冠心病人的術(shù)前評估

冠心病人的術(shù)前評估昆明醫(yī)科大學(xué)第二附屬醫(yī)院麻醉科思永玉CASE男，65歲，高血壓，冠心病三年前急性心梗，放冠脈支架（左前降支）房顫，心室率<100bpm珍菊降壓片可以爬上二、三樓擬輸尿管鏡下放置雙J管放置雙J管能做手術(shù)嗎？我只是放個雙J管！說干就干！AmericanSocietyofAnesthesiologists’physicalstatusclassificationofpatients1normalhealthpatient2輕度系統(tǒng)疾病（活動不受限）3嚴重系統(tǒng)疾?。ú糠只顒邮芟蓿?嚴重系統(tǒng)疾病，威脅到生存（不能活動）5垂死病人，不做手術(shù)就沒有活的希望6腦死亡，準備捐獻器官E急診加“E”JohnF.ButterworthIV，DavidC.Mackey，JohnD.Wasnick

Morgan&MikhailsClinicalAnesthesiology(5th)ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgeryconditionexamplesUnstablecoronarysyndromesUnstableangina(CCSclassⅢorⅣ)RecentMI(7~30d)加拿大心絞痛分級（CCSclass）Ⅰ一般體力活動不引起心絞痛，例如行走和上樓，但緊張、快速或持續(xù)用力可引起心絞痛的發(fā)作Ⅱ日常體力活動稍受限制，快步行走或上樓、登高、飯后行走或上樓、寒冷或風(fēng)中行走、情緒激動可發(fā)作心絞痛或僅在睡醒后數(shù)小時內(nèi)發(fā)作。在正常情況下以一般速度平地步行200m以上或登一層以上的樓梯受限Ⅲ日常體力活動明顯受限，在正常情況下以一般速度平地步行100-200m或登一層樓梯時可發(fā)作心絞痛Ⅳ輕微活動或休息時即可以出現(xiàn)心絞痛癥狀Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgeryconditionexamplesDecompensatedHFNYHAfunctionalclassⅣWorseningornew-onsetHF紐約心臟協(xié)會（NYHA）心力衰竭分級1無癥狀2重度勞力時出現(xiàn)癥狀，體力活動輕度受限3一般活動（如步行）時即出現(xiàn)癥狀，體力活動明顯受限4靜息時出現(xiàn)癥狀癥狀為呼吸困難與乏力Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009CardiacriskstratificationfornoncardiacsurgicalproceduresRiskstratificationProcedureExamplesVascular(cardiacrisk>5%)AorticandothermajorvascularsurgeryPeripheralvascularsurgeryIntermediate(1%<cardiacrisk<5%)IntraperitonealandintrathoracicsurgeryCarotidendarterectomyHeadandnecksurgeryOrthopedicsurgeryProstatesurgeryLow(cardiacrisk<1%)EndoscopicproceduresSuperficialprocedureCataractsurgeryBreastsurgeryAmbulatorysurgeryFleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009心梗三思而后行無ABC冠心病藥物預(yù)防治療A：Aspirin或氯吡格雷

ACEI/ARBB:β

受體阻斷劑

BloodpressureC:Cholesterol

他汀類藥物2013冠心病康復(fù)與二級預(yù)防中國專家共識，中華心血管雜志，2013,41（4）：267-275Clinicalriskfactors?

historyofischemicheartdisease?historyofcompensatedorpriorHF?historyofcerebrovasculardisease?diabetesmellitus;?renalinsufficiency年齡心梗病史心絞痛MET<4腦血管疾病糖尿病慢性心衰肺部疾病AHA臨床危險因素分層Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009

《危重患者圍手術(shù)期心血管疾病臨床防治技術(shù)研究》，云南省社會發(fā)展科技攻關(guān)項目心源性死亡的相關(guān)因素心梗病史心絞痛《危重患者圍手術(shù)期心血管疾病臨床防治技術(shù)研究》，云南省社會發(fā)展科技攻關(guān)項目MINSassociatedwithsubstantialmortalityVISIONWritingGroup,Anesthesiology2014;120:564-78A：Aspirin或氯吡格雷

ACEI/ARBB:β受體阻斷劑

BloodpressureC:Cholesterol

他汀類藥物2013冠心病康復(fù)與二級預(yù)防中國專家共識，中華心血管雜志，2013,41（4）：267-275做活動還可以小手術(shù)停無藥物治療房顫冠心病暫緩手術(shù)！外科醫(yī)師：我就要做！我會打局麻！哈哈哈，不服你咬我啊！麻醉醫(yī)師：病人晚上心梗死亡！外科醫(yī)師：圍術(shù)期ABC治療A：Aspirin或氯吡格雷

ACEI/ARBB:β

受體阻斷劑

BloodpressureC:Cholesterol

他汀類藥物2013冠心病康復(fù)與二級預(yù)防中國專家共識，中華心血管雜志，2013,41（4）：267-275Cholesterol-StatinPerioperativeStatinTherapyStatinsshouldbecontinuedinpatientscurrentlytakingstatinsandscheduledfornoncardiacsurgery(ClassI，LevelofEvidence:B)2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatientsUndergoingNoncardiacSurgery:ExecutiveSummaryCirculation.publishedonlineAugust1,2014;Statin

Therapy

intheReductionofCardiovascularEventsinPatientsUndergoingIntermediate-Risk

Noncardiac,Nonvascular

Surgery他汀組1.45%對照組6.48%30-dayall-causemortalityClinCardiol.

2013May13Storyofβ–blocker?Effectsofextended-releasemetoprololsuccinateinpatientsundergoingnon-cardiacsurgeryMI4.2%VS5.7%2.3%VS3.1%death0.5%VS1.0%strokeDevereauxPJ,etal.Lancet.2008;371(9627):1839-47.

多中心雙盲，隨機大樣本，8000例atheroscleroticdisease2–4hbeforesurgerymetoprolol100mgthefirst6hafterSurgerymetoprolol100mgHR50bpmSBP100mmHgHR80bpmSBP100mmHgmetoprolol200mg/dfor30daysDevereauxPJ,etal.Lancet.2008;371(9627):1839-47.圍術(shù)期使用β-blockerRoutineadministrationofhigh-dosebetablockersintheabsenceofdosetitrationisnotusefulandmaybeharmfultopatientsnotcurrentlytakingbetablockerswhoareundergoingnoncardiacsurgery.(ClassIII，LevelofEvidence:C)2009ACCF/AHAFocusedUpdateonPerioperativeBetaBlockadeIncorporatedIntotheACC/AHA2007GuidelinesCirculationNovember24,2009圍術(shù)期使用β-blockerBetablockersshouldbecontinuedinpatientsundergoingsurgerywhohavebeenonbetablockerschronically.(ClassI，LevelofEvidence:B)2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatientsUndergoingNoncardiacSurgery:ExecutiveSummaryCirculation.publishedonlineAugust1,2014;圍術(shù)期使用β-blockerItisreasonableforthemanagementofbetablockersaftersurgerytobeguidedbyclinicalcircumstances,independentofwhentheagentwasstarted

(ClassIIa，LevelofEvidence:B)2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatientsUndergoingNoncardiacSurgery:ExecutiveSummaryCirculation.publishedonlineAugust1,2014;AntiplateletTherapy:stoporcontinue?AntiplateletTherapyaspirin75to162mg/d.Treatmentwithclopidogrelisreasonablewhenaspiriniscontraindicated.Fihnetal.2012AHAGuidelineStableIschemicHeartDisease:ExecutiveSummary.Circulation.2012;126:3097-3137AdministrationofaspirinhadnosignificanteffectondeathorMINEnglJMed.2014Apr17;370(16):1494-503.AdministrationofaspirinincreasedtheriskofmajorbleedingNEnglJMed.2014Apr17;370(16):1494-503.Restartaspirinwouldbe8to10dayssurgeryNEnglJMed.2014Apr17;370(16):1494-503.圍術(shù)期應(yīng)用抗血小板藥物氯吡格雷停用

阿司匹林：心梗風(fēng)險VS出血PCI病人球囊血管成形術(shù)裸支架藥物洗脫支架<14天>14天擇期手術(shù)推遲>30-45天維持阿司匹林手術(shù)<30-45天<365天擇期手術(shù)推遲>365天維持阿司匹林手術(shù)2009ACCF/AHAFocusedUpdateonPerioperativeBetaBlockadeIncorporatedIntotheACC/AHA2007GuidelinesCirculationNovember24,2009DAPT,dualantiplatelettherapyAdministrationofaspirinhadnosignificanteffectondeathorMINEnglJMed.2014Apr17;370(16):1494-503.阿司匹林N=4998安慰劑組N=5012AdministrationofaspirinhadnosignificanteffectondeathorMINEnglJMed.2014Apr17;370(16):1494-503.術(shù)前服用β受體阻斷劑和statin，均未停藥。Non-cardiacsurgeryi