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"Emergency medicine" 5 (84) 2017

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Evaluation of perioperative risk of cardiac complications

Authors: Павлов О.О., Луцик С.А.
Харківська медична академія післядипломної освіти, м. Харків, Україна

Categories: Medicine of emergency

Sections: Clinical researches

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Досягнення в галузі медичної допомоги, зокрема стратегій лікування гострого коронарного синдрому й раптової смерті, призвели до поліпшення виживаності пацієнтів із хронічними захворюваннями, такими як атеросклероз, гіпертонія та діабет. Одним із факторів, що призвели до такої позитивної динаміки, було широке використання оцінних шкал. Пацієнти, які мають серцеву недостатність, являють собою групу зі значним ризиком післяопераційних ускладнень, як і пацієнти з ішемічною хворобою серця, і повинні бути ретельно обстежені для гарантування переносимості операції і наркозу. Застосування нових методів, таких як вимір біомаркерів, дає можливість більш точно визначити ймовірність розвитку та перспективи прогнозу або ранньої діагностики серцевої недостатності у пацієнтів, які перенесли розширену операцію.

Достижения в области медицинской помощи, в частности стратегий лечения острого коронарного синдрома и внезапной смерти, привели к улучшению выживаемости пациентов с хроническими заболеваниями, такими как атеросклероз, гипертония и диабет. Одним из факторов, которые привели к такой положительной динамике, было широкое использование оценочных шкал. Пациенты, имеющие сердечную недостаточность, представляют собой группу со значительным риском послеоперационных осложнений, как и пациенты с ишемической болезнью сердца, они должны быть тщательно обследованы для обеспечения переносимости операции и наркоза. Применение новых методов, таких как измерение биомаркеров, позволяет более точно определить вероятность развития и перспективы прогноза или ранней диагностики сердечной недостаточности у пациентов, перенесших расширенную операцию.

Advances in medical care, including treatment strategies for acute coronary syndrome and sudden death led to improved survival of patients with chronic diseases such as atherosclerosis, hypertension and diabetes. One of the factors caused this positive dynamics was wide using of rating scales. Patients with heart failure are of high risk of postoperative complications as the patients with coronary heart disease, and they should be thoroughly examined to ensure good tolerance of surgery and anesthesia. Goldman and colleagues proposed a multifactor model of risk for heart failure patients in general surgery, later called the original Cardiac Risk Index, and significantly improved the classification of the American Society of Anesthesiologists (ASA). It is worth noting that other authors developed evaluation system for postoperative complications risk. Howe­ver the estimation of patient’s clinical condition by any scale, the study of history and analysis of basic laboratory parameters are considered as a component of routine preoperative preparation. Goldman et al. have analyzed 1001 patients older than 40 years, which underwent extended planned general surgery. Multivariate models were identified using 9 standard clinical signs and laboratory indices with the formation of four independent factors that demonstrated postoperative high risk for cardiovascular complications. This model served as the basis for many years for assessing preoperative risk. However, the lack of verification of the proposed model in terms of multicenter studies, variability of performance and difficulties with the classification of possible complications resulted in the development of other assessment systems. The above estimation model emerged after the study of 455 patients evaluated preoperatively. The mathematical analysis discovered zone of accumulation risk of the original CH characteristics at 0.69 points lower than in the original studies. They have simplified scoring system, added indicator of severity of angina attacks and proposed criteria of modified HF, which provided improved index more than 0.76 points as compared to the original system. Though it was essentially improved rating scale, due to doubts and prejudice this method did not found widespread usage. In order to further improve existing cardiac risk stratification test more simple risk stratification tool was proposed; it consists of 6 simple factors derived from studies of 4315 patients older than 50 years, examined before investigation or directly at the hospital. Major cardiovascular events occurred in 2 % of patients in the study group and in 2.5 % patients in the control group. Independent risk factors were high-risk surgical intervention, revealed heart failure, revealed brain vascular diseases, preoperative treatment with insulin and preoperative blood creatinine levels more than 2.0 mg/dL (> 176.8 mmol/l). Mathematical modeling by this method showed clustering area of 0.806 compared to 0.582 by modified Cardiac Risk Index, 0.701 for the original Cardiac Risk Index and 0.706 for the classification of ASA. In general, such a simplified approach effectively grouped the patients into 3 groups. It should be noted that during the trial insulin therapy and preoperative creatinine level in blood serum were not so important factors. Another limitation was that the model cannot take into account changes in the patient’s clinical condition over time. For example, if a patient with decompensated heart failure after anesthesiologist’s examination was postponed for a month, and after this period his clinical condition improved, the patient’s calculated risk remains the same, and that may not reflect reality. Exactly the same applies to the patients with acute coronary syndrome, which after coronary artery revascularization are considered as being in need of delay or postpone of operation for a few months. Application of new methods such as biomarkers measurement can more accurately determine the likelihood of heart failure development and allows predict or early diagnosis of heart failure in patients undergoing extended operation.


серцева недостатність; періопераційне обстеження; ускладення

сердечная недостаточность; периоперационное обследование; осложнения

heart failure; perioperative examination; complications

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