Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Anesth Analg. 2011 Apr;112(4):777-99. doi: 10.1213/ANE.0b013e31820e7e4f. Epub 2011 Mar 8.
Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.
需要紧急心脏手术的急性冠状动脉综合征患者存在复杂的管理挑战。抗血小板和抗血栓药物的早期应用提高了急性心肌梗死患者的总体生存率，但为了获得最大益处，这些药物在冠状动脉解剖结构未知以及决定进行经皮冠状动脉介入治疗或手术血运重建之前给予。由于这些药物导致的大出血事件与接受药物治疗的急性冠状动脉综合征患者的高死亡率相关，可能是因为随后停止使用抗血小板和抗血栓治疗，而这些治疗可以降低死亡率、中风或再次心肌梗死的发生率。在接受此类强效抗血小板或抗血栓治疗的心脏手术患者中，术前为急性冠状动脉综合征特别使用这些药物是否会增加出血和输血风险，并影响长期死亡率，目前尚未明确。对于确实需要手术的患者，减少出血的策略包括停止抗凝治疗，并考虑血小板和/或凝血因子输注，以及可能对难治性出血使用重组激活因子 VIIa。机械血液动力学支持已成为心源性休克中急性冠状动脉综合征患者的重要选择。对于这些患者，围手术期的考虑因素包括维持适当的抗凝、确保适当的设备流量，并定期验证设备的正确放置。支持使用这些设备的数据来自于没有解决长期术后结局的小型试验。未来的研究方向将寻求通过更好地对手术候选者进行风险分层，并评估新型可逆药物的有效性，来优化在减少心肌缺血风险与围手术期更高出血率之间的平衡。机械血液动力学支持对长期患者结局的影响需要更严格的分析。
