Pre-anesthesia Evaluation of Cardiac Risk during Non-cardiac Surgeries in  Patients Suffering from Cardiac Diseases<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

闻大翔  博士

杭燕南  教授

上海第二医科大学附属仁济医院麻醉科

Da-xiang Wen and Yan-nan Hang

Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Second Medical University

ABSTRACT

The perioperative risks of patients suffering from cardiac diseases undergoing non-cardiac surgeries are high. As a result, the complete pre-anesthesia evaluation of these patients seems great value. In this paper, we provide the guideline about the perioperative evaluation of cardiac disease undergoing non-cardiac surgery which was constituted by American College of Cardiology (ACC) and American Heart Association(AHA) in 1996 and revised in 2000 and 2001. Meanwhile some other concerning reports are recruited. Our aim is to supply some helpful consults for clinical practices.
Key Words: Coronary artery disease (CAD); Non-cardiac surgery; Pre-anesthesia evaluation; Risk facts; Mortality
Corresponding author: Yan-nan Hang, MD; Department of Anesthesiology, Renji Hospital Affiliated to Shanghai Second Medical University, Shanghai 200001. E-mail: prohynnc@hotmail.com

　　冠心病(CAD)病人施行非心脏手术的种类以腹部、泌尿、骨科手术较多，急症、大手术、失血多和高龄病人的风险较大，围术期心脏事件的发生率很高。近年来，老年手术病人增加，约占手术病人的30%左右，冠心病人的发病率和手术率也相应增多。因此，麻醉前全面评估对减少心脏病人施行非心脏手术的并发症和死亡率具有重要意义。本文介绍美国心脏学会（ACC/AHA）1996年制定，2000年和2001年修订的心脏病人非心脏手术围术期评估指南，并结合文献补充有关内容，供临床应用参考。
一、2002年美国心脏病学会(ACC/AHA)围术期心血管危险性（心肌梗死、心力衰竭或死亡）估计
1. 围术期心血管危险因素分级见表1。
2. 体能状态的评估见表2。
　　根据Duke活动指数（Duke Activity Status Index）和AHA运动标准估计不同活动程度的体能状态以代谢当量（MET）为单位。
3.手术范围大小的危险性分级见表3。
　　综上所述，具有心血管高危因素、体能状态较差和/或经历高危手术的病人，围术期心脏事件发生率和死亡率较高。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

4. ACC/AHA围术期心血管危险因素评估的附加考虑
(1) 术前考虑CAD药物或介入治疗的影响：近期PTCA可增加出血和再狭窄率，抗凝和抗血小板药增加出血危险。4周内行PTCA的病人禁行择期手术，手术前预防性的PTCA对非心脏手术无益，90天内PTCA并不能改善心脏病人非心脏手术的预后。但有文献报告，PTCA 或CABG可降低非心脏手术后心肌再梗死率和死亡率显著降低。
(2) 围术期应用β受体拮抗剂或α₂受体激动剂：可显著降低心脏病人非心脏手术围术期心脏事件的发生，并可能具有良好的远期效应。
(3) 性别与心脏功能评估：绝经后女性CAD发病率较同龄男性低，但危险性更高，未控制的高血压女性比男性更危险。
(4) 高血压：未控制的Ⅲ期高血压(SBP>180mmHg或DPB>100mmHg)仍属心血管低危因素，但目前建议术前应该得到很好的控制。
(5) 严重瓣膜疾病：肥厚型阻塞性心脏病病人围术期发生心衰的危险性增加。严重返流性瓣膜性心脏病病人比严重狭窄性瓣膜性心脏病病人能更好地耐受手术。但有文献报道，严重主动脉瓣狭窄，若围术期合理管理，危险性并不增加。
(6) 心肌缺血：ECG缺血试验(+)、缺血范围及缺血的可逆性是非常重要的。低负荷下缺血试验(+)或中度到大面积缺血预示这围术期心脏事件的高危险性。
(7) 低温：围术期体温过低可增加严重心脏事件的危险性，围术期应积极保温使核心温度>35.5℃。
(8) 血管紧张素转换酶抑制剂(ACEI)或血管紧张素受体阻滞剂：术前肌酐升高与术后肾功能异常和心脏并发症有关。即使在BUN和肌酐升高的病人，术前都应该继续使用ACEI，这类药物可显著改善心衰病人术后的生存率。
(9) 红细胞压积(HCT)：HCT＜28％可增加心脏病人前列腺和血管手术围术期心肌缺血和心脏事件的发生率。目前仍主张输血，使HCT达28％以上。
(10) 血糖：过去对于相对高的血糖水平比低血糖更易接受，但目前主张围术期应对血糖进行积极的控制，必要时输注胰岛素。血糖应维持在4.4～7.0mmol/L，糖尿病别人术前不宜超过11.0mmol/L。已证实能够降低心脏手术和非心脏手术的感染，但未证实其对术后心血管预后的影响。
(11) 监测：经食管心脏超声(TEE)不主张常规应用，肺动脉导管监测可用于高危病人；术前和术后ECG监测是经济而行之有效的手段，对已知的CAD病人和经历高危或中危手术的具有高危或中危心血管危险因素的病人更具有价值；术后24小时、4天或出院时可对具有心功能异常征象的病人进行肌钙蛋白测定，肌钙蛋白升高对术后的心脏事件预测比CK-MB更敏感。
(12) 术后心律失常：①血流动力学稳定的心律失常：窄QRS波的心动过速（阵发性室上性心动过速）可行迷走神经刺激（如压迫眼球或颈动脉窦）或静注腺苷；房颤可用β－受体阻滞剂或硫氮卓酮或地高辛以控制心室率，在基础病因未得到纠正之前不主张使用电复律；单源性或多源性室早无需治疗，除非频发或长时间发作引起症状或血流动力学不稳定。②血流动力学不稳定的心律失常：心动过缓应寻找并纠正基础病因，如缺血、低氧血症、电解质紊乱以及应用了某些导致心动过缓的药物等。
5. 心脏病人非心脏手术围术期心肌再梗死
　　文献报告心脏病人非心脏手术围术期心肌再梗死率及死亡率很高见表4。一般情况下，心肌梗死6个月以内不主张手术，如危及生命的急症手术及恶性肿瘤病人，可在严密监测和管理下施行麻醉和手术。

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