Broustet J P, Douard H, Labbé L, Parrens E
Département des épreuves d'effort et de la réadaptation des cardiaques, Hôpital cardiologique du Haut-Lévêque.
Arch Mal Coeur Vaiss. 1998 Aug;91 Spec No 4:7-16; discussion 29-30.
The growing numbers of elderly and cardiac patients are the consequence of progress in the prevention of the complications of coronary artery and valvular heart disease by surgery and revascularisation and improved treatment of hypertension which delays target organ complications by at least fifteen years. The elderly are particularly exposed to surgical risk: nearly half the patients with ischaemic heart disease die of cancer; a high proportion of elderly people require orthopaedic surgery either as an emergency (fractured femur) or as a standard procedure (knee surgery); nearly a quarter of patients requiring peripheral vascular surgery have coronary artery disease which may be silent. A preoperative consultation with the anaesthetist has been made compulsory, except in emergencies, giving time for preoperative investigations. The decrees of the Court of Cassation have also affected the traditional relationship of trust between patients and their doctors, leading to an increase in the cost of preoperative investigations without an accurate assessment of their benefits with regards to postoperative complications and the cost that they entail. Contrary to present tendencies reflected in the literature, the screening of risks should be simplified: clinical history and examination and resting ECG, often completed by stress testing, are sufficient in the large majority of cases. More importance should be attributed to the functional status than to the lesions. When the cardiac disease is asymptomatic, the chances are that it will remain so during and after surgery.... The main difficulty is not in identifying high risk patients: it is preventing cardiovascular events when surgery is unavoidable. The experience and collaboration between the quartet of anaesthetist, surgeon, cardiologist and general practitioner, are much more useful than the very incomplete bibliographical data concerning this side of the problem.
老年患者和心脏病患者数量的增加，是通过手术和血管重建预防冠状动脉和心脏瓣膜疾病并发症取得进展以及高血压治疗得到改善的结果，后者使靶器官并发症至少推迟了15年。老年人尤其面临手术风险：近一半的缺血性心脏病患者死于癌症；很大一部分老年人需要进行骨科手术，要么是急诊手术（股骨骨折），要么是常规手术（膝关节手术）；近四分之一需要进行外周血管手术的患者患有可能无症状的冠状动脉疾病。除紧急情况外，术前必须与麻醉师进行会诊，以便有时间进行术前检查。最高上诉法院的法令也影响了患者与医生之间传统的信任关系，导致术前检查费用增加，却没有准确评估其对术后并发症的益处以及所带来的成本。与文献中反映的当前趋势相反，风险筛查应简化：在大多数情况下，临床病史、体格检查和静息心电图，通常辅以负荷试验，就足够了。应更多地重视功能状态而非病变情况。当心脏病无症状时，手术期间及术后很可能仍保持无症状……主要困难不在于识别高危患者：而是在手术不可避免时预防心血管事件。麻醉师、外科医生、心脏病专家和全科医生这四人团队的经验与协作，比关于这方面问题的非常不完整的文献数据更有用。
