心臟病人非心臟手術(shù)術(shù)前評估與術(shù)中管理楊柳青6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。心臟病人非心臟手術(shù)術(shù)前評估與術(shù)中管理楊柳青心臟病人非心臟手術(shù)術(shù)前評估與術(shù)中管理楊柳青6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。心臟病人非心臟手術(shù)術(shù)前評估與術(shù)中管理江蘇省蘇北人民醫(yī)院麻醉科楊柳青2009ESC/ESA指南本文檔由醫(yī)學(xué)百事通高端醫(yī)生網(wǎng)專家制作在線咨詢醫(yī)生網(wǎng)址:12320bstImpactFactor9.275IntroductionThepresentguidelinesfocusonthecardiologicalmanagementofpatientsundergoingnon-cardiacsurgery,i.e.patientswhereheartdiseaseisapotentialsourceofcomplicationsduringsurgerymajornon-cardiacsurgeryisassociatedwithanincidenceofcardiacdeathofbetween0.5and1.5%,andofmajorcardiaccomplicationsofbetween2.0and3.5%ImpactoftheageingpopulationItisestimatedthatelderlypeoplerequiresurgeryfourtimesmoreoftenthantherestofthepopulation

Pre-operativeevaluationSurgicalriskforcardiacevents:theurgency,magnitude,type,anddurationoftheprocedure,aswellasthechangeinbodycoretemperature,bloodloss,andfluidshiftsFunctionalcapacity

Functionalcapacityismeasuredinmetabolicequivalents(METs)ExercisetestingprovidesanobjectiveassessmentoffunctionalcapacityWithouttesting,functionalcapacitycanbeestimatedbytheabilitytoperformtheactivitiesofdailyliving

<4METsindicatespoorfunctionalcapacityandisassociatedwithanincreasedincidenceofpost-operativecardiaceventsRiskindicesGoldman(1977),Detsky(1986),Lee(1999)TheLeeindex,tobethebestcurrentlyavailablecardiacriskpredictionindexinnon-cardiacsurgerySixindependentclinicaldeterminants(TheLeeindex)ahistoryofIHDahistoryofcerebrovasculardiseaseheartfailureinsulin-dependentdiabetesmellitusimpairedrenalfunctionHigh-risktypeofsurgery

TheLeeindexAllfactorscontributeequallytotheindex(with1pointeach)theincidenceofmajorcardiaccomplicationsisestimatedat0.4,0.9,7,and11%inpatientswithanindexof0,1,2,and≥3points,respectivelyBiomarkersCardiactroponinsTandI(cTnTandcTnI)arethepreferredmarkersforthediagnosisofMIbecausetheydemonstratesensitivityandtissuespecificitysuperiortootheravailablebiomarkersPlasmaBNPandNT-proBNPimportantprognosticindicatorsinpatientswithheartfailureadditionalprognosticvalueforlong-termmortalityandforcardiaceventsNon-invasivetestingthreecardiacriskmarkers:

LVdysfunctionmyocardialischaemiaheartvalveabnormalities

EchocardiographyAmeta-analysisoftheavailabledatademonstratedthatanLVejectionfractionof<35%hadasensitivityof50%andaspecificityof91%forpredictionofperioperativenon-fatalMIorcardiacdeathawell-establishedinvasivediagnosticprocedure

rarelyindicatedtoassesstheriskofnoncardiacsurgery

AngiographyRiskreductionstrategies

Pharmacological

Besidesspecificriskreductionstrategiesadaptedtopatientcharacteristicsandthetypeofsurgery,preoperativeevaluationisanopportunitytocheckandoptimizethecontrolofallcardiovascularriskfactorsb-blockersThedoseofb-blockersshouldbetitrated,whichrequiresthattreatmentbeinitiatedoptimallybetween30daysandatleast1weekbeforesurgery.treatmentstartwithadailydoseof2.5mgofbisoprololor50mgofmetoprololsuccinatewhichshouldthenbeadjustedbeforesurgerytoachievearestingheartrateofbetween60and70bpmwithSBP>100mmHgNitrates:NitroglycerinDiureticsAspirinAnticoagulanttherapyRevascularizationSpecificdiseasesArterialhypertensionValvularheartdiseaseAorticstenosisMitralstenosisARandMRprostheticvalve(s)Arterialhypertensionantihypertensivemedicationsshouldbecontinuedduringtheperioperativeperiod.Inpatientswithgrade3hypertension(systolicbloodpressure≧180mmHgand/ordiastolicbloodpressure≧110mmHg),thepotentialbenefitsofdelayingsurgerytooptimizethepharmacologicaltherapyshouldbeweighedagainsttheriskofdelayingthesurgicalprocedureValvularheartdiseasehigherriskEchocardiographyshouldbeperformedAorticstenosisSevereAS:aorticvalvearea<1cm2

<0.6cm2/m2bodysurfacearea)Mitralstenosisrelativelylowrisk:non-significantmitralstenosis(MS)(valvearea>1.5cm2)andinasymptomaticpatientswithsignificantMS(valvearea<1.5cm2)andsystolicpulmonaryarterypressure<50mmHgcontrolofheartrateStrictcontroloffluidoverloadanticoagulationAFARandMRNon-significantARandMR(lowrisk)asymptomaticpatientswithsevereARandMRandpreservedLVfunction(lowrisk)SymptomaticpatientsandLVEF<30%(Highrisk,onlyifnecessary,optimizationofpharmacologicaltherapy)prostheticvalve(s)noevidenceofvalveorventriculardysfunction(withoutadditionalrisk)endocarditisprophylaxisanticoagulationregimenmodificationBradyarrhythmiasTemporarycardiacpacingisrarelyrequired,eveninthepresenceofpre-operativeasymptomaticbifascicularblockorCLBBBTheindicationsfortemporarypacemakersaregenerallythesameasthoseforpermanentpacemakersPacemaker/implantablecardioverterdefibrillatorunipolarelectrocauteryrepresentsasignificantriskbeavoidedby

positioningthegroundplateKeepingtheelectrocauterydeviceawayfromthepacemaker,givingonlybriefburstsandusingthelowestpossibleamplitudeTheimplantablecardioverterdefibrillatorshouldbeturnedoffduringsurgeryandswitchedonintherecoveryphasebeforedischargetothewardPerioperativemonitoring

V5(75%),V4(61%),V5+V4(90%),V5+V4+II(96%)ContinuousautomatedSTtrendingmonitors(sensitivityandspecificityof74and73%)ECGTransesophagealechocardiographyRightheartcatherizationbothalargeobservationalstudyandarandomizedmulticentreclinicaltrialdidnotshowabenefitassociatedwiththeuseofrightheartcatheterizationnodifferenceinmortalityandhospitalduration/ahigherincidenceofpulmonaryembolismDisturbedglucosemetabolismpromotesatherosclerosis,endothelialdysfunction,andactivationofplateletsandproinflammatorycytokinesIntraoperativeanaestheticmanagementproperorganperfusionpressureSpinalandepiduralanaesthesia(T4)Onemeta-analysisre