This Article Free upon publication Extract Full Text (PDF) Correction (v113,pe846) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eagle, K. A. Articles by Smith, S. C. Search for Related Content PubMed PubMed Citation Articles by Eagle, K. A. Articles by Smith, S. C., Jr Related Collections Other etiology AHA Statements and Guidelines CV surgery: other A GUIDELINES UPDATE HAS BEEN ISSUED

(Circulation. 2002;105:1257.)
© 2002 American Heart Association, Inc.

ACC/AHA Practice Guidelines

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

Kim A. Eagle, MD FACC, Chair; Peter B. Berger, MD FACC; Hugh Calkins, MD FACC; Bernard R. Chaitman, MD FACC; Gordon A. Ewy, MD FACC; Kirsten E. Fleischmann, MD MPH, FACC; Lee A. Fleisher, MD FACC; James B. Froehlich, MD; Richard J. Gusberg, MD FACS; Jeffrey A. Leppo, MD FACC; Thomas Ryan, MD FACC; Robert C. Schlant, MD FACC; William L. Winters, Jr, MD MACC

Committee Members

Raymond J. Gibbons, MD FACC, Chair; Elliott M. Antman, MD FACC, Vice Chair; Joseph S. Alpert, MD FACC; David P. Faxon, MD FACC; Valentin Fuster, MD PhD, FACC; Gabriel Gregoratos, MD FACC; Alice K. Jacobs, MD FACC; Loren F. Hiratzka, MD FACC; Richard O. Russell, MD FACC^*; Sidney C. Smith, Jr, MD FACC

Task Force Members

Key Words: ACC/AHA Practice Guidelines • surgery • risk factors

	1. Introduction

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
These guidelines represent an update of those published in 1996 and are intended for physicians who are involved in the preoperative, operative, and postoperative care of patients undergoing noncardiac surgery. They provide a framework for considering cardiac risk of noncardiac surgery in a variety of patient and surgical situations. The overriding theme of these guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. The purpose of preoperative evaluation is not simply to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. The goal of the consultation is to identify the most appropriate testing and treatment strategies to optimize care of the patient, provide assessment of both short- and long-term cardiac risk, and avoid unnecessary testing in this era of cost containment.

A. Development of Guidelines
These guidelines are based on an update of a Medline, EMBASE, Cochrane library, and Best Evidence search of the English literature from 1995 through 2000, a review of selected journals, and the expert opinions of 12 committee members representing various disciplines of cardiovascular care, including general cardiology, interventional cardiology, noninvasive testing, vascular medicine, vascular surgery, anesthesiology, and arrhythmia management. As a result of these searches, more than 400 relevant new articles were identified. In addition, draft guidelines were submitted for critical review and amendment to the executive officers representing the American College of Cardiology (ACC) and the American Heart Association (AHA).

A large proportion of the data used to develop these guidelines are based on observational or retrospective studies or knowledge of management of cardiovascular disorders in the nonoperative setting. Although the collective body of knowledge about the identification of high- and low-risk patients by perioperative clinical and noninvasive evaluation is substantial, the number of prospective or randomized studies that have been performed to establish the value of different treatments on perioperative outcomes is small. The ACC/AHA classifications of evidence used in this report to summarize the indication for a particular therapy or treatment are as follows:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure/therapy is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy.

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in some cases may be harmful.

Two versions of the full-text guidelines are available on the World Wide Web sites of both the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org); one version highlights the updated material (deleted text in strikeout and new text in red), and the other fully incorporates the changes. This document was approved for publication by the governing bodies of the ACC and the AHA, will be reviewed annually by the Task Force, and will be considered current unless the Task Force revises or withdraws them from distribution.

B. General Approach
The preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and to the nature of the surgical illness (e.g., acute surgical emergency) as opposed to urgent or elective cases. Successful perioperative evaluation and treatment of cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon. In general, indications for further cardiac testing and treatments are the same as those in the nonoperative setting, but their timing is dependent on such factors as the urgency of noncardiac surgery, the patient’s risk factors, and specific surgical considerations. Coronary revascularization before noncardiac surgery to enable the patient to "get through" the noncardiac procedure is appropriate only for a small subset of patients at very high risk. Preoperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes. A conservative approach to the use of expensive tests and treatments is recommended.

C. Preoperative Clinical Evaluation
The initial history, physical examination, and electrocardiogram (ECG) assessment should focus on identification of potentially serious cardiac disorders, including coronary artery disease (CAD) [e.g., prior myocardial infarction (MI) and angina pectoris], heart failure (HF), symptomatic arrhythmias, presence of pacemaker or implantable cardioverter defibrillator (ICD), or a history of orthostatic intolerance.¹ The presence of anemia may also place a patient at higher perioperative risk.^2–4

In addition to identifying the presence of pre-existing manifested heart disease, it is essential to define disease severity, stability, and prior treatment. Other factors that help determine cardiac risk include functional capacity, age, comorbid conditions (e.g., diabetes mellitus, peripheral vascular disease, renal dysfunction, and chronic pulmonary disease), and type of surgery (vascular procedures and prolonged, complicated thoracic, abdominal, and head and neck procedures are considered higher risk).

Numerous risk indices have been developed over the past 25 years on the basis of multivariate analyses.^5–14 In addition to the presence of CAD and HF, a history of cerebrovascular disease, preoperative elevated creatinine greater than 2 mg per deciliter, insulin treatment for diabetes mellitus, and high-risk surgery have all been associated with increased perioperative cardiac morbidity. Despite these risk indices, there was consensus among the committee members to place clinical risk factors into 3 categories of predictors (see Section II-A).

	II. Further Preoperative Testing to Assess Coronary Risk

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
Which patients are most likely to benefit from preoperative coronary assessment and treatment? The lack of adequately controlled or randomized clinical trials to define the optimal evaluation strategy led to the proposed algorithm based on collected observational data and expert opinion (see Fig. 1). Since publication of the guidelines in 1996, several studies have suggested that this stepwise approach to the assessment of CAD is both efficacious and cost-effective.

View larger version (38K): [in this window] [in a new window]   Figure 1. Stepwise approach to preoperative cardiac assessment. Steps are discussed in text. *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.

A stepwise bayesian strategy that relies on assessment of clinical markers, prior coronary evaluation and treatment, functional capacity, and surgery-specific risk is outlined in Figure 1. A framework for determining which patients are candidates for cardiac testing is presented in algorithmic form. Successful use of the algorithm requires an appreciation of the different levels of risk attributable to certain clinical circumstances, levels of functional capacity, and types of surgery. These are defined below, after which the algorithm is reviewed step by step.

A. Clinical Markers
The major clinical predictors (Table 1) of increased perioperative cardiovascular risk are a recent unstable coronary syndrome such as an acute MI (documented MI less than 7 days previously), recent MI (more than 7 days but less than 1 month before surgery), unstable or severe angina, evidence of a large ischemic burden by clinical symptoms or noninvasive testing, decompensated HF, significant arrhythmias (high-grade atrioventricular block, symptomatic arrhythmias in the presence of underlying heart disease, or supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease.

View this table: [in this window] [in a new window]   Table 1. Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Heart Failure, Death)

Intermediate predictors of increased risk are mild angina pectoris, a more remote prior MI (more than 1 month before planned surgery), compensated HF, preoperative creatinine greater than or equal to 2.0 mg per deciliter, and diabetes mellitus. Minor predictors of risk are advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled systemic hypertension.

A history of MI or abnormal Q waves by ECG is listed as an intermediate predictor, whereas an acute MI (defined as at least 1 documented MI less than or equal to 7 days before the examination) or recent MI (more than 7 days but less than or equal to 1 month before the examination) with evidence of important ischemic risk by clinical symptoms or noninvasive study is a major predictor. This definition reflects the consensus of the ACC Cardiovascular Database Committee. In this way, the separation of MI into the traditional 3- and 6-month intervals has been avoided.^6,15 Current management of MI provides for risk stratification during convalescence.¹⁶ If a recent stress test does not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there are no adequate clinical trials on which to base firm recommendations, it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgery.

B. Functional Capacity
Functional capacity can be expressed in metabolic equivalent (MET) levels (Table 2). Multiples of the baseline MET value can be used to express aerobic demands for specific activities. Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities.^17–19 The Duke Activity Status Index and other activity scales provide the clinician with a set of questions to determine a patient’s functional capacity.^20–22 Energy expenditures for activities such as eating, dressing, walking around the house, and dishwashing range from 1 to 4 METs. Climbing a flight of stairs, walking on level ground at 6.4 km per hour, running a short distance, scrubbing floors, or playing a game of golf represents 4 to 10 METs. Strenuous sports such as swimming, singles tennis, and football often exceed 10 METs.

View this table: [in this window] [in a new window]   Table 2. Estimated Energy Requirements for Various Activities

C. Surgery-Specific Risk
Surgery-specific cardiac risk of noncardiac surgery is related to 2 important factors: the type of surgery itself and the degree of hemodynamic stress associated with the procedures. The duration and intensity of coronary and myocardial stressors can be helpful in estimating the likelihood of perioperative cardiac events, particularly for emergency surgery. Surgery-specific risk for noncardiac surgery can be stratified as high, intermediate, and low (Table 3). ²³ High-risk surgery includes major emergency surgery, particularly in the elderly; aortic and other major vascular surgery; peripheral vascular surgery; and anticipated prolonged procedures associated with large fluid shifts and/or blood loss. Intermediate-risk procedures include intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, and prostate surgery. Low-risk procedures include endoscopic and superficial procedures, cataract surgery, and breast surgery.

View this table: [in this window] [in a new window]   Table 3. Cardiac Risk* Stratification for Noncardiac Surgical Procedures

The following steps correspond to the algorithm presented in Figure 1.

Step 1 What is the urgency of noncardiac surgery? Certain emergencies do not allow time for preoperative cardiac evaluation. Postoperative risk stratification may be appropriate for some patients who have not had such an assessment before.

Step 2 Has the patient undergone coronary revascularization in the past 5 years? If so, and if clinical status has remained stable without recurrent symptoms/signs of ischemia, further cardiac testing is generally not necessary.²⁴

Step 3 Has the patient had a coronary evaluation in the past 2 years? If coronary risk was adequately assessed and the findings were favorable, it is usually not necessary to repeat testing unless the patient has experienced a change or new symptoms of coronary ischemia since the previous evaluation.

Step 4 Does the patient have an unstable coronary syndrome or a major clinical predictor of risk? When elective noncardiac surgery is being considered, the presence of unstable coronary disease, decompensated HF, symptomatic arrhythmias, and/or severe valvular heart disease usually leads to cancellation or delay of surgery until the problem has been identified and treated.

Step 5 Does the patient have intermediate clinical predictors of risk? The presence or absence of prior MI by history or ECG, angina pectoris, compensated or prior HF, preoperative creatinine greater than or equal to 2 mg per deciliter, and/or diabetes mellitus helps to further stratify clinical risk for perioperative coronary events. Consideration of functional capacity and level of surgery-specific risk allows a rational approach to identify patients most likely to benefit from further noninvasive testing.

Step 6 Patients without major but with intermediate predictors of clinical risk and moderate or excellent functional capacity can generally undergo intermediate-risk surgery with little likelihood of perioperative death or MI. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery, especially for patients with 2 or more intermediate predictors of risk.

Step 7 Noncardiac surgery is generally safe for patients with neither major nor intermediate predictors of clinical risk and moderate or excellent functional capacity (4 METs or greater). Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity who are facing higher-risk operations, particularly those with several minor clinical predictors of risk who are scheduled to undergo vascular surgery.

Step 8 The results of noninvasive testing can be used to determine the need for additional preoperative testing and treatment. In some patients with documented CAD, the risk of coronary intervention or corrective cardiac surgery may approach or even exceed the risk of the proposed noncardiac surgery. This approach may be appropriate, however, if it significantly improves the patient’s long-term prognosis.

For some patients, a careful consideration of clinical, surgery-specific, and functional status attributes leads to a decision to proceed to coronary angiography.

	III. Management of Specific Preoperative Cardiovascular Conditions

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
A. Hypertension
Stage 3 hypertension (systolic blood pressure greater than or equal to 180 mm Hg and diastolic blood pressure greater than or equal to 110 mm Hg) should be controlled before surgery. In many such instances, establishment of an effective regimen can be achieved over several days to weeks of preoperative outpatient treatment. If surgery is more urgent, rapid-acting agents can be administered that allow effective control in a matter of minutes or hours. Beta-blockers appear to be particularly attractive agents. Continuation of preoperative antihypertensive treatment through the perioperative period is critical.

B. Valvular Heart Disease
Indications for evaluation and treatment of valvular heart disease are identical to those in the nonpreoperative setting. Symptomatic stenotic lesions are associated with risk of perioperative HF or shock and often require percutaneous valvotomy or valve replacement before noncardiac surgery to lower cardiac risk.^6,25–27 Symptomatic regurgitant valve disease is usually better tolerated perioperatively and may be stabilized preoperatively with intensive medical therapy and monitoring. Regurgitant valve disease can then be treated definitively with valve repair or replacement after noncardiac surgery. Medical therapy and monitoring are appropriate when a delay of several weeks or months before noncardiac surgery may have severe consequences. Exceptions may include severe valvular regurgitation with reduced left ventricular function, in which overall hemodynamic reserve is so limited that destabilization during perioperative stresses is likely.

C. Myocardial Disease
Dilated and hypertrophic cardiomyopathy are associated with an increased incidence of perioperative HF.^6,28,29 Management is aimed at maximizing preoperative hemodynamic status and providing intensive postoperative medical therapy and surveillance. An estimate of hemodynamic reserve is useful for anticipating potential complications from intraoperative or postoperative stress.

D. Arrhythmias and Conduction Abnormalities
The presence of an arrhythmia or cardiac conduction disturbance should provoke a careful evaluation for underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality. Therapy should be initiated for symptomatic or hemodynamically significant arrhythmias, first to reverse an underlying cause and second to treat the arrhythmia. Indications for antiarrhythmic therapy and cardiac pacing are identical to those in the nonoperative setting. Frequent ventricular premature beats and/or asymptomatic nonsustained ventricular tachycardia have not been associated with an increased risk of nonfatal MI or cardiac death in the perioperative period,^30,31 and therefore, aggressive monitoring or treatment in the perioperative period generally is not necessary.

E. Implantable Pacemakers or ICDs
The type and extent of evaluation of a pacemaker or ICD depend on the urgency of the surgery, whether a pacemaker has unipolar or bipolar leads, whether electrocautery is bipolar or unipolar, the distance between electrocautery and pacemaker, and pacemaker dependency. ICD devices should be programmed off immediately before surgery and then on again postoperatively.

	IV. Supplemental Preoperative Evaluation

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
Specific recommendations for supplemental preoperative evaluation must be individualized to each patient and circumstance. The following may be appropriate in specific situations: assessment of resting left ventricular function, exercise stress testing, pharmacological stress testing, ambulatory ECG monitoring, and coronary angiography. In most ambulatory patients, the test of choice is exercise ECG testing, which can both provide an estimate of functional capacity and detect myocardial ischemia through changes in the ECG and hemodynamic response. In patients with important abnormalities on their resting ECG (e.g., left bundle-branch block, left ventricular hypertrophy with strain pattern, or digitalis effect), other techniques such as exercise echocardiography or exercise myocardial perfusion imaging should be considered. Recommendations regarding individual testing modalities are given below.

A. Resting Left Ventricular Function
Resting left ventricular function has not been found to be a consistent predictor of perioperative ischemic events.^32–40

Recommendations for Preoperative Noninvasive Evaluation of Left Ventricular Function
Class I
Patients with current or poorly controlled HF. (If previous evaluation has documented severe left ventricular dysfunction, repeat preoperative testing may not be necessary).

Class IIa
Patients with prior HF and patients with dyspnea of unknown origin.

Class III
As a routine test of left ventricular function in patients without prior HF.

B. 12-Lead ECG
The resting 12-lead ECG does not identify increased perioperative risk in patients undergoing low-risk surgery, but certain ECG abnormalities are clinical predictors of increased perioperative and long-term cardiovascular risk in clinically intermediate- and high-risk patients.^41–45

Recommendations for Preoperative 12-Lead Rest ECG
Class I
Recent episode of chest pain or ischemic equivalent in clinically intermediate- or high-risk patients scheduled for an intermediate- or high-risk operative procedure.

Class IIa
Asymptomatic persons with diabetes mellitus.

Class IIb

1. Patients with prior coronary revascularization.
   
2. Asymptomatic male more than 45 years old or female more than 55 years old with 2 or more atherosclerotic risk factors.
   
3. Prior hospital admission for cardiac causes.
   

Class III
As a routine test in asymptomatic subjects undergoing low-risk operative procedures.

C. Exercise or Pharmacological Stress Testing
Recommendations for Exercise or Pharmacological Stress Testing
Class I

1. Diagnosis of adult patients with intermediate pretest probability of CAD.
   
2. Prognostic assessment of patients undergoing initial evaluation for suspected or proven CAD; evaluation of subjects with significant change in clinical status.
   
3. Demonstration of proof of myocardial ischemia before coronary revascularization.
   
4. Evaluation of adequacy of medical therapy; prognostic assessment after an acute coronary syndrome (if recent evaluation unavailable).
   

Class IIa
Evaluation of exercise capacity when subjective assessment is unreliable.

Class IIb

1. Diagnosis of CAD patients with high or low pretest probability: those with resting ST depression less than 1 mm, those taking digitalis therapy, or those with ECG criteria for left ventricular hypertrophy.
   
2. Detection of restenosis in high-risk asymptomatic subjects within the initial months after percutaneous coronary intervention (PCI).
   

Class III

1. For exercise stress testing, diagnosis of patients with resting ECG abnormalities that preclude adequate assessment, e.g., pre-excitation syndrome, electronically paced ventricular rhythm, rest ST depression greater than 1 mm, or left bundle-branch block.
   
2. Severe comorbidity likely to limit life expectancy or candidacy for revascularization.
   
3. Routine screening of asymptomatic men or women.
   
4. Investigation of isolated ectopic beats in young patients.
   

D. Coronary Angiography
Recommendations for Coronary Angiography in Perioperative Evaluation Before (or After) Noncardiac Surgery
Class I:
Patients With Suspected or Known CAD

1. Evidence for high risk of adverse outcome based on noninvasive test results.
   
2. Angina unresponsive to adequate medical therapy.
   
3. Unstable angina, particularly when facing intermediate-risk^* or high-risk^* noncardiac surgery.
   
4. Equivocal noninvasive test results in patients at high clinical risk undergoing high-risk^* surgery.
   

Class IIa

1. Multiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first).
   
2. Moderate to large ischemia on noninvasive testing but without high-risk features and lower left ventricular ejection fraction.
   
3. Nondiagnostic noninvasive test results in patients at intermediate clinical risk undergoing high-risk^* noncardiac surgery.
   
4. Urgent noncardiac surgery while convalescing from acute MI.
   

Class IIb

1. Perioperative MI.
   
2. Medically stabilized class III or IV angina and planned low-risk or minor surgery.
   

Class III

1. Low Risk^* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
   
2. Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).
   
3. Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
   
4. Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., left ventricular ejection fraction less than 0.20), or refusal to consider revascularization.
   
5. Candidate for liver, lung, or renal transplant less than 40 years old, as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.
   

	V. Perioperative Therapy or Previous Coronary Revascularization

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
A. Coronary Artery Bypass Grafting
Indications for coronary artery bypass grafting (CABG) before noncardiac surgery are identical to those reviewed in the ACC/AHA guidelines for CABG.⁴⁶ CABG is rarely indicated simply to "get a patient through" noncardiac surgery. In patients enrolled in the Coronary Artery Surgery Study (CASS) database, the cardiac risk associated with noncardiac operations involving the thorax, abdomen, arterial vasculature, and head and neck was reduced significantly in those patients who had undergone prior CABG.²³ Patients undergoing elective noncardiac procedures who are found to have prognostic high-risk coronary anatomy and in whom long-term outcome would likely be improved by CABG⁴⁷ should generally undergo revascularization before a noncardiac elective surgical procedure of high or intermediate risk (Table 3).

B. Percutaneous Coronary Intervention
There are no controlled trials comparing perioperative cardiac outcome after noncardiac surgery for patients treated with preoperative PCI versus medical therapy. Several small observational series have suggested that cardiac death is infrequent in patients who have undergone PCI before noncardiac surgery.^48–52 Several studies have also demonstrated a number of complications from angioplasty, including emergency CABG in some patients. Until further data are available, indications for PCI in the perioperative setting are similar to those in the ACC/AHA guidelines for use of PCI in general.⁵³ There is uncertainty regarding how much time should pass between PCI and noncardiac procedures. Delaying surgery for at least 1 week after balloon angioplasty to allow for healing of the vessel injury has theoretical benefits. If a coronary stent is used, a delay of at least 2 weeks and ideally 4 to 6 weeks should occur before noncardiac surgery to allow 4 full weeks of dual antiplatelet therapy and re-endothelialization of the stent to be completed, or nearly so.⁵⁴

	VI. Perioperative Medical Therapy

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
Several recent trials have examined the impact of medical therapy begun just before surgery on reducing cardiac events. Two randomized, placebo-controlled trials of beta-blocker administration have been performed.^13,14,55,56 One trial demonstrated reduced perioperative cardiac events, and the other demonstrated improved 6-month survival with perioperative beta-blocker usage. Several trials have evaluated the utility of alpha-2 agonists, demonstrating reduced cardiac event rates in the subset of patients with known CAD undergoing vascular surgery.^57–60

There are still very few randomized trials of medical therapy before noncardiac surgery to prevent perioperative cardiac complications, and they do not provide enough data from which to draw firm conclusions or recommendations. Most are insufficiently powered to address the effect on outcome of MI or cardiac death, and they rely on the surrogate end point of ECG ischemia to show effect. Current studies, however, suggest that appropriately administered beta-blockers reduce perioperative ischemia and may reduce the risk of MI and death in high-risk patients. When possible, beta-blockers should be started days or weeks before elective surgery, with the dose titrated to achieve a resting heart rate between 50 and 60 beats per minute. Perioperative treatment with alpha-2 agonists may have similar effects on myocardial ischemia, infarction, and cardiac death. Clearly, this is an area in which further research would be valuable.

Recommendations for Perioperative Medical Therapy
Class I

1. Beta-blockers required in the recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension.
   
2. Beta-blockers: patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery.
   

Class IIa

1. Beta-blockers: preoperative assessment identifies untreated hypertension, known coronary disease, or major risk factors for coronary disease.
   

Class IIb

1. Alpha-2 agonist: perioperative control of hypertension, or known CAD or major risk factors for CAD.
   

Class III

1. Beta-blockers: contraindication to beta-blockade.
   
2. Alpha-2 agonists: contraindication to alpha-2 agonists.
   

	VII. Anesthetic Considerations and Intraoperative Management

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
A. Anesthetic Agent
All anesthetic techniques and drugs have known cardiac effects that should be considered in the perioperative plan. There appears to be no one best myocardium-protective anesthetic technique.^61–65 Therefore, the choice of anesthesia and intraoperative monitors is best left to the discretion of the anesthesia care team, which will consider the need for postoperative ventilation, cardiovascular effects (including myocardial depression), sympathetic blockade, and dermatomal level of the procedure. Advocates of monitored anesthesia, in which local anesthesia is supplemented by intravenous sedation/analgesia, have argued that use of this technique avoids the undesirable effects of general or neuraxial techniques, but no studies have established this. Failure to produce complete local anesthesia/analgesia can lead to increased stress response and/or myocardial ischemia.

B. Perioperative Pain Management
Patient-controlled intravenous and/or epidural analgesia is a popular method for reducing postoperative pain. Several studies suggest that effective pain management leads to a reduction in postoperative catecholamine surges and hypercoagulability.^66,67

C. Intraoperative Nitroglycerin
There are insufficient data about the effects of prophylactic intraoperative intravenous nitroglycerin in patients at high risk.^68–71 Nitroglycerin should be used only when the hemodynamic effects of other agents in use have been considered.

D. Transesophageal Echocardiography
There are few data on the value of transesophageal echocardiography to detect transient wall motion abnormalities in predicting cardiac morbidity in noncardiac surgical patients.^72,73 Experience to date suggests that the incremental value of this technique for risk prediction is small.⁷² Guidelines for appropriate use of transesophageal echocardiography have been published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists.⁷⁴

E. Perioperative Maintenance of Body Temperature
One randomized trial demonstrated a reduced incidence of perioperative cardiac events in patients who were maintained in a state of normothermia via forced-air warming compared with routine care.⁷⁵

	VIII. Perioperative Surveillance

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
A. Pulmonary Artery Catheters
Although very few studies that have been reported compare patient outcomes after treatment with or without pulmonary artery catheters, 3 variables are particularly important in assessing benefit versus risk of pulmonary artery catheter use: disease severity, magnitude of anticipated surgery, and practice setting.⁷⁶ The extent of expected fluid shifts is a primary concern. Patients most likely to benefit from perioperative use of a pulmonary artery catheter appear to be those with a recent MI complicated by HF, those with significant CAD who are undergoing procedures associated with significant hemodynamic stress, and those with systolic or diastolic left ventricular dysfunction, cardiomyopathy, and/or valvular disease who are undergoing high-risk operations.

B. Intraoperative and Postoperative ST-Segment Monitoring
Intraoperative and postoperative ST changes indicating myocardial ischemia are strong predictors of perioperative MI in patients at high risk who undergo noncardiac surgery.^77–80 Similarly, postoperative ischemia is a significant predictor of long-term risk of MI and cardiac death.⁸¹ Conversely, in patients at low risk who undergo noncardiac surgery, ST depression may occur and often is not associated with regional wall-motion abnormalities.^82–84 Accumulating evidence suggests that proper use of computerized ST-segment analysis in appropriately selected patients at high risk may improve sensitivity for myocardial ischemia detection.

C. Surveillance for Perioperative MI
Few studies have examined the optimal method for diagnosing a perioperative MI. Clinical symptoms, postoperative ECG changes, and elevation of the MB fraction of creatine kinase (CK-MB) have been studied most extensively. Recently, elevations of myocardium-specific enzymes such as troponin-I, troponin-T, or CK-MB isoforms have also been shown to be of value.^85–90 In patients with known or suspected CAD who are undergoing high-risk procedures, ECGs obtained at baseline, immediately after surgery, and on the first 2 days after surgery appear to be cost-effective.⁹¹ A risk gradient can be based on the magnitude of biomarker elevation, the presence or absence of concomitant new ECG abnormalities, hemodynamic instability, and quality and intensity of chest pain syndrome, if present. Use of cardiac biomarkers is best reserved for patients at high risk and those with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction.

	IX. Postoperative and Long-Term Management

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
Despite even optimal perioperative management, some patients will have perioperative MI, which is associated with a 40% to 70% mortality rate.⁹² For patients who experience a symptomatic perioperative ST-segment-elevation MI as a result of sudden thrombotic coronary occlusion, angioplasty should be considered after the risks versus benefits have been weighed. Pharmacological therapy with aspirin should be initiated as soon as possible, and a beta-blocker and angiotensin converting enzyme inhibitor may also be beneficial. Perioperative MI carries a high risk for future cardiac events. Patients who sustain acute MI in the perioperative period should receive careful medical evaluation for residual ischemia and overall left ventricular function.

It is also appropriate to recommend secondary risk reduction in the relatively large number of elective surgery patients in whom cardiovascular abnormalities are detected during preoperative evaluations. Although the occasion of surgery is often taken as a specific high-risk time, most of the patients who have known or newly detected CAD during their preoperative evaluations will not have any events during elective noncardiac surgery. After the preoperative cardiac risk has been determined by clinical or noninvasive testing, most patients will benefit from pharmacological agents to lower low-density lipoprotein cholesterol levels, increase high-density lipoprotein levels, or both. On the basis of expert opinion, the goal should be to lower the low-density lipoprotein level to less than 100 mg per deciliter (2.6 mmol per deciliter).^93–95

	Footnotes

 
"ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)" was approved by the American College of Cardiology Board of Trustees in December 2001 and by the American Heart Association Science Advisory and Coordinating Committee in November 2001.

When citing this document, the American College of Cardiology and the American Heart Association would appreciate the following citation format: Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL, Jr. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).

This statement has been co-published in the February 6, 2002, issue of the Journal of the American College of Cardiology.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur.

Single reprints of this document are available by calling 800-253-4636 (US only) or writing the American College of Cardiology, Educational Services, 9111 Old Georgetown Road, Bethesda, MD 20814-1699 (product code 71-0220). This document and the companion full-text guidelines (product code 71-0219), are available on the ACC Web site at www.acc.org and the AHA Web site at www.americanheart.org. To purchase additional reprints (specify version): up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1789, fax 214-691-6342; or E-mail pubauth@heart.org.

*Former Task Force member during this writing effort.

*Cardiac risk according to type of noncardiac surgery. High risk: emergent major operations, aortic and major vascular, peripheral vascular, anticipated prolonged surgical procedure associated with large fluid shifts and blood loss; intermediate risk: carotid endarterectomy, major head and neck, intraperitoneal and intrathoracic, orthopedic, prostate; and low risk: endoscopic procedures, superficial procedures, cataract, breast.

Cardiac risk according to clinical predictors of perioperative death, MI, or heart failure. High clinical risk: unstable angina, recent MI, and evidence of important residual ischemic risk, decompensated heart failure, high degree of atrioventricular block, symptomatic ventricular arrhythmias with known structural heart disease, severe symptomatic valvular heart disease, patient with multiple intermediate risk markers such as prior MI, heart failure, and diabetes; intermediate clinical risk: CCS class I or II angina, prior MI by history or ECG, compensated or prior heart failure, diabetes mellitus and renal insufficiency.

	References

Top 1. Introduction II. Further Preoperative Testing... III. Management of Specific... IV. Supplemental Preoperative... V. Perioperative Therapy or... VI. Perioperative Medical... VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... References

 
1. Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation. 1996; 93: 1278–317.

2. Hogue CW, Jr., Goodnough LT, Monk TG. Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion. 1998; 38: 924–31.[CrossRef][Medline] [Order article via Infotrieve]

3. Hahn RG, Nilsson A, Farahmand BY, Persson PG. Blood haemoglobin and the long-term incidence of acute myocardial infarction after transurethral resection of the prostate. Eur Urol. 1997; 31: 199–203.[Medline] [Order article via Infotrieve]

4. Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med. 1993; 21: 860–6.[Medline] [Order article via Infotrieve]

5. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999; 100: 1043–9.[Abstract/Free Full Text]

6. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977; 297: 845–50.[Abstract]

7. Ashton CM, Petersen NJ, Wray NP, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med. 1993; 118: 504–10.[Abstract/Free Full Text]

8. Cooperman M, Pflug B, Martin EW, Jr., Evans WE. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery. 1978; 84: 505–9.[Medline] [Order article via Infotrieve]

9. Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986; 1: 211–9.[Medline] [Order article via Infotrieve]

10. Lette J, Waters D, Bernier H, et al. Preoperative and long-term cardiac risk assessment. Predictive value of 23 clinical descriptors, 7 multivariate scoring systems, and quantitative dipyridamole imaging in 360 patients. Ann Surg. 1992; 216: 192–204.[CrossRef][Medline] [Order article via Infotrieve]

11. Michel LA, Jamart J, Bradpiece HA, Malt RA. Prediction of risk in noncardiac operations after cardiac operations. J Thorac Cardiovasc Surg. 1990; 100: 595–605.[Abstract]

12. Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med. 1989; 110: 859–66.

13. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med,. 1999; 341: 1789–94.[Abstract/Free Full Text]

14. Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery. Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA. 2001; 285: 1865–73.[Abstract/Free Full Text]

15. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA. 1972; 220: 1451–4.[Abstract/Free Full Text]

16. Gunnar RM, Passamani ER, Bourdillon PD, et al. Guidelines for the early management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Develop Guidelines for the Early Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 1990; 16: 249–92.[Medline] [Order article via Infotrieve]

17. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999; 159: 2185–92.[Abstract/Free Full Text]

18. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest. 1999; 116: 355–62.[Abstract/Free Full Text]

19. Bartels C, Bechtel JF, Hossmann V, Horsch S. Cardiac risk stratification for high-risk vascular surgery. Circulation. 1997; 95: 2473–5.[Abstract/Free Full Text]

20. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989; 64: 651–4.[CrossRef][Medline] [Order article via Infotrieve]

21. Nelson CL, Herndon JE, Mark DB, et al. Relation of clinical and angiographic factors to functional capacity as measured by the Duke Activity Status Index. Am J Cardiol. 1991; 68: 973–5.[CrossRef][Medline] [Order article via Infotrieve]

22. Goldman L, Hashimoto B, Cook EF, Loscalzo A. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation. 1981; 64: 1227–34.[Abstract/Free Full Text]

23. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation. 1997; 96: 1882–7.[Abstract/Free Full Text]

24. Mahar LJ, Steen PA, Tinker JH, et al. Perioperative myocardial infarction in patients with coronary artery disease with and without aorta-coronary artery bypass grafts. J Thorac Cardiovasc Surg. 1978; 76: 533–7.[Abstract]

25. Reyes VP, Raju BS, Wynne J, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med. 1994; 331: 961–7.[Abstract/Free Full Text]

26. Raymer K, Yang H. Patients with aortic stenosis: cardiac complications in non-cardiac surgery. Can J Anaesth. 1998; 45: 855–9.[Medline] [Order article via Infotrieve]

27. Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol. 1998; 81: 448–52.[CrossRef][Medline] [Order article via Infotrieve]

28. Thompson RC, Liberthson RR, Lowenstein E. Perioperative anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy. JAMA. 1985; 254: 2419–21.[Abstract/Free Full Text]

29. Haering JM, Comunale ME, Parker RA, et al. Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy. Anesthesiology. 1996; 85: 254–9.[CrossRef][Medline] [Order article via Infotrieve]

30. O’Kelly B, Browner WS, Massie B, Tubau J, Ngo L, Mangano DT. Ventricular arrhythmias in patients undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA. 1992; 268: 217–21.[Abstract/Free Full Text]

31. Mahla E, Rotman B, Rehak P, et al. Perioperative ventricular dysrhythmias in patients with structural heart disease undergoing noncardiac surgery. Anesth Analg. 1998; 86: 16–21.[Abstract]

32. Fletcher JP, Antico VF, Gruenewald S, Kershaw LZ. Risk of aortic aneurysm surgery as assessed by preoperative gated heart pool scan. Br J Surg. 1989; 76: 26–8.[Medline] [Order article via Infotrieve]

33. Pedersen T, Kelbaek H, Munck O. Cardiopulmonary complications in high-risk surgical patients: the value of preoperative radionuclide cardiography. Acta Anaesthesiol Scand. 1990; 34: 183–9.[Medline] [Order article via Infotrieve]

34. Lazor L, Russell JC, DaSilva J, Radford M. Use of the multiple uptake gated acquisition scan for the preoperative assessment of cardiac risk. Surg Gynecol Obstet. 1988; 167: 234–8.[Medline] [Order article via Infotrieve]

35. Pasternack PF, Imparato AM, Bear G, et al. The value of radionuclide angiography as a predictor of perioperative myocardial infarction in patients undergoing abdominal aortic aneurysm resection. J Vasc Surg. 1984; 1: 320–5.[CrossRef][Medline] [Order article via Infotrieve]

36. Mosley JG, Clarke JM, Ell PJ, Marston A. Assessment of myocardial function before aortic surgery by radionuclide angiocardiography. Br J Surg. 1985; 72: 886–7.[Medline] [Order article via Infotrieve]

37. Pasternack PF, Imparato AM, Riles TS, et al. The value of the radionuclide angiogram in the prediction of perioperative myocardial infarction in patients undergoing lower extremity revascularization procedures. Circulation. 1985; 72: II13–7.

38. Kazmers A, Cerqueira MD, Zierler RE. The role of preoperative radionuclide ejection fraction in direct abdominal aortic aneurysm repair. J Vasc Surg. 1988; 8: 128–36.[CrossRef][Medline] [Order article via Infotrieve]

39. Halm EA, Browner WS, Tubau JF, Tateo IM, Mangano DT. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group. Ann Intern Med. 1996; 125: 433–41.[Abstract/Free Full Text]

40. Fiser WP, Thompson BW, Thompson AR, Eason C, Read RC. Nuclear cardiac ejection fraction and cardiac index in abdominal aortic surgery. Surgery. 1983; 94: 736–9.[Medline] [Order article via Infotrieve]

41. Sutherland SE, Gazes PC, Keil JE, Gilbert GE, Knapp RG. Electrocardiographic abnormalities and 30-year mortality among white and black men of the Charleston Heart Study. Circulation. 1993; 88: 2685–92.[Abstract/Free Full Text]

42. Kannel WB, Gordon T, Offutt D. Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study. Ann Intern Med. 1969; 71: 89–105.

43. Tervahauta M, Pekkanen J, Punsar S, Nissinen A. Resting electrocardiographic abnormalities as predictors of coronary events and total mortality among elderly men. Am J Med. 1996; 100: 641–5.[CrossRef][Medline] [Order article via Infotrieve]

44. Kreger BE, Cupples LA, Kannel WB. The electrocardiogram in prediction of sudden death: Framingham Study experience. Am Heart J. 1987; 113: 377–82.[CrossRef][Medline] [Order article via Infotrieve]

45. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med. 2000; 342: 168–75.[Abstract/Free Full Text]

46. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1991 guidelines for coronary artery bypass graft surgery). Circulation. 1999; 100: 1464–80.[Free Full Text]

47. Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol. 1991; 17: 543–89.[Medline] [Order article via Infotrieve]

48. Huber KC, Evans MA, Bresnahan JF, Gibbons RJ, Holmes DR, Jr. Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clin Proc. 1992; 67: 15–21.[Medline] [Order article via Infotrieve]

49. Elmore JR, Hallett JW, Jr., Gibbons RJ, et al. Myocardial revascularization before abdominal aortic aneurysmorrhaphy: effect of coronary angioplasty. Mayo Clin Proc. 1993; 68: 637–41.[Medline] [Order article via Infotrieve]

50. Allen JR, Helling TS, Hartzler GO. Operative procedures not involving the heart after percutaneous transluminal coronary angioplasty. Surg Gynecol Obstet. 1991; 173: 285–8.[Medline] [Order article via Infotrieve]

51. Gottlieb A, Banoub M, Sprung J, Levy PJ, Beven M, Mascha EJ. Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty. J Cardiothorac Vasc Anesth. 1998; 12: 501–6.[CrossRef][Medline] [Order article via Infotrieve]

52. Posner KL, Van Norman GA, Chan V. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analg. 1999; 89: 553–60.[Abstract/Free Full Text]

53. Smith SC, Jr., Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol. 2001; 37: 2215–38.[Free Full Text]

54. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000; 35: 1288–94.[Abstract/Free Full Text]

55. Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology. 1998; 88: 7–17.[CrossRef][Medline] [Order article via Infotrieve]

56. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996; 335: 1713–20.[Abstract/Free Full Text]

57. Oliver MF, Goldman L, Julian DG, Holme I. Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT). Anesthesiology. 1999; 91: 951–61.[Medline] [Order article via Infotrieve]

58. Mangano DT, Martin E, Motsch J, et al. Perioperative sympatholysis: beneficial effects of the ainf 2-adrenoceptor agonist mivazerol on hemodynamic stability and myocardial ischemia. Anesthesiology. 1997; 86: 346–63.[CrossRef][Medline] [Order article via Infotrieve]

59. Stuhmeier KD, Mainzer B, Cierpka J, Sandmann W, Tarnow J. Small, oral dose of clonidine reduces the incidence of intraoperative myocardial ischemia in patients having vascular surgery. Anesthesiology. 1996; 85: 706–12.[CrossRef][Medline] [Order article via Infotrieve]

60. Ellis JE, Drijvers G, Pedlow S, et al. Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. Anesth Analg. 1994; 79: 1133–40.[Abstract/Free Full Text]

61. Leung JM, Goehner P, O’Kelly BF, et al. Isoflurane anesthesia and myocardial ischemia: comparative risk versus sufentanil anesthesia in patients undergoing coronary artery bypass graft surgery. The SPI (Study of Perioperative Ischemia) Research Group. Anesthesiology. 1991; 74: 838–47.[CrossRef][Medline] [Order article via Infotrieve]

62. Baron JF, Bertrand M, Barre E, et al. Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery. Anesthesiology. 1991; 75: 611–8.[CrossRef][Medline] [Order article via Infotrieve]

63. Christopherson R, Beattie C, Frank SM, et al. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993; 79: 422–34.[Medline] [Order article via Infotrieve]

64. Slogoff S, Keats AS. Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. Anesthesiology. 1989; 70: 179–88.[Medline] [Order article via Infotrieve]

65. Tuman KJ, McCarthy RJ, Spiess BD. Epidural anaesthesia and analgesia decreases postoperative hypercoagulability in high-risk vascular patients. Anesth Analg. 1990; 70: S414.

66. Parker SD, Breslow MJ, Frank SM, et al. Catecholamine and cortisol responses to lower extremity revascularization: correlation with outcome variables. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Crit Care Med. 1995; 23: 1954–61.[CrossRef][Medline] [Order article via Infotrieve]

67. Rosenfeld BA, Beattie C, Christopherson R, et al. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993; 79: 435–43.[Medline] [Order article via Infotrieve]

68. Coriat P, Daloz M, Bousseau D, Fusciardi J, Echter E, Viars P. Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous nitroglycerin. Anesthesiology. 1984; 61: 193–6.[Medline] [Order article via Infotrieve]

69. Dodds TM, Stone JG, Coromilas J, Weinberger M, Levy DG. Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia. Anesth Analg. 1993; 76: 705–13.[Abstract/Free Full Text]

70. Gallagher JD, Moore RA, Jose AB, Botros SB, Clark DL. Prophylactic nitroglycerin infusions during coronary artery bypass surgery. Anesthesiology. 1986; 64: 785–9.[Medline] [Order article via Infotrieve]

71. Thompson IR, Mutch WA, Culligan JD. Failure of intravenous nitroglycerin to prevent intraoperative myocardial ischemia during fentanyl-pancuronium anesthesia. Anesthesiology. 1984; 61: 385–93.[CrossRef][Medline] [Order article via Infotrieve]

72. Eisenberg MJ, London MJ, Leung JM, et al. Monitoring for myocardial ischemia during noncardiac surgery. A technology assessment of transesophageal echocardiography and 12-lead electrocardiography. The Study of Perioperative Ischemia Research Group. JAMA. 1992; 268: 210–6.[Abstract/Free Full Text]

73. London MJ, Tubau JF, Wong MG, et al. The natural history of segmental wall motion abnormalities in patients undergoing noncardiac surgery. S.P.I. Research Group. Anesthesiology. 1990; 73: 644–55.[Medline] [Order article via Infotrieve]

74. Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology. 1996; 84: 986–1006.[CrossRef][Medline] [Order article via Infotrieve]

75. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997; 277: 1127–34.[Abstract/Free Full Text]

76. Practice guidelines for pulmonary artery catheterization. A report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 1993; 78: 380–94.[Medline] [Order article via Infotrieve]

77. Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med. 1990; 323: 1781–8.[Abstract]

78. Raby KE, Barry J, Creager MA, Cook EF, Weisberg MC, Goldman L. Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery. JAMA. 1992; 268: 222–7.[Abstract/Free Full Text]

79. Landesberg G, Luria MH, Cotev S, et al. Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery. Lancet. 1993; 341: 715–9.[CrossRef][Medline] [Order article via Infotrieve]

80. Fleisher LA, Nelson AH, Rosenbaum SH. Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease. J Clin Anesh. 1995; 7: 97–102.[CrossRef][Medline] [Order article via Infotrieve]

81. Mangano DT, Browner WS, Hollenberg M, Li J, Tateo IM. Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA. 1992; 268: 233–9.[Abstract/Free Full Text]

82. Fleisher LA, Zielski MM, Schulman SP. Perioperative ST-segment depression is rare and may not indicate myocardial ischemia in moderate-risk patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth. 1997; 11: 155–9.[CrossRef][Medline] [Order article via Infotrieve]

83. Mathew JP, Fleisher LA, Rinehouse JA, et al. ST segment depression during labor and delivery. Anesthesiology. 1992; 77: 635–41.[CrossRef][Medline] [Order article via Infotrieve]

84. Palmer CM, Norris MC, Giudici MC, Leighton BL, DeSimone CA. Incidence of electrocardiographic changes during cesarean delivery under regional anesthesia. Anesth Analg. 1990; 70: 36–43.[Abstract/Free Full Text]

85. Adams JE,III, Sicard GA, Allen BT, et al. Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med. 1994; 330: 670–4.[Abstract/Free Full Text]

86. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW. Myocardial infarction after noncardiac surgery. Anesthesiology. 1998; 88: 572–8.[CrossRef][Medline] [Order article via Infotrieve]

87. Godet G, Ben Ayed S, Bernard M, et al. Cardiac troponin I cutoff values to predict postoperative cardiac complications after circulatory arrest and profound hypothermia. J Cardiothorac Vasc Anesth. 1999; 13: 272–5.[CrossRef][Medline] [Order article via Infotrieve]

88. Lee TH, Thomas EJ, Ludwig LE, et al. Troponin T as a marker for myocardial ischemia in patients undergoing major noncardiac surgery. Am J Cardiol. 1996; 77: 1031–6.[CrossRef][Medline] [Order article via Infotrieve]

89. Lopez-Jimenez F, Goldman L, Sacks DB, et al. Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data. J Am Coll Cardiol. 1997; 29: 1241–5.[Abstract]

90. Metzler H, Gries M, Rehak P, Lang T, Fruhwald S, Toller W. Perioperative myocardial cell injury: the role of troponins. Br J Anaesth. 1997; 78: 386–90.[Abstract/Free Full Text]

91. Charlson ME, MacKenzie CR, Ales K, Gold JP, Fairclough G, Jr. Surveillance for postoperative myocardial infarction after noncardiac operations. Surg Gynecol Obstet. 1988; 167: 404–14.

92. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995; 333: 1750–6.[Free Full Text]

93. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA. 1993; 269: 3015–23.[Abstract/Free Full Text]

94. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 1999; 33: 2092–197.[Free Full Text]

95. Smith SC, Blair SN, Criqui MH, et al. Preventing heart attack and death in patients with coronary disease. Circulation. 1995; 92: 2–4.

96. Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock L. Exercise standards. A statement for healthcare professionals from the American Heart Association. Circulation. 1995; 91: 580–615[Free Full Text]

GUIDELINES UPDATE

ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology

Lee A. Fleisher, Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliott Chaikof, Kirsten E. Fleischmann, William K. Freeman, James B. Froehlich, Edward K. Kasper, Judy R. Kersten, Barbara Riegel, John F. Robb, Sidney C. Smith, Jr, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, David P. Faxon, Valentin Fuster, Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce W. Lytle, Rick Nishimura, Richard L. Page, and Barbara Riegel
Circulation 2006 113: 2662-2674. [Extract] [Full Text]

This article has been cited by other articles:

				P. M. B. van Tilburg, H. Stam, H. C. Hoogsteden, and R. J. van Klaveren Pre-operative pulmonary evaluation of lung cancer patients: a review of the literature Eur. Respir. J., May 1, 2009; 33(5): 1206 - 1215. [Abstract] [Full Text] [PDF]

				D. N. Wijeysundera, P. C. Austin, W. S. Beattie, J. E. Hux, and A. Laupacis A Population-Based Study of Anesthesia Consultation Before Major Noncardiac Surgery Arch Intern Med, March 23, 2009; 169(6): 595 - 602. [Abstract] [Full Text] [PDF]

				L. T. Newsome, R. S. Weller, J. C. Gerancher, M. A. Kutcher, and R. L. Royster Coronary Artery Stents: II. Perioperative Considerations and Management Anesth. Analg., August 1, 2008; 107(2): 570 - 590. [Abstract] [Full Text] [PDF]

				G. Gregoratos Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery Circulation, June 17, 2008; 117(24): 3134 - 3144. [Full Text] [PDF]

				D. E. Jaroszewski, J. Huh, D. Chu, S. C. Malaisrie, A. D. Riffel, H. S. Gordon, X. L. Wang, and F. Bakaeen Utility of detailed preoperative cardiac testing and incidence of post-thoracotomy myocardial infarction J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 648 - 655. [Abstract] [Full Text] [PDF]

				M. D. Kertai Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery: A Core Review Anesth. Analg., March 1, 2008; 106(3): 751 - 758. [Abstract] [Full Text] [PDF]

				C. Marcassa, J. J. Bax, F. Bengel, B. Hesse, C. L. Petersen, E. Reyes, R. Underwood, and on behalf of the European Council of Nuclear Cardi Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy: a position statement Eur. Heart J., February 2, 2008; 29(4): 557 - 563. [Abstract] [Full Text] [PDF]

				T. Abe, M. Kajiyama, K. Ohara, M. Asaoka, M. Toyama, and A. Kobayashi Combined Coronary Artery Re-operation and Pulmonary Resection for Hemoptysis Asian Cardiovasc Thorac Ann, December 1, 2007; 15(6): e75 - e76. [Abstract] [Full Text] [PDF]

				N. Sutaria and J. Mayet Preoperative screening for coronary disease: who needs it and how do you do it? Heart, December 1, 2007; 93(12): 1497 - 1499. [Abstract] [Full Text] [PDF]

				T. Laitio, J. Jalonen, T. Kuusela, and H. Scheinin The Role of Heart Rate Variability in Risk Stratification for Adverse Postoperative Cardiac Events Anesth. Analg., December 1, 2007; 105(6): 1548 - 1560. [Abstract] [Full Text] [PDF]

				V Russo, V Gostoli, L Lovato, M Montalti, A Marzocchi, G Gavelli, A Branzi, R Di Bartolomeo, and R Fattori Clinical value of multidetector CT coronary angiography as a preoperative screening test before non-coronary cardiac surgery Heart, December 1, 2007; 93(12): 1591 - 1598. [Abstract] [Full Text] [PDF]

				J. W. Riddell, L. Chiche, B. Plaud, and M. Hamon Coronary Stents and Noncardiac Surgery Circulation, October 16, 2007; 116(16): e378 - e382. [Full Text] [PDF]

				P.-G. Chassot, A. Delabays, and D. R. Spahn Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction Br. J. Anaesth., September 1, 2007; 99(3): 316 - 328. [Abstract] [Full Text] [PDF]

				G. L. Colice, S. Shafazand, J. P. Griffin, R. Keenan, and C. T. Bolliger Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition) Chest, September 1, 2007; 132(3_suppl): 161S - 177S. [Abstract] [Full Text] [PDF]

				J. W. Sear and G. Howard-Alpe Preoperative plasma BNP concentrations: do they improve our care of high-risk non-cardiac surgical patients? Br. J. Anaesth., August 1, 2007; 99(2): 151 - 154. [Full Text] [PDF]

				L. G. Glance, T. M. Osler, D. B. Mukamel, and A. W. Dick Effect of complications on mortality after coronary artery bypass grafting surgery: Evidence from New York State J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 53 - 58. [Abstract] [Full Text] [PDF]

				P. S. Mueller, V. M. Montori, D. Bassler, B. A. Koenig, and G. H. Guyatt Ethical Issues in Stopping Randomized Trials Early Because of Apparent Benefit Ann Intern Med, June 19, 2007; 146(12): 878 - 881. [Abstract] [Full Text] [PDF]

				E. S. Brilakis, S. Banerjee, and P. B. Berger Perioperative Management of Patients With Coronary Stents J. Am. Coll. Cardiol., June 5, 2007; 49(22): 2145 - 2150. [Abstract] [Full Text] [PDF]

				Y. Le Manach, G. Godet, P. Coriat, C. Martinon, M. Bertrand, M.-H. Fleron, and B. Riou The Impact of Postoperative Discontinuation or Continuation of Chronic Statin Therapy on Cardiac Outcome After Major Vascular Surgery Anesth. Analg., June 1, 2007; 104(6): 1326 - 1333. [Abstract] [Full Text] [PDF]

				G. W. Smetana A 68-Year-Old Man With COPD Contemplating Colon Cancer Surgery JAMA, May 16, 2007; 297(19): 2121 - 2130. [Abstract] [Full Text] [PDF]

				G. M. Howard-Alpe, J. de Bono, L. Hudsmith, W. P. Orr, P. Foex, and J. W. Sear Coronary artery stents and non-cardiac surgery Br. J. Anaesth., May 1, 2007; 98(5): 560 - 574. [Abstract] [Full Text] [PDF]

				D. Poldermans, O. Schouten, R. Vidakovic, J. J. Bax, I. R. Thomson, S. E. Hoeks, H. H.H. Feringa, M. Dunkelgrun, P. de Jaegere, A. Maat, et al. A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients Undergoing Major Vascular Surgery: The DECREASE-V Pilot Study J. Am. Coll. Cardiol., May 1, 2007; 49(17): 1763 - 1769. [Abstract] [Full Text] [PDF]

				S. G. Memtsoudis, P. Rosenberger, and J. M. Walz Critical Care Issues in the Patient After Major Joint Replacement J Intensive Care Med, March 1, 2007; 22(2): 92 - 104. [Abstract] [PDF]

				L. A. Fleisher, L. R. Pasternak, and A. Lyles A Novel Index of Elevated Risk of Inpatient Hospital Admission Immediately Following Outpatient Surgery Arch Surg, March 1, 2007; 142(3): 263 - 268. [Abstract] [Full Text] [PDF]

				P. G Noordzij, E. Boersma, F. Schreiner, M. D Kertai, H. H H Feringa, M. Dunkelgrun, J. J Bax, J. Klein, and D. Poldermans Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery Eur. J. Endocrinol., January 1, 2007; 156(1): 137 - 142. [Abstract] [Full Text] [PDF]

				G. M. Howard-Alpe, J. W. Sear, and P. Foex Methods of detecting atherosclerosis in non-cardiac surgical patients; the role of biochemical markers Br. J. Anaesth., December 1, 2006; 97(6): 758 - 769. [Abstract] [Full Text] [PDF]

				O. Schouten, J. J Bax, and D. Poldermans Assessment of cardiac risk before non-cardiac general surgery Heart, December 1, 2006; 92(12): 1866 - 1872. [Full Text] [PDF]

				R. C. Hendel, M. R. Patel, C. M. Kramer, M. Poon, R. C. Hendel, J. C. Carr, N. A. Gerstad, L. D. Gillam, J. McB. Hodgson, R. J. Kim, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging: A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1475 - 1497. [Full Text] [PDF]

				D. Poldermans, J. J. Bax, O. Schouten, A. N. Neskovic, B. Paelinck, G. Rocci, L. van Dortmont, A. E.S. Durazzo, L. L.M. van de Ven, M. R.H.M. van Sambeek, et al. Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control? J. Am. Coll. Cardiol., September 5, 2006; 48(5): 964 - 969. [Abstract] [Full Text] [PDF]

				S C Chua, R H Ganatra, D J Green, and A M Groves Nuclear cardiology: myocardial perfusion imaging with SPECT and PET Imaging, September 1, 2006; 18(3): 166 - 177. [Abstract] [Full Text] [PDF]

				P. A. McCullough, M. J. Gallagher, A. T. deJong, K. R. Sandberg, J. E. Trivax, D. Alexander, G. Kasturi, S. M. A. Jafri, K. R. Krause, D. L. Chengelis, et al. Cardiorespiratory Fitness and Short-term Complications After Bariatric Surgery. Chest, August 1, 2006; 130(2): 517 - 525. [Abstract] [Full Text] [PDF]

				H. H.H. Feringa, J. J. Bax, E. Boersma, M. D. Kertai, S. H. Meij, W. Galal, O. Schouten, I. R. Thomson, P. Klootwijk, M. R.H.M. van Sambeek, et al. High-Dose {beta}-Blockers and Tight Heart Rate Control Reduce Myocardial Ischemia and Troponin T Release in Vascular Surgery Patients Circulation, July 4, 2006; 114(1_suppl): I-344 - I-349. [Abstract] [Full Text] [PDF]

				A. B. Juul, J. Wetterslev, C. Gluud, A. Kofoed-Enevoldsen, G. Jensen, T. Callesen, P. Norgaard, K. Fruergaard, M. Bestle, R. Vedelsdal, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ, June 24, 2006; 332(7556): 1482 - 1482. [Abstract] [Full Text] [PDF]

				D. R. Spahn, S. J. Howell, A. Delabays, and P.-G. Chassot Coronary stents and perioperative anti-platelet regimen: dilemma of bleeding and stent thrombosis. Br. J. Anaesth., June 1, 2006; 96(6): 675 - 677. [Full Text] [PDF]

				G. W. Smetana, V. A. Lawrence, and J. E. Cornell Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med, April 18, 2006; 144(8): 581 - 595. [Abstract] [Full Text] [PDF]

				A. T. Hirsch, Z. J. Haskal, N. R. Hertzer, C. W. Bakal, M. A. Creager, J. L. Halperin, L. F. Hiratzka, W. R.C. Murphy, J. W. Olin, J. B. Puschett, et al. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive Summary A Collaborative Report From the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation J. Am. Coll. Cardiol., March 21, 2006; 47(6): 1239 - 1312. [Full Text] [PDF]

				A. Auerbach and L. Goldman Assessing and Reducing the Cardiac Risk of Noncardiac Surgery Circulation, March 14, 2006; 113(10): 1361 - 1376. [Full Text] [PDF]

				M. J. London Beta-Blockade in the Perioperative Period: Where Do We Stand After All the Trials? Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 17 - 23. [Abstract] [PDF]

				H. H. H. Feringa, J. J. Bax, O. Schouten, and D. Poldermans Protecting the Heart with Cardiac Medication in Patients with Left Ventricular Dysfunction Undergoing Major Noncardiac Vascular Surgery Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 25 - 31. [Abstract] [PDF]

				C Berry, D Kingsmore, S Gibson, D Hole, J J Morton, D Byrne, and H J Dargie Predictive value of plasma brain natriuretic peptide for cardiac outcome after vascular surgery. Heart, March 1, 2006; 92(3): 401 - 402. [Full Text] [PDF]

				M. H. Shishehbor, D. Litaker, C. E. Pothier, and M. S. Lauer Association of Socioeconomic Status With Functional Capacity, Heart Rate Recovery, and All-Cause Mortality JAMA, February 15, 2006; 295(7): 784 - 792. [Abstract] [Full Text] [PDF]

				T. Theunissen, J. Coddens, L. Foubert, G. Cammu, I. Degrieck, and T. Deloof Intraoperative Severity Assessment of Coronary Artery Stenosis in Patients at Risk: The Role of Transesophageal Echocardiography Anesth. Analg., February 1, 2006; 102(2): 366 - 368. [Abstract] [Full Text] [PDF]

				M. Kikura, T. Takada, and S. Sato Preexisting Morbidity as an Independent Risk Factor for Perioperative Acute Thromboembolism Syndrome Arch Surg, December 1, 2005; 140(12): 1210 - 1217. [Abstract] [Full Text] [PDF]

				F. Bursi, L. Babuin, A. Barbieri, L. Politi, M. Zennaro, T. Grimaldi, A. Rumolo, M. Gargiulo, A. Stella, M. G. Modena, et al. Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation Eur. Heart J., November 2, 2005; 26(22): 2448 - 2456. [Abstract] [Full Text] [PDF]

				L. G. Futterman and L. Lemberg The Expanding Role of the HMG-CoA Reductase Inhibitor, The Most Widely Prescribed Drug in the World Am. J. Crit. Care., November 1, 2005; 14(6): 555 - 558. [Full Text] [PDF]

				R. G. Brindis, P. S. Douglas, R. C. Hendel, E. D. Peterson, M. J. Wolk, J. M. Allen, M. R. Patel, I. E. Raskin, R. C. Hendel, T. M. Bateman, et al. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI): A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology Endorsed by the American Heart Association J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1587 - 1605. [Full Text] [PDF]

				H.-J. Priebe Perioperative myocardial infarction--aetiology and prevention Br. J. Anaesth., July 1, 2005; 95(1): 3 - 19. [Abstract] [Full Text] [PDF]

				J. D. Blankensteijn, S. E.C.A. de Jong, M. Prinssen, A. C. van der Ham, J. Buth, S. M.M. van Sterkenburg, H. J.M. Verhagen, E. Buskens, D. E. Grobbee, and the Dutch Randomized Endovascular Aneurysm Managem Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms N. Engl. J. Med., June 9, 2005; 352(23): 2398 - 2405. [Abstract] [Full Text] [PDF]

				G. Tovey and J. P Thompson Anaesthesia for lower limb revascularization CEACCP, June 1, 2005; 5(3): 89 - 92. [Full Text] [PDF]

				P. Pullicino and J. Halperin Combining carotid endarterectomy with coronary bypass surgery: Is it worth the risk? Neurology, April 26, 2005; 64(8): 1332 - 1333. [Full Text] [PDF]

				M. D. Kertai, E. Boersma, J. Klein, H. van Urk, and D. Poldermans Optimizing the Prediction of Perioperative Mortality in Vascular Surgery by Using a Customized Probability Model Arch Intern Med, April 25, 2005; 165(8): 898 - 904. [Abstract] [Full Text] [PDF]

				G. Landesberg, M. Mosseri, L. A. Fleisher, J. Auer, G. Lamm, B. Eber, A. S. Brett, E. O. McFalls, H. B. Ward, T. Moritz, et al. Coronary Revascularization before Vascular Surgery N. Engl. J. Med., April 7, 2005; 352(14): 1492 - 1495. [Full Text] [PDF]

				T. N. Spackman, M. D. Abel, and T. T. Schlegel Twelve-Lead High-Frequency QRS Electrocardiography During Anesthesia in Healthy Subjects Anesth. Analg., April 1, 2005; 100(4): 1043 - 1047. [Abstract] [Full Text] [PDF]

				E. Marret and P. Albaladejo Are {beta}-Blockers Useful to Protect High-Risk Patients Scheduled for Open Cholecystectomy? Arch Intern Med, February 14, 2005; 165(3): 348 - 348. [Full Text] [PDF]

				M. Moscucci and K. A. Eagle Coronary Revascularization before Noncardiac Surgery N. Engl. J. Med., December 30, 2004; 351(27): 2861 - 2863. [Full Text] [PDF]

				H Becher, J Chambers, K Fox, R Jones, G J Leech, N Masani, M Monaghan, R More, P Nihoyannopoulos, H Rimington, et al. BSE procedure guidelines for the clinical application of stress echocardiography, recommendations for performance and interpretation of stress echocardiography: A report of the British Society of Echocardiography Policy Committee Heart, December 1, 2004; 90(suppl_6): vi23 - vi30. [Full Text] [PDF]

				B. J. Drew, R. M. Califf, M. Funk, E. S. Kaufman, M. W. Krucoff, M. M. Laks, P. W. Macfarlane, C. Sommargren, S. Swiryn, and G. F. Van Hare Practice Standards for Electrocardiographic Monitoring in Hospital Settings: An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses Circulation, October 26, 2004; 110(17): 2721 - 2746. [Abstract] [Full Text] [PDF]

				P Foex and J. Sear The surgical hypertensive patient CEACCP, October 1, 2004; 4(5): 139 - 143. [Abstract] [Full Text] [PDF]

				Task Force Members, J. Lopez-Sendo, K. Swedberg, J. McMurray, J. Tamargo, A. P. Maggioni, H. Dargie, M. Tendera, F. Waagstein, J. Kjekshus, et al. Expert consensus document on {beta}-adrenergic receptor blockers: The Task Force on Beta-Blockers of the European Society of Cardiology Eur. Heart J., August 1, 2004; 25(15): 1341 - 1362. [Full Text] [PDF]

				W. E. Hurford and A. Kratz Case 23-2004 - A 50-Year-Old Woman with Low Oxygen Saturation N. Engl. J. Med., July 22, 2004; 351(4): 380 - 387. [Full Text] [PDF]

				M. Zaugg, C. Schulz, J. Wacker, and M. C. Schaub Sympatho-modulatory therapies in perioperative medicine Br. J. Anaesth., July 1, 2004; 93(1): 53 - 62. [Abstract] [Full Text] [PDF]

				W. W. HERMAN, J. L. KONZELMAN JR., and L. M. PRISANT New national guidelines on hypertension: A summary for dentistry J Am Dent Assoc, May 1, 2004; 135(5): 576 - 584. [Abstract] [Full Text] [PDF]

				D. E. Newby and A. F. Nimmo Editorial II: Prevention of cardiac complications of non-cardiac surgery: stenosis and thrombosis Br. J. Anaesth., May 1, 2004; 92(5): 628 - 632. [Full Text] [PDF]

				C. Marcucci, P.-G. Chassot, J.-P. Gardaz, L. Magnusson, H.-B. Ris, A. Delabays, and D. R. Spahn Fatal myocardial infarction after lung resection in a patient with prophylactic preoperative coronary stenting{dagger} Br. J. Anaesth., May 1, 2004; 92(5): 743 - 747. [Abstract] [Full Text] [PDF]

				D. R. Spahn and H.-J. Priebe Editorial II: Preoperative hypertension: remain wary? 'Yes'--cancel surgery? 'No' Br. J. Anaesth., April 1, 2004; 92(4): 461 - 464. [Full Text] [PDF]

				G. K. Peel, S. C. Stamou, M. K. C. Dullum, P. C. Hill, K. A. Jablonski, A. S. Bafi, S. W. Boyce, K. R. Petro, and P. J. Corso Chronologic distribution of stroke after minimally invasive versus conventional coronary artery bypass J. Am. Coll. Cardiol., March 3, 2004; 43(5): 752 - 756. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, J. Feinglass, G. E. Reiber, R. A. Rodriguez, J. Daley, S. Khuri, W. G. Henderson, and K. L. Johansen Postoperative Mortality after Nontraumatic Lower Extremity Amputation in Patients with Renal Insufficiency J. Am. Soc. Nephrol., February 1, 2004; 15(2): 427 - 434. [Abstract] [Full Text] [PDF]

				M. J. Jacka, T. Schricker, B. Warriner, A. Boulton, R. Hudson, J. L. Parlow, B. Milne, and E. G. VanDenKerkhof More Conclusive Large-Scale Trials Necessary Before Recommending Use of Beta Blockade in Patients at Risk * Response Anesth. Analg., January 1, 2004; 98(1): 269 - 270. [Full Text] [PDF]

				C Anagnostopoulos, M Harbinson, A Kelion, K Kundley, C Y Loong, A Notghi, E Reyes, W Tindale, and S R Underwood Procedure guidelines for radionuclide myocardial perfusion imaging Heart, January 1, 2004; 90(90001): i1 - 10. [Full Text] [PDF]

				A. V. Chobanian, G. L. Bakris, H. R. Black, W. C. Cushman, L. A. Green, J. L. Izzo Jr, D. W. Jones, B. J. Materson, S. Oparil, J. T. Wright Jr, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Hypertension, December 1, 2003; 42(6): 1206 - 1252. [Abstract] [Full Text] [PDF]

				D. N. Wijeysundera and W. S. Beattie Calcium Channel Blockers for Reducing Cardiac Morbidity After Noncardiac Surgery: A Meta-Analysis Anesth. Analg., September 1, 2003; 97(3): 634 - 641. [Abstract] [Full Text] [PDF]

				G. Landesberg, M. Mosseri, Y. G. Wolf, M. Bocher, A. Basevitch, E. Rudis, U. Izhar, H. Anner, C. Weissman, and Y. Berlatzky Preoperative Thallium Scanning, Selective Coronary Revascularization, and Long-Term Survival After Major Vascular Surgery Circulation, July 15, 2003; 108(2): 177 - 183. [Abstract] [Full Text] [PDF]

				E. G. VanDenKerkhof, B. Milne, and J. L. Parlow Knowledge and Practice Regarding Prophylactic Perioperative Beta Blockade in Patients Undergoing Noncardiac Surgery: A Survey of Canadian Anesthesiologists Anesth. Analg., June 1, 2003; 96(6): 1558 - 1565. [Abstract] [Full Text] [PDF]

				A. M. O'Hare, J. Feinglass, A. N. Sidawy, P. Bacchetti, R. A. Rodriguez, J. Daley, S. Khuri, W. G. Henderson, and K. L. Johansen Impact of Renal Insufficiency on Short-Term Morbidity and Mortality after Lower Extremity Revascularization: Data from the Department of Veterans Affairs' National Surgical Quality Improvement Program J. Am. Soc. Nephrol., May 1, 2003; 14(5): 1287 - 1295. [Abstract] [Full Text] [PDF]

				K. De Decker, P. G. Jorens, and P. Van Schil Cardiac complications after noncardiac thoracic surgery: an evidence-based current review Ann. Thorac. Surg., April 1, 2003; 75(4): 1340 - 1348. [Abstract] [Full Text] [PDF]

				P.-G. Chassot, A. Delabays, and D. R. Spahn Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery Br. J. Anaesth., November 1, 2002; 89(5): 747 - 759. [Abstract] [Full Text] [PDF]

				B. Iung, C. Gohlke-Barwolf, P. Tornos, C. Tribouilloy, R. Hall, E. Butchart, and A. Vahanian Recommendations on the management of the asymptomatic patient with valvular heart disease Eur. Heart J., August 2, 2002; 23(16): 1253 - 1266. [PDF]

				S. K. Ahlawat and M.-T. Cuddihy 71-Year-Old Woman With Low Back Pain Mayo Clin. Proc., August 1, 2002; 77(8): 849 - 852. [PDF]

This Article Free upon publication Extract Full Text (PDF) Correction (v113,pe846) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eagle, K. A. Articles by Smith, S. C. Search for Related Content PubMed PubMed Citation Articles by Eagle, K. A. Articles by Smith, S. C., Jr Related Collections Other etiology AHA Statements and Guidelines CV surgery: other A GUIDELINES UPDATE HAS BEEN ISSUED