冠脉支架患者非心脏手术的围手术期处理

Perioperative management of patients with coronary stents undergoing non-cardiac surgery

背景近三十年来，心脏冠脉支架患者日益增多，此类患者在接受非心脏手术时其围手术期将面临特殊挑战。目的现将重点讨论支架血栓的病理生理以及冠脉支架患者非心脏手术围手术期的处理策略。内容冠脉支架患者为预防支架内血栓的发生，通常接受由阿司匹林和氯吡格雷为主要药物的双联抗血小板治疗，其疗程为裸金属支架baremetal stent，BMS）4周～6周，药物洗脱支架（drugeluting，DES）至少1年，冠脉支架患者，尤其是DES患者，临床医生必须审慎权衡，终止抗血小板治疗意味增加围手术期支架内血栓、心肌梗死和心源性死亡的危险；而连续抗血小板治疗则可能增加手术出血的危险。趋向目前比较一致的观点是围手术期心脏并发症的危险远大于出血危险，因此，除颅内和眼球等闭合腔隙手术外，围手术期应尽可能维持抗血小板治疗。

Background The number of patients with coronary stents has increased rapidly over the last three decades. When those patients subsequently present for non-cardiac surgery, they will be posed a particular challenge during perioperative period. Objective This review discusses the pathophysiology of coronary stent thrombosis, and perioperative management strategies for patients with coronary stents undergoing non-cardiac surgery. Content In order to prevent stent thrombosis, patients need to receive dual anti-platelet therapy（generally aspirin combined with clopidogrel） for four to six weeks with bare-metal stents（BMS）, or at least one year with drug-eluting stents （DES） after stents are implanted. Faced with patients with coronary stents, particularly DES, clinicians must carefully balance the risks of discontinuing and continuing anti-platelet drugs. The former means to increase the possibility of perioperative stent thrombosis, MI, and cardiac death, while the latter will lead to potential surgical bleeding, which in certain cases may be life-threatening. Trend It comes into a consensus that the risk of cardiac complications exceeds that of bleeding. Therefore, maintenance of dual anti-platelet therapy perioperatively is recommended, except those surgeries in closed cavities, e.g., intracranial or intraocular surgeries.