Rolul cardiologului în chirurgia non-cardiacă: managementul perioperator

Abstract

Scop: Managementul perioperator adecvat este esențial în prevenirea complicațiilor cardiovasculare, inclusiv decesul de cauza cardiacă Material și metode: Ghidul Societății Europene de Cardiologie (ESC) pentru evaluarea cardiaca si managentul în chirurgia noncardiaca (2022) elaborat in comun cu Societatea Europeana de Anesteziologie si Terapie Intensivă (ESAIC) Rezultate: Aprecierea riscului preoperator trebuie sa țină cont de combinația multiplilor factori: pe de o parte de categoria de risc a operației (mică/intermediară/înaltă) pe de alta parte de factorii intriseci ce țin de pacient, în special vârsta, simptomele, factorii de risc cardiovasculari, precum și bolile cardiace cunoscute. Persoanele până la 65 ani fără factori de risc cardiovasculari sau boli cardiace constituite nu necesită careva evaluare preoperatorie pentru intervenții cu risc scăzut și intermediar, iar la intervențiile cu risc înalt se va efectua electrocardiograma și biomarkerii cardiaci la persoanele peste 45 ani. Pentru persoanele peste 65 ani sau cei cu factori de risc cardiovasculari si o interventie cu risc intermediar/ inalt se va efectua electrocardiograma, biomarkerii cardiaci si se va aprecia capacitatea functionala, iar pentru pacientii cu boli cardiovasculare cunoscute suplimentar se va efectua si consultatia cardiologului, la necesitate evaluare in echipa multidisciplinara. Evaluarea biomarkerilor, in special troponina postoperator depisteaza la timp infarctul miocardic postprocedural, care in 85% cazuri este silentios, fara durere tipica. Decizia continuarii medicamentelor cardiace cronice, in special anticoagulatele/antitromboticele deseori reprezinta o provocare, fiind esentiala examinarea atenta a riscul de sangerare si riscul ischemic, precum si cunoasterea deplina a istoricului medical al pacientului. Concluzii: Pregătirea preoperatorie necesita examinarea atenta a profilului clinic al pacientului si conlucrare interdisciplinara.

Aim: Adequate perioperative management is essential in preventing cardiovascular complications, including cardiac death, during and after non-cardiac surgery. Material and methods: 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC), endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). Results: Cardiovascular risk assesment before non-cardiac surgery comprises a combination of multiple factors: on one hand there is the surgery risk category (low-risk, intermediate and high-risk) and on the other hand there are patient related risk factors to deal with, especially the patient's age, cardiovascular risk factors or even known cardiovascular disease. Individuals that are younger than 65 without any cardiovascular risk factors or known CVD do not need any additional investigations before a low- or intermediate risk surgery, while an ECG and cardiac biomarkers are warranted in those older than 45 before a high risk surgery. In individuals older than 65 or those with cardiovascular risk factors undergoing an intermediate or high risk surgery an ECG, cardiac biomarkers and functional capacity determination is necessary. Patients with known cardiovascular disease need a cardiology consult and sometimes a multidisciplinary team assessment. Dosing of cardiac biomarkers, especially cardiac troponins after surgery helps detect postprocedural myocardial infarction, which can be silent in 85% of cases - patients having no typical pain. Decisions concerning continuing chronic cardiac medication throughout the surgery, especially antithrombotic drugs, are usually quite challenging, as balancing bleeding and ischemic risks needs to be done after carefully studying the patient's history. Conclusion: Perioperative assessment requires a careful examination of the patient's clinical profile as well as interdisciplinary teamwork.