冠心病人的术前评估

冠心病人的术前评估昆明医科大学第二附属医院麻醉科思永玉CASE男，65岁，高血压，冠心病三年前急性心梗，放冠脉支架（左前降支）房颤，心室率<100bpm珍菊降压片可以爬上二、三楼拟输尿管镜下放置双J管放置双J管能做手术吗？我只是放个双J管！说干就干！AmericanSocietyofAnesthesiologists’physicalstatusclassificationofpatients1normalhealthpatient2轻度系统疾病（活动不受限）3严重系统疾病（部分活动受限）4严重系统疾病，威胁到生存（不能活动）5垂死病人，不做手术就没有活的希望6脑死亡，准备捐献器官E急诊加“E”JohnF.ButterworthIV，DavidC.Mackey，JohnD.Wasnick

Morgan&MikhailsClinicalAnesthesiology(5th)ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgeryconditionexamplesUnstablecoronarysyndromesUnstableangina(CCSclassⅢorⅣ)RecentMI(7~30d)加拿大心绞痛分级（CCSclass）Ⅰ一般体力活动不引起心绞痛，例如行走和上楼，但紧张、快速或持续用力可引起心绞痛的发作Ⅱ日常体力活动稍受限制，快步行走或上楼、登高、饭后行走或上楼、寒冷或风中行走、情绪激动可发作心绞痛或仅在睡醒后数小时内发作。在正常情况下以一般速度平地步行200m以上或登一层以上的楼梯受限Ⅲ日常体力活动明显受限，在正常情况下以一般速度平地步行100-200m或登一层楼梯时可发作心绞痛Ⅳ轻微活动或休息时即可以出现心绞痛症状Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgeryconditionexamplesDecompensatedHFNYHAfunctionalclassⅣWorseningornew-onsetHF纽约心脏协会（NYHA）心力衰竭分级1无症状2重度劳力时出现症状，体力活动轻度受限3一般活动（如步行）时即出现症状，体力活动明显受限4静息时出现症状症状为呼吸困难与乏力Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009CardiacriskstratificationfornoncardiacsurgicalproceduresRiskstratificationProcedureExamplesVascular(cardiacrisk>5%)AorticandothermajorvascularsurgeryPeripheralvascularsurgeryIntermediate(1%<cardiacrisk<5%)IntraperitonealandintrathoracicsurgeryCarotidendarterectomyHeadandnecksurgeryOrthopedicsurgeryProstatesurgeryLow(cardiacrisk<1%)EndoscopicproceduresSuperficialprocedureCataractsurgeryBreastsurgeryAmbulatorysurgeryFleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009心梗三思而后行无ABC冠心病药物预防治疗A：Aspirin或氯吡格雷

ACEI/ARBB:β

受体阻断剂

BloodpressureC:Cholesterol

他汀类药物2013冠心病康复与二级预防中国专家共识，中华心血管杂志，2013,41（4）：267-275Clinicalriskfactors•

historyofischemicheartdisease•historyofcompensatedorpriorHF•historyofcerebrovasculardisease•diabetesmellitus;•renalinsufficiency年龄心梗病史心绞痛MET<4脑血管疾病糖尿病慢性心衰肺部疾病AHA临床危险因素分层Fleisheretal.2009ACCF/AHAPerioperativeGuidelines.CirculationNovember24,2009

《危重患者围手术期心血管疾病临床防治技术研究》，云南省社会发展科技攻关项目心源性死亡的相关因素心梗病史心绞痛《危重患者围手术期心血管疾病临床防治技术研究》，云南省社会发展科技攻关项目MINSassociatedwithsubstantialmortalityVISIONWritingGroup,Anesthesiology2014;120:564-78A：Aspirin或氯吡格雷

ACEI/ARBB:β受体阻断剂

BloodpressureC:Cholesterol

他汀类药物2013冠心病康复与二级预防中国专家共识，中华心血管杂志，2013,41（4）：267-275做活动还可以小手术停无药物治疗房颤冠心病暂缓手术！外科医师：我就要做！我会打局麻！哈哈哈，不服你咬我啊！麻醉医师：病人晚上心梗死亡！外科医师：围术期ABC治疗A：Aspirin或氯吡格雷

ACEI/ARBB:β

受体阻断剂

BloodpressureC:Cholesterol

他汀类药物2013冠心病康复与二级预防中国专家共识，中华心血管杂志，2013,41（4）：267-275Cholesterol-StatinPerioperativeStatinTherapyStatinsshouldbecontinuedinpatientscurrentlytakingstatinsandscheduledfornoncardiacsurgery(ClassI，LevelofEvidence:B)2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatientsUndergoingNoncardiacSurgery:ExecutiveSummaryCirculation.publishedonlineAugust1,2014;Statin

Therapy

intheReductionofCardiovascularEventsinPatientsUndergoingIntermediate-Risk

Noncardiac,Nonvascular

Surgery他汀组1.45%对照组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.

多中心双盲，随机大样本，8000例atheroscleroticdisease2–4hbeforesurgerymetoprolol100mgthefirst6hafterSurgerymetoprolol100mgHR50bpmSBP100mmHgHR80bpmSBP100mmHgmetoprolol200mg/dfor30daysDevereauxPJ,etal.Lancet.2008;371(9627):1839-47.围术期使用β-blockerRoutineadministrationofhigh-dosebetablockersintheabsenceofdosetitrationisnotusefulandmaybeharmfultopatientsnotcurrentlytakingbetablockerswhoareundergoingnoncardiacsurgery.(ClassIII，LevelofEvidence:C)2009ACCF/AHAFocusedUpdateonPerioperativeBetaBlockadeIncorporatedIntotheACC/AHA2007GuidelinesCirculationNovember24,2009围术期使用β-blockerBetablockersshouldbecontinuedinpatientsundergoingsurgerywhohavebeenonbetablockerschronically.(ClassI，LevelofEvidence:B)2014ACC/AHAGuidelineonPerioperativeCardiovascularEvaluationandManagementofPatientsUndergoingNoncardiacSurgery:ExecutiveSummaryCirculation.publishedonlineAugust1,2014;围术期使用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.围术期应用抗血小板药物氯吡格雷停用

阿司匹林：心梗风险VS出血PCI病人球囊血管成形术裸支架药物洗脱支架<14天>14天择期手术推迟>30-45天维持阿司匹林手术<30-45天<365天择期手术推迟>365天维持阿司匹林手术2009ACCF/AHAFocusedUpdateonPerioperativeBetaBlockadeIncorporatedIntotheACC/AHA2007GuidelinesCirculationNovember24,2009DAPT,dualantiplatelettherapyAdministrationofaspirinhadnosignificanteffectondeathorMINEnglJMed.2014Apr17;370(16):1494-503.阿司匹林N=4998安慰剂组N=5012AdministrationofaspirinhadnosignificanteffectondeathorMINEnglJMed.2014Apr17;370(16):1494-503.术前服用β受体阻断剂和statin，均未停药。Non-cardiacsurgeryi