围手术期心血管评估和非心脏手术护理指南.pptx

WRITING COMMITTEE MEMBERSLee A.Fleisher,MD,FACC,FAHA,ChairJoshua A.Beckman,MD,FACCKenneth A.Brown,MD,FACC,FAHAHugh Calkins,MD,FACC,FAHAElliott Chaikof,MDKirsten E.Fleischmann,MD,MPH,FACCWilliam K.Freeman,MD,FACCJames B.Froehlich,MD,MPH,FACCEdward K.Kasper,MD,FACCJudy R.Kersten,MD,FACCBarbara Riegel,DNSc,RN,FAHAJohn F.Robb,MD,FACCACC/AHA 2007 Guidelines on ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgeryand Care for Noncardiac Surgery第1页/共30页Class 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 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 recommendedis 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 not useful/effective/beneficialmay be harmfulApplying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence 第2页/共30页Level 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-analysesClass 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-analysesClass 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 第3页/共30页Level BLimited(2-3)population risk strata evaluatedClass I Recommen-dation 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 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 studiesApplying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence 第4页/共30页Applying Classification of Applying Classification of Recommendations and Level of Evidence Recommendations and Level of Evidence Level 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 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 studies,or standard-of-care第5页/共30页Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac SurgeryConditionExamplesUnstable coronary syndromesUnstable or severe angina*(CCS class III or IV)Recent MIDecompensated HF NYHA functional class IV;Worsening or new-onset HFSignificant arrhythmiasHigh-grade atrioventricular blockMobitz II atrioventricular blockThird-degree atrioventricular heart blockSymptomatic ventricular arrhythmiasSupraventricular arrhythmias(including atrial fibrillation)with uncontrolled ventricular rate(HR 100 bpm at rest)Symptomatic bradycardiaNewly recognized ventricular tachycardiaSevere valvular diseaseSevere aortic stenosis(mean pressure gradient greater than 40 mm Hg,aortic valve area less than 1.0 cm2,or 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 in patients who are unusually sedentary.The ACC National Database Library defines recent MI as more than 7 days but within 30 days)第6页/共30页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,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,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;kph,kilometers per hour.*Modified from Hlatky et al,11 copyright 1989,with permission from Elsevier,and adapted from Fletcher et al.12第7页/共30页Cardiac Risk Stratification for Noncardiac Surgical ProceduresRisk Stratification Procedure Examples Vascular(reported cardiac Aortic and other major vascular surgery risk often 5%)Peripheral vascular 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 Ambulatory surgery 第8页/共30页Recommendations for Preoperative Noninvasive Evaluation of LV FunctionClass I(none)Class IIaIt 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 dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months.(C)Class IIbReassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established.(C)Class IIIRoutine perioperative evaluation of LV function in patients is not recommended.(B)第9页/共30页Recommendations for Preoperative Resting 12-Lead ECGClass 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 arterial 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 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 factors include history of ischemic heart disease,history of compensated or prior HF,history of cerebrovascular disease,DM,and renal insufficiency.第10页/共30页Recommendations for Noninvasive Stress Testing Before Noncardiac SurgeryClass I:Patients with active cardiac conditions in whom noncardiac surgery is planned should 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 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 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)第11页/共30页Prognostic Gradient of Ischemic Responses 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 response 3 minutes after exertionTypical anginaExercise-induced decrease in systolic BP by 10 mm Hg第12页/共30页Prognostic 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 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 130 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,the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.第13页/共30页Preoperative Coronary Revascularization With CABG or Percutaneous Coronary InterventionClass I:Patients with active cardiac conditions in whom noncardiac surgery is planned should 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 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 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)第14页/共30页Cardiac evaluation and care algorithm for noncardiac surgery(1)第15页/共30页Cardiac evaluation and care algorithm for noncardiac surgery(2)第16页/共30页Proposed approach to the management of patients with previous PCI who require noncardiac surgery第17页/共30页Treatment for patients requiring PCI who need subsequent surgery第18页/共30页Drug Eluting Stents(DES)and Stent ThrombosisA 2007 AHA/ACC/SCAI/ACS/ADA science advisory report concludes that premature discontinuation of dual antiplatelet therapy markedly increases the risk of catastrophic stent thrombosis and death or MI.To eliminate the premature discontinuation of thienopyridine therapy,the advisory group recommends the following:1.Before implantation of a stent,the physician should discuss the need for dual-antiplatelet therapy.In patients not expected to comply with 12 months of thienopyridine therapy,whether for economic or other reasons,strong consideration should be given to avoiding a DES.2.In patients who are undergoing preparation for PCI and who are likely to require invasive or surgical procedures within the next 12 months,consideration should be given to implantation of a baremetal stent or performance of balloon angioplasty with provisional stent implantation instead of the routine use of a DES.Grines CL,et al.Circulation.2007;115:813-818.第19页/共30页Drug Eluting Stents(DES)and Stent Thrombosis3.A greater effort by healthcare professionals must be made before patient discharge to ensure that patients are properly and thoroughly educated about the reasons they are prescribed thienopyridines and the significant risks associated with prematurely discontinuing such therapy.4.Patients should be specifically instructed before hospital discharge to contact their treating cardiologist before stopping any antiplatelet therapy,even if instructed to stop such therapy by another healthcare provider.5.Healthcare providers who perform invasive or surgical procedures and who are concerned about periprocedural and postprocedural bleeding must be made aware of the potentially catastrophic risks of premature discontinuation of thienopyridine therapy.Such professionals who perform these procedures should contact the patients cardiologist if issues regarding the patients antiplatelet therapy are unclear,to discuss optimal patient management strategy.Grines CL,et al.Circulation.2007;115:813-818.第20页/共30页Drug Eluting Stents(DES)and Stent Thrombosis6.Elective procedures for which there is significant risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate course of thienopyridine therapy(12 months after DES implantation if they are not at high risk of bleeding and a minimum of 1 month for bare-metal stent implantation).7.For patients treated with DES who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy,aspirin should be continued if at all possible and the thienopyridine restarted as soon as possible after the procedure because of concerns about late stent thrombosis.Grines CL,et al.Circulation.2007;115:813-818.第21页/共30页Recommendations for Beta-Blocker Medical TherapyCLASS I1.Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina,symptomatic arrhythmias,hypertension,or other ACC/AHA class I guideline indications.(C)2.Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing.(B)CLASS II