心脏病人非心脏手术术前评估与术中管理.pptx
Impact Factor 9.275第1页/共61页The Preambleu 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 ultimate judgement regarding the care of an individual patient 第2页/共61页第3页/共61页IntroductionThe 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 associated 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%第4页/共61页Impact of the ageing populationIt is estimated that elderly people require surgery four times more often than the rest of the population 第5页/共61页Pre-operative evaluationSurgical risk 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 第6页/共61页第7页/共61页第8页/共61页Functional capacity Functional capacity is measured in metabolic equivalents(METs)Exercise testing provides an objective assessment of functional capacity Without testing,functional capacity can be estimated by the ability to perform the activities of daily living 第9页/共61页 4 METs indicates poor functional capacity and is associatedwith an increased incidence of post-operative cardiac events 第10页/共61页Risk indicesGoldman(1977),Detsky(1986),Lee(1999)The Lee index,to be the best currently available cardiac risk prediction index in non-cardiac surgery 第11页/共61页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 第12页/共61页The Lee indexAll 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 第13页/共61页第14页/共61页BiomarkersCardiac troponins T and I(cTnT and cTnI)are the preferredmarkers for the diagnosis of MI because they demonstrate sensitivity and tissue specificity superior to other available biomarkers 第15页/共61页Plasma BNP and NT-proBNPimportant prognostic indicators in patients with heart failure additional prognostic value for long-term mortality and for cardiac events 第16页/共61页Non-invasive testingthree cardiac risk markers:LV dysfunction myocardial ischaemia heart valve abnormalities 第17页/共61页第18页/共61页Echocardiography A meta-analysis of the available data demonstrated that an LV ejection fraction of 100 mmHg 第24页/共61页第25页/共61页第26页/共61页Nitrates:Nitroglycerin 第27页/共61页第28页/共61页第29页/共61页Diuretics第30页/共61页Aspirin第31页/共61页Anticoagulant therapy 第32页/共61页第33页/共61页第34页/共61页第35页/共61页Revascularization第36页/共61页第37页/共61页Specific diseases Arterial hypertensionValvular heart diseaseAortic stenosisMitral stenosisAR and MRprosthetic valve(s)第38页/共61页Arterial hypertensionantihypertensive 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 optimize the pharmacological therapy should be weighed against the risk of delaying the surgical procedure 第39页/共61页Valvular heart diseasehigher risk Echocardiography should be performed 第40页/共61页Aortic stenosisSevere AS:aortic valve area 1 cm2 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第42页/共61页AR and MR Non-significant AR and MR(low risk)asymptomatic patients 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)第43页/共61页prosthetic valve(s)no evidence of valve or ventricular dysfunction(without additional risk)endocarditis prophylaxis anticoagulation regimen modification 第44页/共61页BradyarrhythmiasTemporary 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 第45页/共61页Pacemaker/implantable cardioverter defibrillatorunipolar 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第46页/共61页The implantable cardioverter defibrillator should be turned off during surgery and switched on in the recovery phase before discharge to the ward 第47页/共61页Perioperative monitoringV5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)Continuous automated ST trending monitors(sensitivity and specificity of 74 and 73%)ECG第48页/共61页第49页/共61页Transesophageal echocardiography第50页/共61页Right heart catherizationboth a large observational 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第51页/共61页Disturbed glucose metabolism promotes atherosclerosis,endothelial dysfunction,and activation of platelets and proinflammatory cytokines 第52页/共61页第53页/共61页Intraoperative anaesthetic managementproper organ perfusion pressureSpinal and epidural anaesthesia(T4)One meta-analysis reported significantly improved survival and reduced incidence of post-operative thromboembolic,cardiac and pulmonary complications with neuraxial blockade compared with general anaesthesia 第54页/共61页Putting the puzzle together第55页/共61页第56页/共61页第57页/共61页第58页/共61页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）、进进行手术治疗行手术治疗、围术期ECG监测第59页/共61页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第60页/共61页感谢您的观看！第61页/共61页
