Maddox Thomas M
Zena and Michael A. Wiener Cardiovascular Institute, Box 1030, Mount Sinai School of Medicine, One East 100th Street, New York, NY 10029-6574, USA.
Mt Sinai J Med. 2005 May;72(3):185-92.
Cardiovascular complications following noncardiac surgery constitute an enormous burden of perioperative morbidity and mortality. Annually, more than one million operations are complicated by adverse cardiovascular events, such as perioperative myocardial infarction or death from cardiac causes. In order to combat this problem, cardiac evaluation prior to noncardiac surgery should ask two questions about the patient: What is the risk of cardiac complications during and after surgery? How can that risk be reduced or eliminated? Risk assessment evaluates patients' co-morbidities and exercise tolerance, as well as the type of surgery to be performed, to determine the overall risk of perioperative cardiac complications. Previous or current cardiac disease, diabetes and renal insufficiency all confer higher risks for perioperative cardiac complications. Poor exercise tolerance and high-risk surgical procedures (e.g., vascular, prolonged thoracic or abdominal operations) also predict worse perioperative outcomes. Noninvasive stress testing is widely used to help predict risk of perioperative complications, but the poor predictive power of these tests hampers their usefulness. After estimating the risk of cardiac complications, one should take measures to reduce it. Beta blockade has shown clear benefits in risk reduction. At this time, there are no data suggesting benefits of percutaneous coronary intervention or coronary artery bypass grafting in reducing noncardiac surgical risk. In addition, angioplasty with stenting and its attendant need for anticoagulation can expose patients to increased risk of perioperative bleeding. Thus, the use of coronary revascularization prior to noncardiac surgery should be reserved for those patients with an independent cardiac need for the procedure, such as unstable angina or stable angina refractory to medical therapy. In summary, patients with low clinical risk factors and good functional status, undergoing a low or intermediate risk surgery, have an excellent prognosis and may proceed to surgery without further delay. In addition, stable patients who have previously undergone coronary revascularization may also safely undergo surgery. Patients requiring urgent surgery should proceed immediately, since the consequences of delay usually outweigh the benefits of preoperative risk assessment. However, elective surgery should be indefinitely deferred for those patients with unstable coronary syndromes, since consequences of the cardiac disease usually negate the benefits of surgery. Controversy involves the intermediate or high clinical risk patient considering high-risk, but elective, surgery. Noninvasive testing offers only limited assistance in estimating risk for these patients. The best risk reduction strategy for these patients is perioperative beta blockade use. The role of coronary revascularization specifically to reduce perioperative cardiac complications remains unproven.
非心脏手术后的心血管并发症构成了围手术期发病和死亡的巨大负担。每年，超过一百万例手术会因不良心血管事件而变得复杂，如围手术期心肌梗死或心源性死亡。为了解决这个问题，非心脏手术前的心脏评估应针对患者提出两个问题：手术期间及术后心脏并发症的风险是什么？如何降低或消除该风险？风险评估会评估患者的合并症、运动耐量以及拟进行的手术类型，以确定围手术期心脏并发症的总体风险。既往或当前的心脏病、糖尿病和肾功能不全都会使围手术期心脏并发症的风险更高。运动耐量差和高风险手术（如血管手术、长时间的胸科或腹部手术）也预示着更差的围手术期结局。无创应激测试被广泛用于帮助预测围手术期并发症的风险，但这些测试的预测能力较差，限制了其效用。在估计心脏并发症的风险后，应采取措施降低风险。β受体阻滞剂已显示出在降低风险方面有明显益处。目前，没有数据表明经皮冠状动脉介入治疗或冠状动脉旁路移植术在降低非心脏手术风险方面有好处。此外，血管成形术加支架置入及其伴随的抗凝需求会使患者面临围手术期出血风险增加。因此，非心脏手术前冠状动脉血运重建的应用应仅限于那些有独立心脏手术需求的患者，如不稳定型心绞痛或药物治疗无效的稳定型心绞痛患者。总之，临床风险因素低且功能状态良好、接受低风险或中等风险手术的患者预后良好，可立即进行手术。此外，先前接受过冠状动脉血运重建的稳定患者也可安全地进行手术。需要紧急手术的患者应立即进行手术，因为延迟的后果通常超过术前风险评估的益处。然而，对于患有不稳定冠状动脉综合征的患者，择期手术应无限期推迟，因为心脏病的后果通常会抵消手术的益处。争议涉及考虑进行高风险但为择期手术的中度或高度临床风险患者。无创测试在估计这些患者的风险方面仅提供有限的帮助。这些患者最佳的风险降低策略是围手术期使用β受体阻滞剂。专门用于降低围手术期心脏并发症的冠状动脉血运重建的作用仍未得到证实。
