围手术期心脏评价

1、内科会诊的原则内科会诊的原则(一一)1、内科会诊医师应意识到自己代表的是整个内科、内科会诊医师应意识到自己代表的是整个内科 2、电话里简单询问患者情况，判断是否急会诊；没有看患、电话里简单询问患者情况，判断是否急会诊；没有看患者之前在电话里只能回答一些笼统问题者之前在电话里只能回答一些笼统问题 3、会诊目的应具体而明确，申请会诊的医师不要写、会诊目的应具体而明确，申请会诊的医师不要写“排除排除内科情况内科情况”，或，或“处理内科问题处理内科问题”之类的话之类的话 4、应与患者的主管医师充分交流，会诊时与主管医师见面、应与患者的主管医师充分交流，会诊时与主管医师见面5、不能依赖别人提供病史，必须

2、亲自床边看患者、不能依赖别人提供病史，必须亲自床边看患者 6、会诊意见应简单明确而富有建设性，最好不超过、会诊意见应简单明确而富有建设性，最好不超过5条条内科会诊的原则（二）内科会诊的原则（二） 7、会诊医师应意识到自己的局限和不足，尊重主管医、会诊医师应意识到自己的局限和不足，尊重主管医师的决策，千万不要在未通知主管医师的情况下自己开师的决策，千万不要在未通知主管医师的情况下自己开医嘱医嘱 8、在主管医师不在场的情况下，不要向家属发表有关、在主管医师不在场的情况下，不要向家属发表有关病情的看法病情的看法 9、外科患者术前请内科会诊是为了评估风险，因此不、外科患者术前请内科会诊是为了评估风险，

3、因此不要写要写“可以手术可以手术”或或“可以全麻可以全麻”之类的话之类的话 10、应随访会诊过的患者，你可能会有很多意外的发现、应随访会诊过的患者，你可能会有很多意外的发现和收获，患者病情的发展可能会出乎你的意料，甚至与和收获，患者病情的发展可能会出乎你的意料，甚至与你最初的判断完全相反你最初的判断完全相反 11、不要过于自信，遇到自己不能解决的问题，应向有、不要过于自信，遇到自己不能解决的问题，应向有经验的医师请教经验的医师请教 12、珍惜医疗资源和他人时间，尽量避免不必要的会诊、珍惜医疗资源和他人时间，尽量避免不必要的会诊 围手术期的心脏评估及治疗围手术期的心脏评估及治疗方案的选择方案的选

4、择 吉林大学第二医院吉林大学第二医院 孙孙 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麻醉对心脏的影响： 1、全身麻醉、全身麻醉 （1）正压通气可减少右心回心血量，此时不宜）正压通气可减少右心回心血量，此时不宜过度补液。过度补液。 （2）麻醉结束，停止正压通气时，前负荷可突）麻醉结束，停止正压通气时，前负荷可突然增高，导致血压升高和肺充血。然增高，导致血压升高和肺充血。 2、脊髓和硬膜外麻醉、脊髓和硬膜外麻醉 通过阻断交感神经，使外周小动脉和静脉扩张，通过阻断交感神经，使外周小动脉和静脉扩张，外周血管阻力下降外周血管阻力下降10%-15%，引起右心室前，引起右心室前负荷降低。负荷降低。手术对心脏的影响外科手术应激反应可使心律增快，

16、血压升高，外科手术应激反应可使心律增快，血压升高，可诱发冠心病人心肌缺血，增加心脏风险。可诱发冠心病人心肌缺血，增加心脏风险。围手术期如发生心动过速，可导致冠脉斑块围手术期如发生心动过速，可导致冠脉斑块破裂。破裂。术中麻醉，术中麻醉，SBP可降至可降至95-105mmHg，可使，可使冠心病患者冠脉血流减少，加重心肌缺血。冠心病患者冠脉血流减少，加重心肌缺血。术中刺激迷走神经可引起一过性窦性心动过术中刺激迷走神经可引起一过性窦性心动过缓或交界性心律。血容量不足，外周血管扩缓或交界性心律。血容量不足，外周血管扩张和心肌对儿茶酚胺的敏感性增高可引起快张和心肌对儿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。二尖瓣狭窄患者对心动过速耐受性差二尖瓣狭窄患者对心动过速耐受性差诊治过程中需注意的关键问题1、对冠心病是否进行评估 冠心病的诊断依据： 典型的心绞痛症状 心肌梗死病史 冠脉搭桥术后 PCI后 冠脉造影证实狭窄50% 如果有心肌缺血的证据，至少在心梗如果有心肌缺血的证据，至少在心梗 后后6周后方可行外科心脏手术周后方可行外科心脏手术 择期手术可以等择期手术可以等6个月以后个月以后 恶性肿瘤这类限期手术，应权衡利恶性肿瘤这类限期手术，应权衡利 弊，积极治疗冠心病后尽快手术弊，积极治疗冠心病后尽快手术 2、PCI手术多长时间行外科手术： 急性血栓形成多发性裸支架术后急性血栓形成多发性

18、裸支架术后2周周以后，以后，6-8周内开始再狭窄周内开始再狭窄 目前资料，目前资料，PCI后（裸支架）后（裸支架）2周以周以 后，后，8 周以内或（药物支架）周以内或（药物支架）1年以年以 后行外科心脏手术相对安全后行外科心脏手术相对安全3 3、术前高血压是否得到较好的控制、术前高血压是否得到较好的控制 研究证实研究证实1级和级和2级高血压级高血压（SBP180mmHg,DBP110mmHg）,无严无严重靶器官损害的患者，不增加围手术期的重靶器官损害的患者，不增加围手术期的心脏风险，没有必要推迟手术，但要将血心脏风险，没有必要推迟手术，但要将血压控制在术前水平。压控制在术前水平。 3级高血压级

19、高血压（SBP180mmHg,DBP110mmHg）在术）在术前必须得到控制。前必须得到控制。4 4、CHFCHF患者心功能是否评价和治疗患者心功能是否评价和治疗 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、体格检查重点：、体格检查重点： 生命体征生命体征 颈动脉搏动和杂音、双肺听诊颈动脉搏动和杂音、双肺听诊 腹部叩诊、双下肢浮肿腹部叩诊、双下肢浮肿 脐周血管杂音提示肾动脉狭窄；上肢血压高、脐周血管杂音提示肾动脉狭窄；上肢血压高、下肢无脉提示主动脉狭窄下肢无脉提示主动脉狭窄 心尖部第三心音提示左心功能不全，心脏杂音心尖部第三心音提

22、示左心功能不全，心脏杂音首先排除瓣膜病，主动脉瓣狭窄手术风险大，首先排除瓣膜病，主动脉瓣狭窄手术风险大，特别注意主动脉并听诊无杂音特别注意主动脉并听诊无杂音 严重二尖瓣狭窄或返流使围手术期心力衰竭风严重二尖瓣狭窄或返流使围手术期心力衰竭风险增加，二尖瓣听诊也是检查重点。险增加，二尖瓣听诊也是检查重点。3 3、辅助检查重点、辅助检查重点 生化检查：未用利尿剂而出现低血钾提示醛固生化检查：未用利尿剂而出现低血钾提示醛固酮增多酮增多 心电图：心电图：度房室传导阻滞、右束支阻滞不会度房室传导阻滞、右束支阻滞不会增加围手术期风险增加围手术期风险 超声心动图负荷试验超声心动图负荷试验 优点：随心率和心肌收

23、缩力增加，能动态优点：随心率和心肌收缩力增加，能动态观察心肌缺血。如心率低时室壁运动异常或大观察心肌缺血。如心率低时室壁运动异常或大面积室壁运动异常都提示预后不良。面积室壁运动异常都提示预后不良。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、冠状动脉造影：、冠状动脉造影： 非心脏手术围手术期冠脉

45、造影的指证：非心脏手术围手术期冠脉造影的指证： 怀疑或确诊冠心病患者，无创检查提示心脏事件怀疑或确诊冠心病患者，无创检查提示心脏事件 风险高风险高 充分药物治疗不能稳定的心绞痛充分药物治疗不能稳定的心绞痛 级或级或级心绞痛级心绞痛 不稳定心绞痛，特别是拟行中高危手术患者不稳定心绞痛，特别是拟行中高危手术患者 有高危因素拟行高危手术的患者，无创检查不能有高危因素拟行高危手术的患者，无创检查不能 除外冠心病除外冠心病 多个中危因素，拟行血管手术及高危非心脏手术多个中危因素，拟行血管手术及高危非心脏手术 无创检查提示中到大面积心肌缺血无创检查提示中到大面积心肌缺血 急性心肌梗死恢复期拟行急诊非心脏手

46、术急性心肌梗死恢复期拟行急诊非心脏手术不建议非心脏手术期术前冠脉造影不建议非心脏手术期术前冠脉造影：（1）已知冠心病，拟行低危手术，无创检查）已知冠心病，拟行低危手术，无创检查 无高危结果无高危结果（2）冠脉重建后无症状，活动耐力良好）冠脉重建后无症状，活动耐力良好 （7METS）（3）轻度不稳定性心绞痛，左室功能良好）轻度不稳定性心绞痛，左室功能良好（4）因为其他合并疾病不能行冠脉重建，）因为其他合并疾病不能行冠脉重建， 或患者拒绝血管重建，严重左心功能或患者拒绝血管重建，严重左心功能 不全（不全（LVEF176.8umol/L。 术前评估步骤第一步：明确手术的急缓，急诊手术就不允许过第一步

47、：明确手术的急缓，急诊手术就不允许过 多的术前检查多的术前检查第二步：患者如第二步：患者如5年内接受过搭桥手术或年内接受过搭桥手术或6个月到个月到 5年内接受过年内接受过PCI，并且无心肌缺血的症，并且无心肌缺血的症 状和证据，则风险很低且不必进一步检查。状和证据，则风险很低且不必进一步检查。第三步：是否第三步：是否2年内接受过冠状动脉评估：如果结果年内接受过冠状动脉评估：如果结果 正常，不必重复检查，如有缺血症状则应正常，不必重复检查，如有缺血症状则应 重新评估。重新评估。第四步：如行择期手术，存在下列情况手术 应取消或推迟： 1 1、不稳定冠心病、不稳定冠心病 2 2、失代偿、失代偿CHF

48、CHF 3 3、血液动力学不稳定性心律失常：、血液动力学不稳定性心律失常： 高度高度AVBAVB 有症状室性心律失常伴基础心脏病有症状室性心律失常伴基础心脏病 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、严重瓣膜病、严重瓣膜病第五步：是否存在中度临床预测危第五步：是否存在中度临床预测危险因素：险因素： 轻度心绞痛（轻度心绞痛（级或级或级）级） 陈旧性心梗或病理陈旧性心梗或病理Q波波 心衰史或失代偿心衰史或失代偿CHF 1型糖尿病型糖尿病 血清肌酐血清肌酐176.8umol/L 同时考虑运动耐力和手术本身的风险同时考虑运动耐力和手术本身的风险 运动耐力：良好：运动耐力：良好：10METS 好：好：7-10METS 中等：中等：4-7METS 差：差：177umol/L级：级：0