圍手術(shù)期心臟評價(jià)課件

內(nèi)科會(huì)診的原則(一)1、內(nèi)科會(huì)診醫(yī)師應(yīng)意識到自己代表的是整個(gè)內(nèi)科2、電話里簡單詢問患者情況，判斷是否急會(huì)診；沒有看患者之前在電話里只能回答一些籠統(tǒng)問題

3、會(huì)診目的應(yīng)具體而明確，申請會(huì)診的醫(yī)師不要寫“排除內(nèi)科情況”，或“處理內(nèi)科問題”之類的話4、應(yīng)與患者的主管醫(yī)師充分交流，會(huì)診時(shí)與主管醫(yī)師見面5、不能依賴別人提供病史，必須親自床邊看患者6、會(huì)診意見應(yīng)簡單明確而富有建設(shè)性，最好不超過5條內(nèi)科會(huì)診的原則（二）7、會(huì)診醫(yī)師應(yīng)意識到自己的局限和不足，尊重主管醫(yī)師的決策，千萬不要在未通知主管醫(yī)師的情況下自己開醫(yī)囑8、在主管醫(yī)師不在場的情況下，不要向家屬發(fā)表有關(guān)病情的看法9、外科患者術(shù)前請內(nèi)科會(huì)診是為了評估風(fēng)險(xiǎn)，因此不要寫“可以手術(shù)”或“可以全麻”之類的話10、應(yīng)隨訪會(huì)診過的患者，你可能會(huì)有很多意外的發(fā)現(xiàn)和收獲，患者病情的發(fā)展可能會(huì)出乎你的意料，甚至與你最初的判斷完全相反11、不要過于自信，遇到自己不能解決的問題，應(yīng)向有經(jīng)驗(yàn)的醫(yī)師請教12、珍惜醫(yī)療資源和他人時(shí)間，盡量避免不必要的會(huì)診

圍手術(shù)期的心臟評估及治療方案的選擇

吉林大學(xué)第二醫(yī)院

孫健ClassI

Benefit>>>Risk

Procedure/TreatmentSHOULDbeperformed/administeredClassIIa

Benefit>>Risk

AdditionalstudieswithfocusedobjectivesneededITISREASONABLEtoperformprocedure/administertreatmentClassIIb

Benefit≥Risk

Additionalstudieswithbroadobjectivesneeded;Additionalregistrydatawouldbehelpful

Procedure/TreatmentMAYBECONSIDEREDClassIII

Risk≥Benefit

NoadditionalstudiesneededProcedure/TreatmentshouldNOTbeperformed/administeredSINCEITISNOTHELPFULANDMAYBEHARMFULshouldisrecommendedisindicatedisuseful/effective/beneficialisreasonablecanbeuseful/effective/beneficialisprobablyrecommendedorindicatedmay/mightbeconsideredmay/mightbereasonableusefulness/effectivenessis

unknown/unclear/uncertainornotwellestablishedisnotrecommendedisnotindicatedshouldnotisnotuseful/effective/beneficialmaybeharmfulApplyingClassificationofRecommendationsandLevelofEvidenceLevelA

Multiple(3-5)populationriskstrataevaluated

GeneralconsistencyofdirectionandmagnitudeofeffectClassI?Recommen-dationthatprocedureortreatmentisuseful/effective?Sufficientevidencefrommultiplerandomizedtrialsormeta-analysesClassIIa?Recommen-dationinfavoroftreatmentorprocedurebeinguseful/effective?Someconflictingevidencefrommultiplerandomizedtrialsormeta-analysesClassIIb?Recommen-dation’susefulness/efficacylesswellestablished?Greaterconflictingevidencefrommultiplerandomizedtrialsormeta-analysesClassIII?Recommen-dationthatprocedureortreatmentnotuseful/effectiveandmaybeharmful?Sufficientevidencefrommultiplerandomizedtrialsormeta-analysesApplyingClassificationofRecommendationsandLevelofEvidenceLevelBLimited(2-3)populationriskstrataevaluatedClassI?Recommen-dationthatprocedureortreatmentisuseful/effective?Limitedevidencefromsinglerandomizedtrialornon-randomizedstudiesClassIIa?Recommen-dationinfavoroftreatmentorprocedurebeinguseful/effective?Someconflictingevidencefromsinglerandomizedtrialornon-randomizedstudiesClassIIb?Recommen-dation’susefulness/efficacylesswellestablished?Greaterconflictingevidencefromsinglerandomizedtrialornon-randomizedstudiesClassIII?Recommen-dationthatprocedureortreatmentnotuseful/effectiveandmaybeharmful?Limitedevidencefromsinglerandomizedtrialornon-randomizedstudiesApplyingClassificationofRecommendationsandLevelofEvidenceApplyingClassificationofRecommendationsandLevelofEvidenceLevelC

Verylimited(1-2)populationriskstrataevaluated

ClassI?Recommen-dationthatprocedureortreatmentisuseful/effective?Onlyexpertopinion,casestudies,orstandard-of-careClassIIa?Recommen-dationinfavoroftreatmentorprocedurebeinguseful/effective?Onlydivergingexpertopinion,casestudies,orstandard-of-careClassIIb?Recommen-dation’susefulness/efficacylesswellestablished?Onlydivergingexpertopinion,casestudies,orstandard-of-careClassIII?Recommend-ationthatprocedureortreatmentnotuseful/effectiveandmaybeharmful?Onlyexpertopinion,casestudies,orstandard-of-care手術(shù)對心臟的影響外科手術(shù)應(yīng)激反應(yīng)可使心律增快，血壓升高，可誘發(fā)冠心病人心肌缺血，增加心臟風(fēng)險(xiǎn)。圍手術(shù)期如發(fā)生心動(dòng)過速，可導(dǎo)致冠脈斑塊破裂。術(shù)中麻醉，SBP可降至95-105mmHg，可使冠心病患者冠脈血流減少，加重心肌缺血。術(shù)中刺激迷走神經(jīng)可引起一過性竇性心動(dòng)過緩或交界性心律。血容量不足，外周血管擴(kuò)張和心肌對兒茶酚胺的敏感性增高可引起快速的心律失常。二尖瓣狹窄患者對心動(dòng)過速耐受性差如果有心肌缺血的證據(jù)，至少在心梗后6周后方可行外科心臟手術(shù)擇期手術(shù)可以等6個(gè)月以后惡性腫瘤這類限期手術(shù)，應(yīng)權(quán)衡利弊，積極治療冠心病后盡快手術(shù)3、術(shù)前高血壓是否得到較好的控制研究證實(shí)1級和2級高血壓（SBP<180mmHg,DBP<110mmHg）,無嚴(yán)重靶器官損害的患者，不增加圍手術(shù)期的心臟風(fēng)險(xiǎn)，沒有必要推遲手術(shù)，但要將血壓控制在術(shù)前水平。3級高血壓（SBP≥180mmHg,DBP≥110mmHg）在術(shù)前必須得到控制。4、CHF患者心功能是否評價(jià)和治療LVEF<35%患者，圍手術(shù)期CHF加重和死亡風(fēng)險(xiǎn)增加。

基礎(chǔ)心臟病尤其冠心病導(dǎo)致CHF預(yù)后差5、瓣膜性心臟病狹窄及關(guān)閉不全的程度及心功能是否得到評價(jià)，術(shù)前是否需要治療：（1）瓣膜性心臟病行外科手術(shù)時(shí)可能有心衰、感染性心內(nèi)膜炎、心動(dòng)過速和栓塞的風(fēng)險(xiǎn)。（2）體力活動(dòng)不受限制或輕度受限的患者（心功能Ⅰ級或Ⅱ級），可很好耐受麻醉和手術(shù)，但需手術(shù)期嚴(yán)密監(jiān)護(hù)和預(yù)防心內(nèi)膜炎。（3）輕微體力活動(dòng)出現(xiàn)喘憋或不能行手術(shù)患者（心功能Ⅲ級或Ⅳ級），對手術(shù)耐受性差，應(yīng)術(shù)前通過超聲心動(dòng)圖對瓣膜狹窄和關(guān)閉不全進(jìn)行準(zhǔn)確評估。（4）嚴(yán)重主動(dòng)脈瓣狹窄，死亡率接近10%，有心絞痛、暈厥、心衰癥狀患者，應(yīng)取消或推遲手術(shù)。6、心律失常是否存在？是否需要處理快速心律失常使心肌缺血加重?zé)o癥狀的心臟病的單個(gè)室早或非持續(xù)性室速，如果無癥狀不會(huì)增加手術(shù)風(fēng)險(xiǎn)。持續(xù)性或有癥狀室性心律失常應(yīng)該在手術(shù)前得到控制β受體阻滯劑能降低圍手術(shù)期的心律失常發(fā)生及心血管并發(fā)癥發(fā)生率和死亡率7、是否明確置入起搏器和ICD患者的注意事項(xiàng)單極電極可引起：

起搏器模式轉(zhuǎn)化起搏電流受抑制增加起搏頻率引起ICD放電建議使用雙極電烙，術(shù)前應(yīng)該關(guān)閉心率應(yīng)答裝置，置入ICD患者在術(shù)前關(guān)閉、術(shù)后重啟。診斷1、病史回顧重點(diǎn)心絞痛、心肌梗死、心力衰竭、有癥狀的心律失常、起搏器、ICD病史冠心病危險(xiǎn)因素和外周血管病運(yùn)動(dòng)耐力：如一個(gè)高齡患者每天輕松跑步30分鐘，不需要進(jìn)一步檢查ActiveCardiacConditionsforWhichthePatientShouldUndergoEvaluationandTreatmentBeforeNoncardiacSurgeryConditionExamplesUnstablecoronarysyndromesUnstableorsevereangina*(CCSclassIIIorIV)?RecentMI?DecompensatedHFNYHAfunctionalclassIV;Worseningornew-onsetHFSignificantarrhythmiasHigh-gradeatrioventricularblockMobitzIIatrioventricularblockThird-degreeatrioventricularheartblockSymptomaticventriculararrhythmiasSupraventriculararrhythmias(includingatrialfibrillation)withuncontrolledventricularrate(HR>100bpmatrest)SymptomaticbradycardiaNewlyrecognizedventriculartachycardiaSeverevalvulardiseaseSevereaorticstenosis(meanpressuregradientgreaterthan40mmHg,aorticvalvearealessthan1.0cm2,orsymptomatic)Symptomaticmitralstenosis(progressivedyspneaonexertion,exertionalpresyncope,orHF)CCSindicatesCanadianCardiovascularSociety;HF,heartfailure;HR,heartrate;MI,myocardialinfarction;NYHA,NewYorkHeartAssociation.*AccordingtoCampeau.10?Mayincludestableanginainpatientswhoareunusuallysedentary.?TheACCNationalDatabaseLibrarydefinesrecentMIasmorethan7daysbutwithin30days)3、輔助檢查重點(diǎn)生化檢查：未用利尿劑而出現(xiàn)低血鉀提示醛固酮增多心電圖：Ⅰ度房室傳導(dǎo)阻滯、右束支阻滯不會(huì)增加圍手術(shù)期風(fēng)險(xiǎn)超聲心動(dòng)圖負(fù)荷試驗(yàn)優(yōu)點(diǎn)：隨心率和心肌收縮力增加，能動(dòng)態(tài)觀察心肌缺血。如心率低時(shí)室壁運(yùn)動(dòng)異?；虼竺娣e室壁運(yùn)動(dòng)異常都提示預(yù)后不良。CardiacRiskStratificationforNoncardiacSurgicalProceduresRiskStratificationProcedureExamplesVascular(reportedcardiacAorticandothermajorvascularsurgeryriskoften>5%)PeripheralvascularsurgeryIntermediate(reportedIntraperitonealandintrathoracicsurgerycardiacriskgenerally1%-5%)Carotidendarterectomy

HeadandnecksurgeryOrthopedicsurgeryProstatesurgeryLow?(reportedcardiacEndoscopicproceduresriskgenerally<1%SuperficialprocedureCataractsurgeryBreastsurgeryAmbulatorysurgeryRecommendationsforPreoperativeResting12-LeadECGClassI:Preoperativeresting12-leadECGisrecommendedforptswith:Atleast1clinicalriskfactor*whoareundergoingvascularsurgicalprocedures.(B)KnownCHD,peripheralarterialdisease,orcerebrovasculardiseasewhoareundergoingintermediate-risksurgicalprocedures.(C)ClassIIa:Preoperativeresting12-leadECGisreasonableinpersonswithnoclinicalriskfactorswhoareundergoingvascularsurgicalprocedures.(B)ClassIIb:Preoperativeresting12-leadECGmaybereasonableinpatientswithatleast1clinicalriskfactorwhoareundergoingintermediate-riskoperativeprocedures.(B)ClassIII:Preoperativeandpostoperativeresting12-leadECGsarenotindicatedinasymptomaticpersonsundergoinglow-risksurgicalprocedures.(B)*Clinicalriskfactorsincludehistoryofischemicheartdisease,historyofcompensatedorpriorHF,historyofcerebrovasculardisease,DM,andrenalinsufficiency.EstimatedEnergyRequirementsforVariousActivitiesCanYou…CanYou…1MetTakecareofyourself?4MetsClimbaflightofstairsorwalkupahill?Eat,dress,orusethetoilet?Walkonlevelgroundat4mph(6.4kph)?Walkindoorsaroundthehouse?Doheavyworkaroundthehouselikescrubbingfloorsorliftingormovingheavyfurniture?Walkablockor2onlevelgroundat2to3mph(3.2to4.8kph)?Participateinmoderaterecreationalactivitieslikegolf,bowling,dancing,doublestennis,orthrowingabaseballorfootball?4MetsDolightworkaroundthehouselikedustingorwashingdishes?≥10MetsParticipateinstrenuoussportslikeswimming,singlestennis,football,basketball,orskiing?METindicatesmetabolicequivalent;mph,milesperhour;kph,kilometersperhour.*ModifiedfromHlatkyetal,11copyright1989,withpermissionfromElsevier,andadaptedfromFletcheretal.12RecommendationsforNoninvasiveStressTestingBeforeNoncardiacSurgeryClassI:PatientswithactivecardiacconditionsinwhomnoncardiacsurgeryisplannedshouldbeevaluatedandtreatedperACC/AHAguidelinesbeforenoncardiacsurgery.(B)ClassIIa:Noninvasivestresstestingofpatientswith3ormoreclinicalriskfactorsandpoorfunctionalcapacity(lessthan4METs)whorequirevascularsurgeryisreasonableifitwillchangemanagement.(B)ClassIIb:Noninvasivestresstestingmaybeconsideredforpatients:Withatleast1to2clinicalriskfactorsandpoorfunctionalcapacity(lessthan4METs)whorequireintermediate-risknoncardiacsurgeryifitwillchangemanagement.(B)Withatleast1to2clinicalriskfactorsandgoodfunctionalcapacity(greaterthanorequalto4METs)whoareundergoingvascularsurgery.(B)ClassIII:Noninvasivetestingisnotusefulforpatients:Withnoclinicalriskfactorsundergoingintermediate-risknoncardiacsurgery.(C)Undergoinglow-risknoncardiacsurgery.(C)PrognosticGradientofIschemicResponsesDuringanECG-MonitoredExerciseTestinPatientsWithSuspectedorProvenCADIntermediate: Ischemiainducedbymoderate-levelexercise(4to6METsorHR100to130bpm(70%to85%ofage-predictedheartrate))manifestedby>1ofthefollowing:HorizontalordownslopingSTdepression>0.1mVPersistentischemicresponsegreaterthan1to3minutesafterexertionThreeto4abnormalleadsLow Noischemiaorischemiainducedathigh-levelexercise(>7METsorHR>130bpm(greaterthan85%ofage-predictedheartrate))manifestedby:HorizontalordownslopingSTdepression>0.1mVOneor2abnormalleadsInadequatetest Inabilitytoreachadequatetargetworkloadorheartrateresponseforagewithoutanischemicresponse.Forpatientsundergoingnoncardiacsurgery,theinabilitytoexercisetoatleasttheintermediate-risklevelwithoutischemiashouldbeconsideredaninadequatetest.PreoperativeCoronaryRevascularizationWithCABGorPercutaneousCoronaryInterventionClassI:PatientswithactivecardiacconditionsinwhomnoncardiacsurgeryisplannedshouldbeevaluatedandtreatedperACC/AHAguidelinesbeforenoncardiacsurgery.(B)ClassIIa:Noninvasivestresstestingofpatientswith3ormoreclinicalriskfactorsandpoorfunctionalcapacity(lessthan4METs)whorequirevascularsurgeryisreasonableifitwillchangemanagement.(B)ClassIIb:Noninvasivestresstestingmaybeconsideredforpatients:Withatleast1to2clinicalriskfactorsandpoorfunctionalcapacity(lessthan4METs)whorequireintermediate-risknoncardiacsurgeryifitwillchangemanagement.(B)Withatleast1to2clinicalriskfactorsandgoodfunctionalcapacity(greaterthanorequalto4METs)whoareundergoingvascularsurgery.(B)ClassIII:Noninvasivetestingisnotusefulforpatients:Withnoclinicalriskfactorsundergoingintermediate-risknoncardiacsurgery.(C)Undergoinglow-risknoncardiacsurgery.(C)4、冠狀動(dòng)脈造影：

非心臟手術(shù)圍手術(shù)期冠脈造影的指證：懷疑或確診冠心病患者，無創(chuàng)檢查提示心臟事件風(fēng)險(xiǎn)高充分藥物治療不能穩(wěn)定的心絞痛Ⅲ級或Ⅳ級心絞痛不穩(wěn)定心絞痛，特別是擬行中高危手術(shù)患者有高危因素?cái)M行高危手術(shù)的患者，無創(chuàng)檢查不能除外冠心病多個(gè)中危因素，擬行血管手術(shù)及高危非心臟手術(shù)無創(chuàng)檢查提示中到大面積心肌缺血急性心肌梗死恢復(fù)期擬行急診非心臟手術(shù)不建議非心臟手術(shù)期術(shù)前冠脈造影：（1）已知冠心病，擬行低危手術(shù)，無創(chuàng)檢查無高危結(jié)果（2）冠脈重建后無癥狀，活動(dòng)耐力良好（≥7METS）（3）輕度不穩(wěn)定性心絞痛，左室功能良好（4）因?yàn)槠渌喜⒓膊〔荒苄泄诿}重建，或患者拒絕血管重建，嚴(yán)重左心功能不全（LVEF<20%）

術(shù)前心臟評估步驟Lee制定的“簡單指數(shù)”，共有6個(gè)獨(dú)立危險(xiǎn)因素冠心病（心梗病史、平板試驗(yàn)陽性、使用硝酸甘油、近期心絞痛、病理性Q波）CHF（心衰病史、肺水腫、夜間陣發(fā)呼吸困難、外周水腫、雙肺啰音、第三心音、X片示肺淤血）腦血管?。═IA、中風(fēng)）高風(fēng)險(xiǎn)手術(shù)（腹主動(dòng)脈瘤、血管手術(shù)、胸腹手術(shù)、矯形手術(shù)）血清肌酐>176.8umol/L。術(shù)前評估步驟第一步：明確手術(shù)的急緩，急診手術(shù)就不允許過多的術(shù)前檢查第二步：患者如5年內(nèi)接受過搭橋手術(shù)或6個(gè)月到5年內(nèi)接受過PCI，并且無心肌缺血的癥狀和證據(jù)，則風(fēng)險(xiǎn)很低且不必進(jìn)一步檢查。第三步：是否2年內(nèi)接受過冠狀動(dòng)脈評估：如果結(jié)果正常，不必重復(fù)檢查，如有缺血癥狀則應(yīng)重新評估。第四步：如行擇期手術(shù)，存在下列情況手術(shù)應(yīng)取消或推遲：

1、不穩(wěn)定冠心病2、失代償CHF3、血液動(dòng)力學(xué)不穩(wěn)定性心律失常：高度AVB有癥狀室性心律失常伴基礎(chǔ)心臟病未控制室率的室上性心律失常4、嚴(yán)重瓣膜病第五步：是否存在中度臨床預(yù)測危險(xiǎn)因素：輕度心絞痛（Ⅰ級或Ⅱ級）陳舊性心梗或病理Q波心衰史或失代償CHF1型糖尿病血清肌酐>176.8umol/L同時(shí)考慮運(yùn)動(dòng)耐力和手術(shù)本身的風(fēng)險(xiǎn)運(yùn)動(dòng)耐力：良好：>10METS

好：7-10METS

中等：4-7METS

差：<4METS手術(shù)風(fēng)險(xiǎn)大第六步：有中度臨床預(yù)測危險(xiǎn)因素的患者運(yùn)動(dòng)耐力良好，中等——可接受中度危險(xiǎn)手術(shù)運(yùn)動(dòng)耐力差或中等，高危手術(shù)——進(jìn)一步檢查第七步：手術(shù)本身風(fēng)險(xiǎn)沒有或低度預(yù)測危險(xiǎn)或運(yùn)動(dòng)耐力中等至良好（安全）第八步：根據(jù)無創(chuàng)檢查結(jié)果制定進(jìn)一步方案無創(chuàng)檢查示冠脈風(fēng)險(xiǎn)低——按計(jì)劃手術(shù)風(fēng)險(xiǎn)較重——強(qiáng)化藥物治療或冠脈造影。Cardiacevaluationandcarealgorithmfornoncardiacsurgery(1)圍手術(shù)期心臟逐步評估法第一步判斷非心臟手術(shù)的緊急性。緊急手術(shù)立即送入手術(shù)室，進(jìn)行圍手術(shù)期監(jiān)護(hù)及術(shù)后風(fēng)險(xiǎn)分層并處理危險(xiǎn)因素（IC）。擇期手術(shù)的術(shù)后危險(xiǎn)分層常在患者恢復(fù)健康后進(jìn)行，以避免失血、機(jī)體失調(diào)和其他術(shù)后并發(fā)癥可能混淆非侵入性檢查的結(jié)果。第二步患者有無活動(dòng)性心臟病。如果有不穩(wěn)定心絞痛、失代償心衰、嚴(yán)重心律失?；虬昴ぜ膊〕?dǎo)致取消或推遲手術(shù)，直到心臟疾病得到確診和合適的治療（IB）。許多上述患者需行冠脈造影評估進(jìn)一步的治療方案。對計(jì)劃手術(shù)的患者進(jìn)行最大限度的藥物治療是恰當(dāng)?shù)摹５谌交颊哌M(jìn)行的是低風(fēng)險(xiǎn)手術(shù)嗎？如果是低風(fēng)險(xiǎn)手術(shù)（內(nèi)窺鏡治療、皮膚治療、白內(nèi)障手術(shù)、乳腺手術(shù)、無需臥床的手術(shù)等）可按計(jì)劃手術(shù)（IB）。即使是高?；颊撸渑c低風(fēng)險(xiǎn)手術(shù)相關(guān)的致殘率和致死率總數(shù)不到1％。Cardiacevaluationandcarealgorithmfornoncardiacsurgery(2)ProposedapproachtothemanagementofpatientswithpreviousPCIwhorequirenoncardiacsurgeryTreatmentforpatientsrequiringPCIwhoneedsubsequentsurgery治療方案的選擇DrugElutingStents(DES)andStentThrombosisA2007AHA/ACC/SCAI/ACS/ADAscienceadvisoryreportconcludesthatprematurediscontinuationofdualantiplatelettherapymarkedlyincreasestheriskofcatastrophicstentthrombosisanddeathorMI.Toeliminatetheprematurediscontinuationofthienopyridinetherapy,theadvisorygrouprecommendsthefollowing:1.Beforeimplantationofastent,thephysicianshoulddiscusstheneedfordual-antiplatelettherapy.Inpatientsnotexpectedtocomplywith12monthsofthienopyridinetherapy,whetherforeconomicorotherreasons,strongconsiderationshouldbegiventoavoidingaDES.2.InpatientswhoareundergoingpreparationforPCIandwhoarelikelytorequireinvasiveorsurgicalprocedureswithinthenext12months,considerationshouldbegiventoimplantationofabaremetalstentorperformanceofballoonangioplastywithprovisionalstentimplantationinsteadoftheroutineuseofaDES.GrinesCL,etal.Circulation.2007;115:813-818.DrugElutingStents(DES)andStentThrombosis3.Agreatereffortbyhealthcareprofessionalsmustbemadebeforepatientdischargetoensurethatpatientsareproperlyandthoroughlyeducatedaboutthereasonstheyareprescribedthienopyridinesandthesignificantrisksassociatedwithprematurelydiscontinuingsuchtherapy.4.Patientsshouldbespecificallyinstructedbeforehospitaldischargetocontacttheirtreatingcardiologistbeforestoppinganyantiplatelettherapy,evenifinstructedtostopsuchtherapybyanotherhealthcareprovider.5.Healthcareproviderswhoperforminvasiveorsurgicalproceduresandwhoareconcernedaboutperiproceduralandpostproceduralbleedingmustbemadeawareofthepotentiallycatastrophicrisksofprematurediscontinuationofthienopyridinetherapy.Suchprofessionalswhoperformtheseproceduresshouldcontactthepatient’scardiologistifissuesregardingthepatient’santiplatelettherapyareunclear,todiscussoptimalpatientmanagementstrategy.GrinesCL,etal.Circulation.2007;115:813-818.DrugElutingStents(DES)andStentThrombosis6.Electiveproceduresforwhichthereissignificantriskofperioperativeorpostoperativebleedingshouldbedeferreduntilpatientshavecompletedanappropriatecourseofthienopyridinetherapy(12monthsafterDESimplantationiftheyarenotathighriskofbleedingandaminimumof1monthforbare-metalstentimplantation).7.ForpatientstreatedwithDESwhoaretoundergosubsequentproceduresthatmandatediscontinuationofthienopyridinetherapy,aspirinshouldbecontinuedifatallpossibleandthethienopyridinerestartedassoonaspossibleaftertheprocedurebecauseofconcernsaboutlatestentthrombosis.GrinesCL,etal.Circulation.2007;115:813-818.RecommendationsforBeta-BlockerMedicalTherapyCLASSI1.Betablockersshouldbecontinuedinpatientsundergoingsurgerywhoarereceivingbetablockerstotreatangina,symptomaticarrhythmias,hypertension,orotherACC/AHAclassIguidelineindications.(C)2.Betablockersshouldbegiventopatientsundergoingvascularsurgerywhoareathighcardiacriskowingtothefindingofischemiaonpreoperativetesting.(B)CLASSIIa1.BetablockersareprobablyrecommendedforpatientsundergoingvascularsurgeryinwhompreoperativeassessmentidentifiesCHD.(B)2.Betablockersareprobablyrecommendedforpatientsinwhompreoperativeassessmentforvascularsurgeryidentifieshighcardiacrisk,asdefinedbythepresenceofmorethan1clinicalriskfactor.*(B)3.BetablockersareprobablyrecommendedforpatientsinwhompreoperativeassessmentidentifiesCHDorhighcardiacrisk,asdefinedbythepresenceofmorethan1clinicalriskfactor,*whoareundergoingintermediate-riskorvascularsurgery.(B)RecommendationsforBeta-BlockerMedicalTherapyCLASSIIbTheusefulnessofbetablockersisuncertainforpatientswhoareundergoingeitherintermediate-riskproceduresorvascularsurgery,inwhompreoperativeassessmentidentifiesasingleclinicalriskfactor.*(C)2.Theusefulnessofbetablockersisuncertaininpatientsundergoingvascularsurgerywithnoclinicalriskfactorswhoarenotcurrentlytakingbetablockers.(B)CLASSIII1.Betablockersshouldnotbegiventopatientsundergoingsurgerywhohaveabsolutecontraindicationstobetablockade.(C)RecommendationsforPerioperativeBeta-BlockerTherapyRecommendationsforStatinTherapyCLASSI1.Forpatientscurrentlytakingstatinsandscheduledfornoncardiacsurgery,statinsshouldbecontinued.(B)CLASSIIa1.Forpatientsundergoingvascularsurgerywithorwithoutclinicalriskfactors,statinuseisreasonable.(B)CLASSIIb1.Forpatientswithatleast1clinicalriskfactorwhoareundergoingintermediate-riskprocedures,statinsmaybeconsidered.(C)RecommendationsforAlpha-2AntagonistsandTEEchoCLASSIIb1.Alpha-2agonistsforperioperativecontrolofhypertensionmaybeconsideredforpatientswithknownCADoratleast1clinicalriskfactorwhoareundergoingsurgery.(B)CLASSIII1.Alpha-2agonistsshouldnotbegiventopatientsundergoingsurgerywhohavecontraindicationstothismedication.(C)CLASSIIa1.TheemergencyuseofintraoperativeorperioperativeTEEisreasonabletodeterminethecauseofanacute,persistent,andlife-threateninghemodynamicabnormality.(LevelofEvidence:C)RecommendationsforPACathetersandIVNitroCLASSIIbPreoperativeintensivecaremonitoringwithapulmonaryarterycatheterforoptimizationofhemodynamicstatusmightbeconsidered;however,itisrarelyrequiredandshouldberestrictedtoaverysmallnumberofhighlyselectedpatientswhosepresentationisunstableandcomplexandwhohavemultiplecomorbidconditions.(B)Theusefulnessofintraoperativenitroglycerinasaprophylacticagenttopreventmyocardialischemiaandcardiacmorbidityisunclearforhigh-riskpatientsundergoingnoncardiacsurgery,particularlythosewhohaverequirednitratetherapytocontrolangina.TherecommendationforprophylacticuseofnitroglycerinmusttakeintoaccounttheanestheticplanandpatienthemodynamicsandmustrecognizethatvasodilationandhypovolemiacanreadilyIntraoperativeandPostoperativeUseofST-SegmentMonitoringCLASSIIa1.Intraoperativeandpostoper