Duceppe Emmanuelle, Parlow Joel, MacDonald Paul, Lyons Kristin, McMullen Michael, Srinathan Sadeesh, Graham Michelle, Tandon Vikas, Styles Kim, Bessissow Amal, Sessler Daniel I, Bryson Gregory, Devereaux P J
Department of Medicine, University of Montreal, Montreal, Quebec, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada.
Can J Cardiol. 2017 Jan;33(1):17-32. doi: 10.1016/j.cjca.2016.09.008. Epub 2016 Oct 4.
The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.
加拿大心血管学会指南委员会及加拿大主要意见领袖认为，有必要制定最新指南，采用推荐分级的评估、制定与评价（GRADE）证据评估系统，用于接受非心脏手术的患者。强烈推荐包括：1）术前测量脑钠肽（BNP）或N末端脑钠肽原（NT-proBNP），以提高65岁及以上患者、45 - 64岁患有严重心血管疾病患者或修订心脏风险指数评分≥1患者的围手术期心脏风险评估；2）不建议进行术前静息超声心动图、冠状动脉计算机断层扫描血管造影、运动或心肺运动试验、药物负荷超声心动图或放射性核素成像以提高围手术期心脏风险评估；3）不建议为预防围手术期心脏事件而开始或继续使用乙酰水杨酸，近期置入冠状动脉支架的患者或即将接受颈动脉内膜切除术的患者除外；4）不建议在手术前24小时内开始使用α激动剂或β受体阻滞剂；5）在手术前24小时开始停用血管紧张素转换酶抑制剂和血管紧张素II受体阻滞剂；6）促进术前戒烟；7）对于术前NT-proBNP/BNP测量值升高的患者，或术前未进行NT-proBNP/BNP测量但修订心脏风险指数评分≥1、45 - 64岁患有严重心血管疾病或65岁及以上的患者，术后48至72小时每日测量肌钙蛋白；8）对术后发生心肌损伤/梗死的患者开始长期使用乙酰水杨酸和他汀类药物治疗。
