問患者情況，判斷是否急會診；沒有看患、電話里簡單詢問患者情況，判斷是否急會診；沒有看患者之前在電話里只能回答一些籠統(tǒng)問題者之前在電話里只能回答一些籠統(tǒng)問題 3、會診目的應(yīng)具體而明確，申請會診的醫(yī)師不要寫、會診目的應(yīng)具體而明確，申請會診的醫(yī)師不要寫“排除排除內(nèi)科情況內(nèi)科情況”，或，或“處理內(nèi)科問題處理內(nèi)科問題”之類的話之類的話 4、應(yīng)與患者的主管醫(yī)師充分交流，會診時與主管醫(yī)師見面、應(yīng)與患者的主管醫(yī)師充分交流，會診時與主管醫(yī)師見面5、不能依賴別人提供病史，必須

2、親自床邊看患者、不能依賴別人提供病史，必須親自床邊看患者 6、會診意見應(yīng)簡單明確而富有建設(shè)性，最好不超過、會診意見應(yīng)簡單明確而富有建設(shè)性，最好不超過5條條內(nèi)科會診的原則（二）內(nèi)科會診的原則（二） 7、會診醫(yī)師應(yīng)意識到自己的局限和不足，尊重主管醫(yī)、會診醫(yī)師應(yīng)意識到自己的局限和不足，尊重主管醫(yī)師的決策，千萬不要在未通知主管醫(yī)師的情況下自己開師的決策，千萬不要在未通知主管醫(yī)師的情況下自己開醫(yī)囑醫(yī)囑 8、在主管醫(yī)師不在場的情況下，不要向家屬發(fā)表有關(guān)、在主管醫(yī)師不在場的情況下，不要向家屬發(fā)表有關(guān)病情的看法病情的看法 9、外科患者術(shù)前請內(nèi)科會診是為了評估風(fēng)險，因此不、外科患者術(shù)前請內(nèi)科會診是為了評估風(fēng)險，

3、因此不要寫要寫“可以手術(shù)可以手術(shù)”或或“可以全麻可以全麻”之類的話之類的話 10、應(yīng)隨訪會診過的患者，你可能會有很多意外的發(fā)現(xiàn)、應(yīng)隨訪會診過的患者，你可能會有很多意外的發(fā)現(xiàn)和收獲，患者病情的發(fā)展可能會出乎你的意料，甚至與和收獲，患者病情的發(fā)展可能會出乎你的意料，甚至與你最初的判斷完全相反你最初的判斷完全相反 11、不要過于自信，遇到自己不能解決的問題，應(yīng)向有、不要過于自信，遇到自己不能解決的問題，應(yīng)向有經(jīng)驗的醫(yī)師請教經(jīng)驗的醫(yī)師請教 12、珍惜醫(yī)療資源和他人時間，盡量避免不必要的會診、珍惜醫(yī)療資源和他人時間，盡量避免不必要的會診 圍手術(shù)期的心臟評估及治療圍手術(shù)期的心臟評估及治療方案的選擇方案的選

4、擇 吉林大學(xué)第二醫(yī)院吉林大學(xué)第二醫(yī)院 孫孫 健健ACC/AHA 2007 Guidelines on Perioperative CardiovascularEvaluation and Care for Noncardiac SurgeryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardi

5、ovascular Evaluation for Noncardiac Surgery)J Am Coll Cardiol 2007;50 e159-e241Class I Benefit RiskProcedure/ Treatment SHOULD be performed/ administeredClass IIa Benefit RiskAdditional studies with focused objectives neededIT IS REASONABLE to perform procedure/administer treatmentClass IIb Benefit

6、RiskAdditional studies with broad objectives needed; Additional registry data would be helpfulProcedure/Treatment MAY BE CONSIDERED Class III Risk BenefitNo additional studies neededProcedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFULshouldis recommende

7、dis indicatedis useful/effective/ beneficialis reasonablecan be useful/effective/ beneficialis probably recommended or indicatedmay/might be consideredmay/might be reasonableusefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommendedis not indicatedshould notis

8、not useful/effective/beneficialmay be harmfulLevel AMultiple (3-5) population risk strata evaluatedGeneral consistency of direction and magnitude of effectClass I Recommen-dation that procedure or treatment is useful/ effective Sufficient evidence from multiple randomized trials or meta-analysesClas

9、s IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from multiple randomized trials or meta-analysesClass IIb Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence from multiple randomized trials or meta-analys

10、esClass III Recommen-dation that procedure or treatment not useful/effective and may be harmful Sufficient evidence from multiple randomized trials or meta-analysesApplying Classification of Recommendations and Level of Evidence Level BLimited (2-3) population risk strata evaluatedClass I Recommen-d

11、ation that procedure or treatment is useful/effective Limited evidence from single randomized trial or non-randomized studiesClass IIa Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from single randomized trial or non-randomized studiesClass IIb

12、Recommen-dations usefulness/ efficacy less well established Greater conflicting evidence from single randomized trial or non-randomized studiesClass III Recommen-dation that procedure or treatment not useful/effective and may be harmful Limited evidence from single randomized trial or non-randomized

13、 studiesLevel C Very limited (1-2) population risk strata evaluatedClass I Recommen-dation that procedure or treatment is useful/ effective Only expert opinion, case studies, or standard-of-careClass IIa Recommen-dation in favor of treatment or procedure being useful/effective Only diverging expert

14、opinion, case studies, or standard-of-careClass IIb Recommen-dations usefulness/ efficacy less well established Only diverging expert opinion, case studies, or standard-of-careClass III Recommend-ation that procedure or treatment not useful/effective and may be harmful Only expert opinion, case stud

15、ies, or standard-of-care麻醉對心臟的影響： 1、全身麻醉、全身麻醉 （1）正壓通氣可減少右心回心血量，此時不宜）正壓通氣可減少右心回心血量，此時不宜過度補液。過度補液。 （2）麻醉結(jié)束，停止正壓通氣時，前負(fù)荷可突）麻醉結(jié)束，停止正壓通氣時，前負(fù)荷可突然增高，導(dǎo)致血壓升高和肺充血。然增高，導(dǎo)致血壓升高和肺充血。 2、脊髓和硬膜外麻醉、脊髓和硬膜外麻醉 通過阻斷交感神經(jīng)，使外周小動脈和靜脈擴張，通過阻斷交感神經(jīng)，使外周小動脈和靜脈擴張，外周血管阻力下降外周血管阻力下降10%-15%，引起右心室前，引起右心室前負(fù)荷降低。負(fù)荷降低。手術(shù)對心臟的影響外科手術(shù)應(yīng)激反應(yīng)可使心律增快，

16、血壓升高，外科手術(shù)應(yīng)激反應(yīng)可使心律增快，血壓升高，可誘發(fā)冠心病人心肌缺血，增加心臟風(fēng)險?？烧T發(fā)冠心病人心肌缺血，增加心臟風(fēng)險。圍手術(shù)期如發(fā)生心動過速，可導(dǎo)致冠脈斑塊圍手術(shù)期如發(fā)生心動過速，可導(dǎo)致冠脈斑塊破裂。破裂。術(shù)中麻醉，術(shù)中麻醉，SBP可降至可降至95-105mmHg，可使，可使冠心病患者冠脈血流減少，加重心肌缺血。冠心病患者冠脈血流減少，加重心肌缺血。術(shù)中刺激迷走神經(jīng)可引起一過性竇性心動過術(shù)中刺激迷走神經(jīng)可引起一過性竇性心動過緩或交界性心律。血容量不足，外周血管擴緩或交界性心律。血容量不足，外周血管擴張和心肌對兒茶酚胺的敏感性增高可引起快張和心肌對兒茶酚胺的敏感性增高可引起快速的心律失常

17、。速的心律失常。二尖瓣狹窄患者對心動過速耐受性差二尖瓣狹窄患者對心動過速耐受性差診治過程中需注意的關(guān)鍵問題1、對冠心病是否進行評估 冠心病的診斷依據(jù)： 典型的心絞痛癥狀 心肌梗死病史 冠脈搭橋術(shù)后 PCI后 冠脈造影證實狹窄50% 如果有心肌缺血的證據(jù)，至少在心梗如果有心肌缺血的證據(jù)，至少在心梗 后后6周后方可行外科心臟手術(shù)周后方可行外科心臟手術(shù) 擇期手術(shù)可以等擇期手術(shù)可以等6個月以后個月以后 惡性腫瘤這類限期手術(shù)，應(yīng)權(quán)衡利惡性腫瘤這類限期手術(shù)，應(yīng)權(quán)衡利 弊，積極治療冠心病后盡快手術(shù)弊，積極治療冠心病后盡快手術(shù) 2、PCI手術(shù)多長時間行外科手術(shù)： 急性血栓形成多發(fā)性裸支架術(shù)后急性血栓形成多發(fā)性

18、裸支架術(shù)后2周周以后，以后，6-8周內(nèi)開始再狹窄周內(nèi)開始再狹窄 目前資料，目前資料，PCI后（裸支架）后（裸支架）2周以周以 后，后，8 周以內(nèi)或（藥物支架）周以內(nèi)或（藥物支架）1年以年以 后行外科心臟手術(shù)相對安全后行外科心臟手術(shù)相對安全3 3、術(shù)前高血壓是否得到較好的控制、術(shù)前高血壓是否得到較好的控制 研究證實研究證實1級和級和2級高血壓級高血壓（SBP180mmHg,DBP110mmHg）,無嚴(yán)無嚴(yán)重靶器官損害的患者，不增加圍手術(shù)期的重靶器官損害的患者，不增加圍手術(shù)期的心臟風(fēng)險，沒有必要推遲手術(shù)，但要將血心臟風(fēng)險，沒有必要推遲手術(shù)，但要將血壓控制在術(shù)前水平。壓控制在術(shù)前水平。 3級高血壓級

19、高血壓（SBP180mmHg,DBP110mmHg）在術(shù)）在術(shù)前必須得到控制。前必須得到控制。4 4、CHFCHF患者心功能是否評價和治療患者心功能是否評價和治療 LVEF 100 bpm at rest) Symptomatic bradycardia Newly recognized ventricular tachycardiaSevere valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, o

20、r symptomatic) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association. *According to Campeau.10 May include stable angina

21、in patients who are unusually sedentary. The ACC National Database Library defines recent MI as more than 7 days but within 30 days)2 2、體格檢查重點：、體格檢查重點： 生命體征生命體征 頸動脈搏動和雜音、雙肺聽診頸動脈搏動和雜音、雙肺聽診 腹部叩診、雙下肢浮腫腹部叩診、雙下肢浮腫 臍周血管雜音提示腎動脈狹窄；上肢血壓高、臍周血管雜音提示腎動脈狹窄；上肢血壓高、下肢無脈提示主動脈狹窄下肢無脈提示主動脈狹窄 心尖部第三心音提示左心功能不全，心臟雜音心尖部第三心音提

22、示左心功能不全，心臟雜音首先排除瓣膜病，主動脈瓣狹窄手術(shù)風(fēng)險大，首先排除瓣膜病，主動脈瓣狹窄手術(shù)風(fēng)險大，特別注意主動脈并聽診無雜音特別注意主動脈并聽診無雜音 嚴(yán)重二尖瓣狹窄或返流使圍手術(shù)期心力衰竭風(fēng)嚴(yán)重二尖瓣狹窄或返流使圍手術(shù)期心力衰竭風(fēng)險增加，二尖瓣聽診也是檢查重點。險增加，二尖瓣聽診也是檢查重點。3 3、輔助檢查重點、輔助檢查重點 生化檢查：未用利尿劑而出現(xiàn)低血鉀提示醛固生化檢查：未用利尿劑而出現(xiàn)低血鉀提示醛固酮增多酮增多 心電圖：心電圖：度房室傳導(dǎo)阻滯、右束支阻滯不會度房室傳導(dǎo)阻滯、右束支阻滯不會增加圍手術(shù)期風(fēng)險增加圍手術(shù)期風(fēng)險 超聲心動圖負(fù)荷試驗超聲心動圖負(fù)荷試驗 優(yōu)點：隨心率和心肌收

23、縮力增加，能動態(tài)優(yōu)點：隨心率和心肌收縮力增加，能動態(tài)觀察心肌缺血。如心率低時室壁運動異?；虼笥^察心肌缺血。如心率低時室壁運動異?；虼竺娣e室壁運動異常都提示預(yù)后不良。面積室壁運動異常都提示預(yù)后不良。Cardiac Risk Stratification for Noncardiac Surgical ProceduresRisk Stratification Procedure Examples Vascular (reported cardiac Aortic and other major vascular surgery risk often 5%) Peripheral vascular

24、 surgery Intermediate (reported Intraperitoneal and intrathoracic surgery cardiac risk generally 1%-5%) Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Low (reported cardiac Endoscopic procedures risk generally 1%Superficial procedure Cataract surgery Breast surgery

25、Ambulatory surgery Recommendations for Preoperative Noninvasive Evaluation of LV Function Class I (none) Class IIa It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. (C) It is reasonable for patients with current or prior HF with worsening

26、 dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months. (C) Class IIb Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (C) Class III Routine perioperat

27、ive evaluation of LV function in patients is not recommended. (B)Recommendations for Preoperative Resting 12-Lead ECG Class I: Preoperative resting 12-lead ECG is recommended for pts with: At least 1 clinical risk factor* who are undergoing vascular surgical procedures. (B) Known CHD, peripheral art

28、erial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (C) Class IIa: Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (B) Class IIb: Preoperative resting 12-lead ECG

29、may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (B) Class III: Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (B)*Clinical risk factor

30、s include history of ischemic heart disease, history of compensated or prior HF, history of cerebrovascular disease, DM, and renal insufficiency.Estimated Energy Requirements for Various ActivitiesCan YouCan You1 MetTake care of yourself?4 Mets Climb a flight of stairs or walk up a hill?Eat, dress,

31、or use the toilet?Walk on level ground at 4 mph (6.4 kph)?Walk indoors around the house?Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?Walk a block or 2 on level ground at 2 to 3 mph (3.2 to 4.8 kph)?Participate in moderate recreational activities like golf

32、, bowling, dancing, doubles tennis, or throwing a baseball or football?4 MetsDo light work around the house like dusting or washing dishes? 10 MetsParticipate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?MET indicates metabolic equivalent; mph, miles per hour; k

33、ph, kilometers per hour. *Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.12Recommendations for Noninvasive Stress Testing Before Noncardiac SurgeryClass I: Patients with active cardiac conditions in whom noncardiac surgery is planned shou

34、ld be evaluated and treated per ACC/AHA guidelines before noncardiac surgery. (B)Class IIa: Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery is reasonable if it will change management. (B)Class II

35、b: Noninvasive stress testing may be considered for patients: With at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (B) With at least 1 to 2 clinical risk factors and good functional c

36、apacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (B)Class III: Noninvasive testing is not useful for patients: With no clinical risk factors undergoing intermediate-risk noncardiac surgery. (C) Undergoing low-risk noncardiac surgery. (C)Prognostic Gradient of Ischemic R

37、esponses During an ECG-Monitored Exercise Test in Patients With Suspected or Proven CADHigh Risk Ischemic Response Ischemia induced by low-level exercise* (less than 4 METs or heart rate 100 bpm or 0.1 mVST-segment elevation 0.1 mV in noninfarct leadFive or more abnormal leadsPersistent ischemic res

38、ponse 3 minutes after exertionTypical anginaExercise-induced decrease in systolic BP by 10 mm HgPrognostic Gradient of Ischemic Responses During an ECG-Monitored Exercise Test in Patients With Suspected or Proven CADIntermediate: Ischemia induced by moderate-level exercise (4 to 6 METs or HR 100 to

39、130 bpm (70% to 85% of age-predicted heart rate) manifested by 1 of the following:Horizontal or downsloping ST depression 0.1 mVPersistent ischemic response greater than 1 to 3 minutes after exertionThree to 4 abnormal leadsLow No ischemia or ischemia induced at high-level exercise ( 7 METs or HR 13

40、0 bpm (greater than 85% of age-predicted heart rate) manifested by:Horizontal or downsloping ST depression 0.1 mVOne or 2 abnormal leadsInadequate test Inability to reach adequate target workload or heart rate response for age without an ischemic response. For patients undergoing noncardiac surgery,

41、 the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.Preoperative Coronary Revascularization With CABG or Percutaneous Coronary InterventionClass I: Patients with active cardiac conditions in whom noncardiac surgery is planned sh

42、ould be evaluated and treated per ACC/AHA guidelines before noncardiac surgery. (B)Class IIa: Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery is reasonable if it will change management. (B)Class

43、IIb: Noninvasive stress testing may be considered for patients: With at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (B) With at least 1 to 2 clinical risk factors and good functional

44、 capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (B)Class III: Noninvasive testing is not useful for patients: With no clinical risk factors undergoing intermediate-risk noncardiac surgery. (C) Undergoing low-risk noncardiac surgery. (C)4 4、冠狀動脈造影：、冠狀動脈造影： 非心臟手術(shù)圍手術(shù)期冠脈

45、造影的指證：非心臟手術(shù)圍手術(shù)期冠脈造影的指證： 懷疑或確診冠心病患者，無創(chuàng)檢查提示心臟事件懷疑或確診冠心病患者，無創(chuàng)檢查提示心臟事件 風(fēng)險高風(fēng)險高 充分藥物治療不能穩(wěn)定的心絞痛充分藥物治療不能穩(wěn)定的心絞痛 級或級或級心絞痛級心絞痛 不穩(wěn)定心絞痛，特別是擬行中高危手術(shù)患者不穩(wěn)定心絞痛，特別是擬行中高危手術(shù)患者 有高危因素擬行高危手術(shù)的患者，無創(chuàng)檢查不能有高危因素擬行高危手術(shù)的患者，無創(chuàng)檢查不能 除外冠心病除外冠心病 多個中危因素，擬行血管手術(shù)及高危非心臟手術(shù)多個中危因素，擬行血管手術(shù)及高危非心臟手術(shù) 無創(chuàng)檢查提示中到大面積心肌缺血無創(chuàng)檢查提示中到大面積心肌缺血 急性心肌梗死恢復(fù)期擬行急診非心臟手

46、術(shù)急性心肌梗死恢復(fù)期擬行急診非心臟手術(shù)不建議非心臟手術(shù)期術(shù)前冠脈造影不建議非心臟手術(shù)期術(shù)前冠脈造影：（1）已知冠心病，擬行低危手術(shù)，無創(chuàng)檢查）已知冠心病，擬行低危手術(shù)，無創(chuàng)檢查 無高危結(jié)果無高危結(jié)果（2）冠脈重建后無癥狀，活動耐力良好）冠脈重建后無癥狀，活動耐力良好 （7METS）（3）輕度不穩(wěn)定性心絞痛，左室功能良好）輕度不穩(wěn)定性心絞痛，左室功能良好（4）因為其他合并疾病不能行冠脈重建，）因為其他合并疾病不能行冠脈重建， 或患者拒絕血管重建，嚴(yán)重左心功能或患者拒絕血管重建，嚴(yán)重左心功能 不全（不全（LVEF176.8umol/L。 術(shù)前評估步驟第一步：明確手術(shù)的急緩，急診手術(shù)就不允許過第一步

47、：明確手術(shù)的急緩，急診手術(shù)就不允許過 多的術(shù)前檢查多的術(shù)前檢查第二步：患者如第二步：患者如5年內(nèi)接受過搭橋手術(shù)或年內(nèi)接受過搭橋手術(shù)或6個月到個月到 5年內(nèi)接受過年內(nèi)接受過PCI，并且無心肌缺血的癥，并且無心肌缺血的癥 狀和證據(jù)，則風(fēng)險很低且不必進一步檢查。狀和證據(jù)，則風(fēng)險很低且不必進一步檢查。第三步：是否第三步：是否2年內(nèi)接受過冠狀動脈評估：如果結(jié)果年內(nèi)接受過冠狀動脈評估：如果結(jié)果 正常，不必重復(fù)檢查，如有缺血癥狀則應(yīng)正常，不必重復(fù)檢查，如有缺血癥狀則應(yīng) 重新評估。重新評估。第四步：如行擇期手術(shù)，存在下列情況手術(shù) 應(yīng)取消或推遲： 1 1、不穩(wěn)定冠心病、不穩(wěn)定冠心病 2 2、失代償、失代償CHF

48、CHF 3 3、血液動力學(xué)不穩(wěn)定性心律失常：、血液動力學(xué)不穩(wěn)定性心律失常： 高度高度AVBAVB 有癥狀室性心律失常伴基礎(chǔ)心臟病有癥狀室性心律失常伴基礎(chǔ)心臟病 未控制室率的室上性心律失常未控制室率的室上性心律失常 4 4、嚴(yán)重瓣膜病、嚴(yán)重瓣膜病第五步：是否存在中度臨床預(yù)測危第五步：是否存在中度臨床預(yù)測危險因素：險因素： 輕度心絞痛（輕度心絞痛（級或級或級）級） 陳舊性心?；虿±黻惻f性心?；虿±鞶波波 心衰史或失代償心衰史或失代償CHF 1型糖尿病型糖尿病 血清肌酐血清肌酐176.8umol/L 同時考慮運動耐力和手術(shù)本身的風(fēng)險同時考慮運動耐力和手術(shù)本身的風(fēng)險 運動耐力：良好：運動耐力：良好：10METS 好：好：7-10METS 中等：中等：4-7METS 差：差：177umol/L級：級：0