Статья
Оценка сердечно-сосудистого риска и профилактика осложнений при внесердечной хирургии у больных ишемической болезнью сердца
Частота развития сердечно-сосудистых осложнений при внесердечных операциях составляет около 3%. В обзоре представлены литературные данные относительно оценки сердечно-сосудистого риска (ССР) при внесердечных операциях. Рассматривается алгоритм принятия решений с учетом функционального состояния больного и категории ССР предстоящей операции. Функциональное тестирование не показано пациентам с низким ССР. Стресс-тесты следует рассматривать у больных высокого риска, если результаты тестирования могут изменить периоперационную медикаментозную терапию, способ анестезии или хирургический подход. Рутинная коронарная реваскуляризация не снижает периоперационные риски и применяется по специальным показаниям. Чрескожное коронарное вмешательство и связанная с ним двойная антиагрегантная терапия может задерживать сроки выполнения внесердечных операций. Периоперационная медикаментозная терапия (β-адреноблокаторы, аспирин, ингибиторы ангиотензинпревращающего фермента, блокаторы рецепторов к ангиотензину II и статины) должна назначаться с учетом специфического риска пациента.
1. Российский статистический ежегодник. М., 2019. 708 с. URL: https://rosstat.gov.ru/folder/210/document/12994.
2. Smilowitz NR, Gupta N, Ramakrishna H, Guo Y, Berger JS, Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2017;2(2):181–187. doi:10.1001/jamacardio.2016.4792
3. Smilowitz NR, Redel-Traub G, Hausvater A, Armanious A, Nicholson J, Puelacher C et al. Myocardial injury after noncardiac surgery: a systematic review and meta-analysis. Cardiol Rev. 2019;27(6):267–273. doi:10.1097/CRD.0000000000000254
4. Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK et al. Writing Committee for the VISION Study Investigators. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. J Am Med Assoc. 2017;317(16):1642–1651. doi:10.1001/jama.2017.4360
5. Smilowitz NR, Gupta N, Guo Y, Beckman JA, Bangalore S, Berger JS. Trends in cardiovascular risk factor and disease prevalence in patients undergoing non-cardiac surgery. Heart. 2018;104(14):1180–1186. doi:10.1136/heartjnl-2017-312391
6. Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology(ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35(35):2383–2431. doi:10.1093/eurheartj/ehu282
7. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkur B et al; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology / American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77–e137. doi:10.1016/j.jacc.2014.07.944
8. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ; United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362(20):1863–1871. doi:10.1056/ NEJMoa0909305
9. Browner WS, Li J, Mangano DT. Study of perioperative ischemia research Group. In-hospital and long-term mortality in male veterans following noncardiac surgery. J Am Med Assoc. 1992;268(2):228–232. doi:10.1001/jama.1992.03490020076034
10. Mahmoud KD, Sanon S, Habermann EB, Lennon RJ, Thomsen KM, Wood DL et al. Perioperative cardiovascular risk of prior coronary stent implantation among patients undergoing noncardiac surgery. J Am Coll Cardiol. 2016;67(9):1038–1049. doi:10.1016/j.jacc.2015.11.063
11. Hernandez AF, Whellan DJ, Stroud S, Sun JL, O’Connor CM, Jollis JG. Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 2004;44(7):1446–1453. doi:10.1016/j.jacc. 2004.06.059
12. van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. Circulation. 2011;124(3):289–296. doi:10.1161/CIRCULATIONAHA.110.011130
13. Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol. 2015;65(3):295–302. doi:10.1016/j.jacc.2014.10.051
14. Lapage KG, Wouters PF. The patient with hypertension undergoing surgery Current Opinion in Anaesthesiology 2016; 29(3):397–402 doi:10.1097/ACO.0000000000000343
15. Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol. 2005;45(10):1691–1699. doi:10.1016/j.jacc.2005.02.055
16. Smilowitz NR, Armanious A, Bangalore S, Ramakrishna H, Berger JS. Cardiovascular outcomes of patients with pulmonary hypertension undergoing noncardiac surgery. Am J Cardiol. 2019;123(9):1532–1537. doi:10.1016/j.amjcard.2019.02.006
17. Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL et al; American Heart Association Council on the Kidney in Cardiovascular Disease and Council on Peripheral Vascular Disease; American Heart Association; American College of Cardiology Foundation. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation: endorsed by the American Society of Transplant Surgeons, American Society of Transplantation, and National Kidney Foundation. Circulation. 2012;126(5):617–663 doi.org/10.1161/CIR.0b013e31823eb07a
18. Meersch M, Schmidt Ch, Zarbock A. Patient with chronic renal failure undergoing surgery Current Opinion in Anaesthesiology: 2016;29(3):413–420 doi:10.1097/ACO.0000000000000329
19. Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986; 1(4):211–219
20. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845– 850. doi:10.1056/NEJM197710202971601
21. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–1049. doi:10.1161/01.CIR.100.10.1043
22. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42. e1, e3. doi:10.1016/j.jamcollsurg.2013.07.385
23. Dakik HA, Chehab O, Eldirani M, Sbeity E, Karam C, Hassan OA et al. A new index for pre-operative cardiovascular evaluation. J Am Coll Cardiol. 2019;73(24):3067–3078. doi:10.1016/j.jacc.2019.04.023
24. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26–35. doi:10.7326/0003-4819-152-1-201001050-00007
25. Bertges DJ, Goodney PP, Zhao Y, Schanzer A, Nolan BW, Likosky DS et al. Vascular Study Group of New England The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg. 2010;52(3):674–83,683.e1–683.e3. doi:10.1016/j.jvs.2010.03.031
26. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64(10):651–654. doi:10.1016/0002-9149(89)90496-7
27. Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A et al. METS Study Investigators. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018;391(10140):2631– 2640. doi:10.1016/S0140-6736(18)31131-0
28. Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S et al. Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol. 2017;33(1):17–32. doi:10.1016/j.cjca.2016.09.008
29. Smilowitz NR, Berger JS. Perioperative cardiovascular risk assessment and management for noncardiac surgery: A Review. J Am Med Assoc. 2020;324(3):279–290. doi:10.1001/jama.2020.7840
30. Noordzij PG, Boersma E, Bax JJ, Feringa HHH, Schreiner F, Schouten O et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol. 2006;97(7):11031106. doi:10.1016/j.amjcard.2005.10.058
31. Landesberg G, Einav S, Christopherson R, Beattie C, Berlatzky Y, Rosenfeld B et al. Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram. J Vasc Surg. 1997;26(4):570–578. doi:10.1016/S0741-5214(97)70054-5
32. Hreybe H, Zahid M, Sonel A, Good CB, Shaver J, Saba S. Noncardiac surgery and the risk of death and other cardiovascular events in patients with hypertrophic cardiomyopathy. Clin Cardiol. 2006;29(2):65–68. doi:10.1002/clc.4960290206
33. Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F et al. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004;116(1):8–13. doi:10.1016/j.amjmed.2003.07.012
34. Healy KO, Waksmonski CA, Altman RK, Stetson PD, Reyentovich A, Maurer MS. Perioperative outcome and long-term mortality for heart failure patients undergoing intermediate- and high-risk noncardiac surgery: impact of left ventricular ejection fraction. Congest Heart Fail. 2010;16(2):45–49. doi:10.1111/j.1751–7133.2009.00130.x
35. Rohde LE, Polanczyk CA, Goldman L, Cook EF, Lee RT, Lee TH. Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery. Am J Cardiol. 2001;87(5):505–509. doi:10.1016/S0002-9149(00)01421-1
36. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm Ch, Holm PJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017;38(36):2739–2791. doi:10.1093/eurheartj/ehx391
37. Schulman-Marcus J, Feldman DN, Rao SV, Prasad A, McCoy L, Garratt K et al. Characteristics of patients undergoing cardiac catheterization before noncardiac surgery: a report from the national cardiovascular data registry Cath PCI Registry. JAMA Intern Med. 2016;176(5):611–618. doi:10.1001/jamainternmed.2016.0259
38. Koshy AN, Ha FJ, Gow PJ, Han HC, Amirul-Islam FM, Lim HS et al. Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis. Heart. 2019;105(17):1335–1342. doi:10.1136/heartjnl-2018-314649
39. Ahn JH, Park JR, Min JH, Sohn JT, Hwang SJ, Park Y et al. Risk stratification using computed tomography coronary angiography in patients undergoing intermediate-risk noncardiac surgery. J Am Coll Cardiol. 2013;61(6):661–668. doi:10.1016/j.jacc.2012.09.060
40. Sheth T, Chan M, Butler C, Chow B, Tandon V, Nagele P et al. Coronary computed tomographic angiography and vascular events in noncardiac surgery patients cohort evaluation study investigators. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. Br Med J. 2015;350: h1907. doi:10.1136/bmj.h1907
41. Rodseth RN, Biccard BM, Le Manach Y, Sessler DI, Buse GAL, Thabane L et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170–180. doi:10.1016/j.jacc.2013.08.1630
42. Duceppe E, Patel A, Chan MTV, Berwanger O, Ackland G, Kavsak PA et al. Preoperative N-terminal pro-B-type natriuretic peptide and cardiovascular events after noncardiac surgery: a cohort study. Ann Intern Med. 2020;172(2):96–104. doi:10.7326/M19-2501
43. Stevens RD, Burri H, Tramer MR. Pharmacologic myocardial protection in patients undergoing noncardiac surgery: a quantitative systematic review. Anesth Analg. 2003;97(3):623–633. doi:10.1213/01.ane.0000074795.68061.16
44. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353(4):349– 361. doi:10.1056/NEJMoa041895
45. London MJ, Hur K, Schwartz GG, Henderson WG. Association of perioperative β-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309(16):1704–1713. doi:10.1001/jama.2013.4135
46. Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, Fleischmann KE et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology / American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):2406–2425. doi:10.1016/j.jacc.2014.07.939
47. Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC et al; POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–1847. doi:10.1016/S0140-6736(08)60601-7
48. Flu WJ, van Kuijk JP, Chonchol M, Winkel TA, Verhagen HJM, Bax JJ et al. Timing of pre-operative beta-blocker treatment in vascular surgery patients: influence on post-operative outcome. J Am Coll Cardiol. 2010;56(23):1922–1929. doi:10.1016/j.jacc.2010.05.056
49. Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, AlonsoCoello P, Kurz A et al; POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494– 1503. doi:10.1056/NEJMoa1401105
50. Wolf G, Navarese EP, Brockmeyer M, Lin Y, Karathanos A, Kołodziejczak M et al. Perioperative aspirin therapy in non-cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol. 2018;258:59–67. doi: https://doi.org/10.1016/j.ijcard.2017.12.088
51. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. J Am Med Assoc. 2004;291(17):2092– 2099. doi:10.1001/jama.291.17.2092
52. London MJ, Schwartz GG, Hur K, HendersonWG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017;177(2): 231–242. doi:10.1001/jamainternmed.2016.8005
53. Berwanger O, Le Manach Y, Suzumura EA, Biccard B, Srinathan SK, Szczeklik W et al. et al; VISION Investigators. Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. Eur Heart J. 2016;37(2):177–185. doi:10.1093/eurheartj/ehv456
54. Sanders RD, Nicholson A, Lewis SR, Smith AF, Alderson P. Perioperative statin therapy for improving outcomes during and after noncardiac vascular surgery. Cochrane Database Syst Rev. 2013;7(7):CD 009971. doi:10.1002/14651858.CD009971.pub2
55. Berwanger O, de Barros E Silva Pedro G M, Barbosa R, Precoma DB, Estêvão Lanna Figueiredo, Ludhmila Abrahão Hajjar et al. LOAD Investigators. Atorvastatin for high-risk statin-naive patients undergoing noncardiac surgery: the Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial. Am Heart J. 2017;184:88–96. doi:10.1016/j.ahj.2016.11.001
56. Putzu A, de Carvalho E Silva CMPD, Pinheiro de Almeida J, Belletti A, Cassina T, Landoni G, Abrahao Hajjar L. Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Ann Intensive Care. 2018;8(1):95. doi:10.1186/s13613-018-0441-3
57. Coriat P, Richer C, Douraki T, Gomez C, Hendricks K, Giudicelli JF, Viars P Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Anesthesiology. 1994; 81(2):299–307. doi:10.1097/00000542-199408000-00006
58. Bertrand M, Godet G, Meersschaert K, Brun L, Salcedo E, Coriat P. Should the angiotensin II antagonists be discontinued before surgery? Anesth Analg. 2001;92(1):26–30. doi:10.1097/00000539-200101000-00006
59. Schirmer U, Schurmann W. Preoperative administration of angiotensin-converting enzyme inhibitors. Article in German. Anaesthesist. 2007;56(6):557–561. doi:10.1007/s00101-007-1177-x
60. Roshanov PS, Rochwerg B, Patel A, Salehian O, Duceppe E, Belley-Côté EP et al. Withholding versus continuing angiotensin converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: an analysis of the vascular events in noncardiac surgery patients cohort evaluation prospective cohort. Anesthesiology. 2017;126(1):16–27. doi:10.1097/ALN.0000000000001404
61. Douketis JD. Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood. 2011;117(19):5044. doi:10.1182/blood-2011-02-329979
62. Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330–1393. doi:10.1093/eurheartj/ehy136
63. Siegal D, Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC. Periprocedural heparin bridging in patients receiving vitamin K antagonists systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation. 2012;126(13):1630–1639. doi:10.1161/CIRCULATIONAHA.112.105221
64. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS et al; BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823–833. doi:10.1056/NEJMoa1501035
65. Santilli SM.The Coronary Artery Revascularization Prophylaxis (CARP) Trial: results and remaining controversies Perspect Vasc Surg Endovasc Ther. 2006;18(4):282–285. doi:10.1177/1531003506295144
66. Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U et al. 2018 ESC/EACTS Guidelines on myocardial revascularization The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI) Eur Heart J. 2019;40(2):87–165. doi:10.1093/eurheartj/ehy394
67. Прогнозирование и профилактика кардиальных осложнений внесердечных хирургических вмешательств. Национальные рекомендации. М., 2011. Приложение 3 к журналу «Кардиоваскулярная терапия и профилактика». 2011;10(6): 1–28..
68. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351(27): 2795–2804. doi:10.1056/NEJMoa041905
69. Gro E, Dalby KS, Troels T, Olesen KK, Madsen M, Jensen SE et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol. 2016;68(24):2633–2636.
70. Valgimigli M, Bueno H, Byrne RA, Collet JPh, Costa F, Jeppsson A et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018;39(3):213–260.