负荷超声心动图对非心血管手术心脏事件危险性的预测研究

目的:探讨研究负荷超声心动图(DSE)对于非心血管手术心脏事件危险性的预测。方法:选取我院2017年1月-2018年10月106例非心血管手术的已确诊或是可疑冠心病患者,术前对患者进行负荷超声心动图检查,并进行随访了解术后心脏事件的发生情况。结果:106例患者中DSE阴性者占据57%,一共有60名,这一组没有患者在术后出现恶性心脏事件,因此属于低危人群;负荷超声心动图诱发了患者出现心肌缺血缺血阈≥60%,一共有37名,其中3人在术后出现了恶性心脏事件,因此属中危人群;DSE过程中缺血阈<60%的共有9人,其中出现恶性心脏事件的则一共有4人,属于高危人群。结论:负荷超声心动图可以评估对接受非心血管的手术患者,并已经确诊或是疑似冠心病患者在术后发生恶性心脏事件的危险性。根据负荷超声心动图是否诱发心肌缺血及缺血阈是否<60%,能够将患者进行人群的划分,主要为低危、中危或高危这三个等级。     

超声对老年人非心脏术后心脏事件的预测价值

目的　评价超声心动图测定左室射血分数预测老年人择期大中型非心脏手术后心脏事件的价值。方法　对 2 0 0例术前进行超声心动图检查的资料 ,采用单变量及Logistic多变量逐步回归分析。结果　 2 0 0例患者中 ,发生心脏事件 2 5例 (12 .5 % ) ,单变量分析提示 ,术前心电图示心肌梗死、左室射血分数≤ 5 0 %、麻醉方式、手术历时 >2h、胸腔手术和术后窦性心动过速 6个变量是术后心脏事件的危险因素 (P <0 .0 5或 <0 .0 1)。Logistic多变量逐步回归分析表明 ,左室射血分数≤ 5 0 %、胸腔手术是术后心脏事件的独立危险因素 (P =0 .0 18及 0 .0 0 2 )。结论　术前超声心动图测量左室射血分数是预测老年人围手术期心脏事件发生的一项重要指标     

术前评估量表对非心脏手术患者围手术期主要心脏不良事件的预测价值

非心脏手术患者围手术期主要心脏不良事件是其并发症和病死率增加的重要原因, 术前应用恰当的评估量表进行风险评估至关重要, 临床已达成共识并进行广泛实践。修订的心脏风险指数、美国外科医师协会国家外科质量改进计划心肌梗死或心脏骤停风险计算器和美国外科医师协会国家外科质量改进计划手术风险计算器是目前临床常用的评估量表。目前尚缺乏相关研究分析上述评估量表的适用条件和优缺点, 以及何种评估量表能较为准确地预测非心脏手术患者围手术期主要心脏不良事件风险。本文总结上述评估量表在非心脏手术患者中的应用表现, 旨在为这一人群寻找最优化的评估量表提供指导。     

负荷超声心动图对非心血管手术心脏事件危险性的预测价值

目的:本研究旨在探讨多巴酚丁胺负荷超声心动图(DSE)对接受非心血管手术的患者术后发生恶性心脏事件危险性的预测价值。方法:选择拟行非心血管手术的已确诊或可疑冠心病患者106名,术前进行DSE检查,并进行随访以了解术后恶性心脏事件的发生情况。结果:106名患者中DSE阴性者60名(57％),该组无工人术后发生恶性心脏事件,属低危人群;DSE诱发了心肌缺血但缺血阈≥60％者37名(35％),其中3人(8％)术后发生了恶性心脏事件,属中危人群;DSE过程中缺血阙<60％者9人(8％)中发生恶性心脏事件4人(44％),属于高危人群。结论:DSE可以对接受非心血管手术的已确诊或可疑冠心病患者术后发生恶性心脏事件的危险性作出有意义的评估。根据DSE是否诱发心肌缺血及缺血阚是否<60％可以将患者划分为低危、中危或高危人群。     

老年冠心病非心脏手术患者围术期心脏事件危险评估

目的提出适合于老年冠心病患者的围术期心血管系统危险的评估标准。方法选择412例连续的老年冠心病非心脏手术患者的病例资料，对术前、术中和术后的相关数据进行记录，并通过Logistic逐步回归的统计学方法得出老年冠心病非心脏手术患者围术期心血管系统危险指数。结果术前心肌梗死、不稳定型心绞痛、心功能不全、脑卒中病史以及术前ST段压低≥0．05mV、血红蛋白〈120g／L、白细胞计数〉1．0×10^9／L是围术期心脏事件的危险因素。患者根据计分的不同可分为四级危险程度。分级程度越高，心脏事件的发生率越高。从心性死亡的发生情况来看，单纯以死亡率比较，随着危险程度的增加心性死亡率也逐渐增加，但是通过统计学分析表明，只有Ⅰ级和Ⅳ级、Ⅱ级和Ⅳ级差异具有统计学意义。结论老年冠心病患者非心脏手术围术期心脏事件危险程度越高，围术期心脏事件的发生率越高。     

非心脏手术围术期β受体阻滞剂的心脏保护作用

围术期心脏事件是非心脏手术围术期严重并发症和死亡的重要原因,有关该问题的研究已有数十年的历史[1]。尽管当今麻醉和手术技术迅猛发展,但在普通非心脏手术人群中,仍有约1%的患者发生围术期心脏事件[2]。临床上广泛应用的修订心脏风险指数及美国心脏病学会（American College of Cardiology,ACC）/美国心脏学会（American Heart Association,AHA）制定的非心脏手术围术期评估指南,可协助临床医生评价非心脏手术的心脏风险,并作     

心脏病人非心脏手术的评估

心脏病患者需进行非心脏手术时必须权衡手术的 危险性及手术后益处,我院肿瘤患者因同时伴有心脏 病而放弃手术机会的不少见,但如果在术前认真作好 心脏危险性评估,并采取一些积极措施,仍能减少非心 脏手术的心脏事件。     

超声心动图多巴酚丁胺负荷试验在非心脏手术患者术前心肌缺血评价中的意义

为评价超声心动图多巴酚丁胺负荷试验（ＤＳＥ）在非心脏手术患者术前心肌缺血评价中的意义，对２８例各种非心脏手术患者临床资料及ＤＳＥ结果进行了分析，男１３例，女１５例，平均年龄５９岁（２９～７５岁）。结果：可得出结论者２１例，其中阳性提示有心肌缺血者７例，占３３．３％，均首先接受了抗心肌缺血治疗。７例未达到预期心率，其中５例因不良反应而提前中止试验，而采用其他评价方法，全组围手术期无一例心肌梗塞或死亡发生。结论：ＤＳＥ是一种安全有效的术前心肌缺血评价手段，可用于非心脏手术患者中筛选围手术期心肌梗塞或死亡的高危或低危患者群     

心肌酶谱与肌钙蛋白Ⅰ对老年冠心病非心脏手术围术期不良事件的预测价值

目的探讨围术期监测心肌酶谱与肌钙蛋白Ⅰ对老年冠心病患者实施非心脏手术预测围术期不良事件的价值。方法 223例择期行非心脏手术老年冠心病患者,根据围术期是否发生不良事件分为发生不良事件组(A组)与未发生不良事件组(B组),比较2组术前及术后3 d内心肌酶谱及肌钙蛋白I水平。结果 2组术前心肌酶谱各项指标与肌钙蛋白I水平均在正常值范围;术后3 d内2组肌酸激酶水平较术前升高(P<0.05),但2组间比较差异无统计学意义(P>0.05);术后肌钙蛋白Ⅰ水平逐渐升高,A组超出正常值范围,B组仍在正常值范围;与术前比较,差异均有统计学意义(P<0.05),且A组高于B组(P<0.05)。结论老年冠心病非心脏手术患者围术期检测心肌酶谱对预测不良事件价值有限;术后3 d内检测肌钙蛋白I对早期发现围术期不良事件有一定预测价值。     

心脏瓣膜置换术后再次心脏手术的围手术期护理

总结14例心脏瓣膜置换术后再次心脏手术病人的围手术期护理经验。包括术前心理护理,一般术前护理,积极药物治疗,术后血流动力学的监测和调控,肾功能监护,心包、纵隔引流管的护理及并发症的防护。认为围手术期良好的针对性护理对心脏瓣膜置换术后再次心脏手术病人的手术成功和减少并发症具重要意义。     

AANA Journal course: Update for nurse anesthetists--Part 4--preoperative cardiac evaluation

This AANA Journal course discusses the American College of Cardiology (ACC) and American Heart Association (AHA) guideline on perioperative cardiovascular evaluation for noncardiac surgery. The intent of the ACC/AHA guideline is to assist clinicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of cardiac diseases. Optimizing the anesthetic management of the cardiac patient undergoing noncardiac surgery is becoming increasingly important: as the percentage of Americans older than 65 years continues to grow, so does the prevalence of cardiac disease in this population. Simply accepting a preoperative cardiology clearance for the cardiac patient undergoing noncardiac surgery provides little information that can be used for risk assessment and management of anesthesia. While national practice patterns vary significantly, there is an important need to standardize cost-effective preoperative cardiac evaluation. By using evidence-based studies, the ACC/AHA guideline delineates methods to objectively categorize cardiovascular risk and use data from the cardiology consultation to refine anesthetic management. Use of the guideline can lead to more efficient evaluation of the noncardiac patient with cardiac disease, which can decrease morbidity, mortality, and cost.     

Cardiac risk assessment for noncardiac surgery: Current concepts

Strategies for perioperative risk assessment in patients undergoing noncardiac surgery vary among physicians and are aimed to estimate the risk and minimize complications. We propose simplistic guidelines for assessing and modifying risk for patients undergoing a wide variety of procedures.     

Noncardiac surgery in the patient with heart disease

Optimal care of the patient with heart disease undergoing noncardiac surgery requires that the members of the surgical team, including anesthesiologist, internist-cardiologist, and surgeon, be familiar with the cardiovascular response to surgery, preoperative cardiac risk stratification, and the unique pathogenesis of cardiac complications that may occur in the perioperative period. Preoperative evaluation and computation of cardiac risk, anesthetic considerations, along with perioperative care of the patient with ischemic heart disease, valvular heart disease, congestive heart failure, arrhythmias and conduction disorders, and hypertension is discussed.     

Preoperative cardiac risk assessment

Heart disease is the leading cause of mortality in the United States. An important subset of heart disease is perioperative myocardial infarction, which affects approximately 50,000 persons each year. The American College of Cardiology (ACC) and American Heart Association (AHA) have coauthored a guideline on preoperative cardiac risk assessment, as has the American College of Physicians (ACP). The ACC/AHA guideline uses major, intermediate, and minor clinical predictors to stratify patients into different cardiac risk categories. Patients with poor functional status or those undergoing high-risk surgery require further risk stratification via cardiac stress testing. The ACP guideline also starts by screening patients for clinical variables that predict perioperative cardiac complications. However, the ACP did not feel there was enough evidence to support poor functional status as a significant predictor of increased risk. High-risk patients would sometimes merit preoperative cardiac catheterization by the ACC/AHA guideline, while the ACP version would reserve catheterization only for those who were candidates for cardiac revascularization independent of their noncardiac surgery. A recent development in prophylaxis of surgery-related cardiac complications is the use of beta blockers perioperatively for patients with cardiac risk factors.     

Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.     

Effects of Perioperative Dexmedetomidine on Postoperative Mortality and Morbidity: A Systematic Review and Meta-analysis

Purpose

Major postoperative complications translate into increased health care resource utilization, prolonged hospital stays, and increased mortality. We aimed to assess the effects of perioperative dexmedetomidine use on postoperative mortality and the prevalence of major complications after cardiac and noncardiac surgery.

Perioperative cardiac evaluation: novel interventions and clinical challenges

Cardiac complications are one of the most important sources of morbidity and mortality after noncardiac surgery. In this review, we discuss the pathophysiology of postoperative cardiac complications and published risk indices and guidelines that allow an estimation of preoperative risk. Recent evidence has challenged the primary role of perioperative beta blockers as a risk reduction strategy. The highest level of evidence for their use is for patients with coronary artery disease or multiple risk factors undergoing vascular surgery. Beta blockers may provide no benefit or may be potentially harmful for low- and intermediate-risk patients and surgeries. For patients with contraindications to beta blockers, diltiazem and clonidine are alternative agents that reduce cardiac risk. Statins are emerging as another potential strategy to reduce cardiac risk, although the evidence is based primarily on retrospective analyses. Coronary artery revascularization does not reduce cardiac complications after noncardiac surgery among patients with stable coronary artery disease.     

Perioperative Cardiac Risk Reduction in Noncardiac Surgery

Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of—and intervention for—any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.     

Perioperative risk of patients undergoing noncardiac surgery after coronary artery bypass surgery

BACKGROUND: Most data suggesting that noncardiac surgery early after coronary artery bypass surgery carries low risk are derived from post hoc analyses of randomized controlled trials, with only limited data derived from contemporary, nonselected, and nontrial patients. METHODS: We retrospectively reviewed the medical records of patients who underwent coronary artery bypass surgery at our institution between January 1999 and October 2006 to determine whether they subsequently had major noncardiac surgery and what the outcomes of the noncardiac surgery were. RESULTS: During the study period, 1065 patients underwent coronary artery bypass surgery, and 272 (26%) subsequently underwent 467 major noncardiac surgeries. The mean interval from coronary artery bypass to noncardiac surgery was 1.9 +/- 1.9 years (range, 0-7.8 years). A major complication occurred in 3 surgeries (0.6% [95% confidence interval, 0.1%-1.9%]). Two patients died (both from respiratory arrest during the postoperative period: 1 patient had a tongue cancer excision, and the other patient had polycythemia vera), and the third patient had a perioperative arrhythmia. CONCLUSIONS: Noncardiac surgery is often required early after coronary artery bypass surgery and carries very low risk for cardiac complications, suggesting that preoperative cardiac evaluation may not be required in most such patients.