Bodenheimer M M
Long Island Jewish Medical Center, New Hyde Park, New York, USA.
Ann Intern Med. 1996 Apr 15;124(8):763-6. doi: 10.7326/0003-4819-124-8-199604150-00010.
Before having major noncardiac surgery, patients with known or suspected coronary artery disease frequently have noninvasive cardiac testing to better define their cardiac risk. The rationale for this approach is that prophylactic coronary revascularization will significantly reduce the number of adverse cardiac events. No randomized studies support this conclusion. Furthermore, recent studies have suggested that adverse cardiac events result from postoperative stress and excess catecholamine levels, which cause an imbalance between myocardial oxygen supply and demand. Plaque rupture in this setting, if it occurs, is secondary and not primary, in contrast to its pivotal role in spontaneous myocardial infarction. Therefore, improved clinical outcomes are more likely to result from preventing excess oxygen demand after surgery rather than from deciding which tests optimally predict adverse events. The exception is the patient with a clinical syndrome consistent with existing plaque rupture who requires active therapy for the cardiac disease independent of the need for noncardiac surgery. Otherwise, the tests should be skipped and the patient cleared.
在进行重大非心脏手术前，已知或疑似患有冠状动脉疾病的患者经常会接受非侵入性心脏检查，以更好地确定其心脏风险。这种方法的基本原理是预防性冠状动脉血运重建将显著减少不良心脏事件的数量。没有随机研究支持这一结论。此外，最近的研究表明，不良心脏事件是由术后应激和儿茶酚胺水平过高导致心肌氧供需失衡引起的。在这种情况下，如果发生斑块破裂，它是继发性而非原发性的，这与它在自发性心肌梗死中的关键作用形成对比。因此，改善临床结果更有可能来自于术后预防过多的氧需求，而不是决定哪些检查能最佳地预测不良事件。例外情况是患有与现有斑块破裂相符的临床综合征的患者，无论是否需要进行非心脏手术，都需要对心脏病进行积极治疗。否则，应跳过检查并让患者通过。
