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(Circulation. 2007;116:1971-1996.)
© 2007 American Heart Association, Inc.

ACC/AHA Guideline

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

WRITING COMMITTEE: Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC^¶; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD^#; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC^*; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC^||

	Introduction

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 

Preamble...1972

   I. Definition of the Problem...1974

      A. Purpose of These Guidelines...1974

      B. Methodology and Evidence...1974

   II. General Approach to the Patient...1977

      A. History...1978

      B. Physical Examination and Routine Laboratory Tests...1979

      C. Multivariable Indices to Predict Preoperative Cardiac Morbidity...1979

      D. Clinical Assessment...1979

         1. Stepwise Approach to Perioperative Cardiac Assessment...1980

   III. Disease-Specific Approaches...1981

      A. Coronary Artery Disease...1981

         1. Patients With Known CAD...1981

      B. Hypertension...1981

      C. Valvular Heart Disease...1982

   IV. Surgery-Specific Issues...1982

   V. Supplemental Preoperative Evaluation...1982

      A. Assessment of LV Function...1982

      B. Assessment of Risk for CAD and Assessment of Functional Capacity...1982

         1. The 12-Lead ECG...1982

         2. Exercise Stress Testing for Myocardial Ischemia and Functional Capacity...1982

         3. Noninvasive Stress Testing...1983

   VI. Perioperative Therapy...1983

      A. Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or PCI...1983

         1. Preoperative Coronary Artery Bypass Grafting...1983

         2. Preoperative PCI ...1983

         3. PCI Without Stents: Coronary Balloon Angioplasty...1983

         4. PCI: Bare-Metal Coronary Stents...1983

         5. PCI: Drug-Eluting Stents...1984

         6. Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery...1984

         7. Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy...1985

         8. Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery...1985

      B. Perioperative Medical Therapy...1986

         1. Perioperative Beta-Blocker Therapy...1986

            a. Titration of Beta Blockers...1986

            b. Withdrawal of Beta Blockers...1986

         2. Perioperative Statin Therapy...1986

         3. Alpha-2 Agonists...1986

         4. Perioperative Calcium Channel Blockers...1986

      C. Intraoperative Electromagnetic Interference With Implanted Pacemakers and Cardioverter Defibrillators...1986

   VII. Anesthetic Considerations and Intraoperative Management...1987

      A. Intraoperative Management...1987

      B. Perioperative Pain Management...1987

   VIII. Perioperative Surveillance...1987

      A. Intraoperative and Postoperative Use of Pulmonary Artery Catheters...1987

      B. Surveillance for Perioperative MI...1987

   IX. Postoperative and Long-Term Management...1988

      A. Myocardial Infarction: Surveillance and Treatment...1988

      B. Long-Term Management...1988

   X. Conclusions...1988

   Appendix I...1989

   Appendix II...1990

   Appendix III...1994

	Preamble

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting the absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

The American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop, update, or revise written recommendations for clinical practice.

Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of particular tests or therapies are considered, as well as frequency of follow-up and cost-effectiveness. When available, information from studies on cost will be considered; however, review of data on efficacy and clinical outcomes will constitute the primary basis for preparing recommendations in these guidelines.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflicts of interest that may arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that may be perceived as real or potential conflicts of interest. Writing committee members are also strongly encouraged to declare a previous relationship with industry that may be perceived as relevant to guideline development. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. The continued participation of the writing committee member will be reviewed. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please refer to the methodology manual for ACC/AHA guideline writing committees, available on the ACC and AHA World Wide Web sites (http://www.acc.org/qualityandscience/clinical/manual/manual_I.htm and http://circ.ahajournals.org/manual/), for further description of the policy on relationships with industry. Please see Appendix I for author relationships with industry and Appendix II for peer reviewer relationships with industry that are pertinent to these guidelines.

These practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care.

Patient adherence to prescribed and agreed on medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations will only be effective if they are followed. Because lack of patient understanding and adherence may adversely affect treatment outcomes, physicians and other healthcare providers should make every effort to engage the patient in active participation with prescribed medical regimens and lifestyles.

If these guidelines are used as the basis for regulatory or payer decisions, the ultimate goal is quality of care and serving the patient’s best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient. There are circumstances in which deviations from these guidelines are appropriate.

The guidelines will be reviewed annually by the ACC/AHA Task Force on Practice Guidelines and will be considered current unless they are updated, revised, or sunsetted and withdrawn from distribution. The executive summary and recommendations are published in the October 23, 2007, issue of the Journal of the American College of Cardiology and October 23, 2007, issue of Circulation. The full text-guidelines are e-published in the same issue of the journals noted above, as well as posted on the ACC (www.acc.org) and AHA (www.americanheart.org) Web sites. Copies of the full text and the executive summary are available from both organizations.

Sidney C. Smith, Jr, MD, FACC, FAHA Chair, ACC/AHA Task Force on Practice Guidelines

Alice K. Jacobs, MD, FACC, FAHA Vice Chair, ACC/AHA Task Force on Practice Guidelines

	I. Definition of the Problem

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
A. Purpose of These Guidelines
These guidelines represent an update to those published in 2002 and are intended for physicians and nonphysician caregivers 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 writing committee that prepared these guidelines strove to incorporate what is currently known about perioperative risk and how this knowledge can be used in the individual patient.

The tables and algorithms provide quick references for decision making. The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. The purpose of preoperative evaluation is not 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 and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. No test should be performed unless it is likely to influence patient treatment. The goal of the consultation is the optimal care of the patient.

B. Methodology and Evidence
The ACC/AHA Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery conducted a comprehensive review of the literature relevant to perioperative cardiac evaluation published since the last publication of these guidelines in 2002. Literature searches were conducted in the following databases: PubMed, MEDLINE, and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register). Searches were limited to the English language, the years 2002 through 2007, and human subjects. Related-article searches were conducted in MEDLINE to find additional relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches.

All of the recommendations in this guideline update were converted from the tabular format used in the 2002 guidelines to a listing of recommendations that has been written in full sentences to express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document, would still convey the full intent of the recommendation. It is hoped that this will increase the reader’s comprehension of the guidelines. Also, the level of evidence, either an A, B, or C, for each recommendation is now provided (Table 1).

View larger version (57K): [in this window] [in a new window]   Table 1. Applying classification of recommendations and level of evidence.

Recommendations
Recommendations for Preoperative Noninvasive Evaluation of Left Ventricular Function

Class IIa

1. It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of left ventricular (LV) function. (Level of Evidence: C)
   
2. It is reasonable for patients with current or prior heart failure with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months. (Level of Evidence: C)
   

Class IIb

1. Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (Level of Evidence: C)
   

Class III

1. Routine perioperative evaluation of LV function in patients is not recommended. (Level of Evidence: B)
   

Recommendations for Preoperative Resting 12-Lead ECG

Class I

1. Preoperative resting 12-lead ECG is recommended for patients with at least 1 clinical risk factor^* who are undergoing vascular surgical procedures. (Level of Evidence: B)
   
2. Preoperative resting 12-lead ECG is recommended for patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (Level of Evidence: C)
   

Class IIa

1. Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are under-going vascular surgical procedures. (Level of Evidence: B)
   

Class IIb

1. Preoperative resting 12-lead ECG may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (Level of Evidence: B)
   

Class III

1. Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (Level of Evidence: B)
   

Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery

Class I

1. Patients with active cardiac conditions (Table 2) in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines before noncardiac surgery. (Level of Evidence: B)
   

Class IIa

1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 metabolic equivalents [METs]) who require vascular surgery is reasonable if it will change management. (Level of Evidence: B)
   

Class IIb

1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B)
   
2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (Level of Evidence: B)
   

Class III

1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery. (Level of Evidence: C)
   
2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence: C)
   

Recommendations for Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention
(All of the Class I indications below are consistent with the ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery.)

Class I

1. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have significant left main coronary artery stenosis. (Level of Evidence: A)
   
2. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 3-vessel disease. (Survival benefit is greater when left ventricular ejection fraction is less than 0.50.) (Level of Evidence: A)
   
3. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 2-vessel disease with significant proximal left anterior descending stenosis and either ejection fraction less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of Evidence: A)
   
4. Coronary revascularization before noncardiac surgery is recommended for patients with high-risk unstable angina or non–ST-segment elevation myocardial infarction (MI). (Level of Evidence: A)
   
5. Coronary revascularization before noncardiac surgery is recommended in patients with acute ST-elevation MI. (Level of Evidence: A)
   

Class IIa

1. In patients in whom coronary revascularization with percutaneous coronary intervention (PCI) is appropriate for mitigation of cardiac symptoms and who need elective noncardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is probably indicated. (Level of Evidence: B)
   
2. In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Level of Evidence: C)
   

Class IIb

1. The usefulness of preoperative coronary revascularization is not well established in high-risk ischemic patients (eg, abnormal dobutamine stress echocardiogram with at least 5 segments of wall-motion abnormalities). (Level of Evidence: C)
   
2. The usefulness of preoperative coronary revascularization is not well established for low-risk ischemic patients with an abnormal dobutamine stress echocardiogram (segments 1 to 4). (Level of Evidence: B)
   

Class III

1. It is not recommended that routine prophylactic coronary revascularization be performed in patients with stable coronary artery disease (CAD) before noncardiac surgery. (Level of Evidence: B)
   
2. Elective noncardiac surgery is not recommended within 4 to 6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy or aspirin and thienopyridine therapy will need to be discontinued perioperatively. (Level of Evidence: B)
   
3. Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. (Level of Evidence: B)
   

Recommendations for Beta-Blocker Medical Therapy^||

Class I

1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications. (Level of Evidence: C)
   
2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level of Evidence: B)
   

Class IIa

1. Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative assessment identifies coronary heart disease. (Level of Evidence: B)
   
2. Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.^* (Level of Evidence: B)
   
3. Beta blockers are probably recommended for patients in whom preoperative assessment identifies coronary heart disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,^* who are undergoing intermediate-risk or vascular surgery. (Level of Evidence: B)
   

Class IIb

1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.^* (Level of Evidence: C)
   
2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers. (Level of Evidence: B)
   

Class III

1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)
   

Recommendations for Statin Therapy

Class I

1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B)
   

Class IIa

1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B)
   

Class IIb

1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (Level of Evidence: C)
   

Recommendations for Alpha-2 Agonists

Class IIb

1. Alpha-2 agonists for perioperative control of hypertension may be considered for patients with known CAD or at least 1 clinical risk factor who are undergoing surgery. (Level of Evidence: B)
   

Class III

1. Alpha-2 agonists should not be given to patients undergoing surgery who have contraindications to this medication. (Level of Evidence: C)
   

Recommendation for Preoperative Intensive Care Monitoring

Class IIb

1. Preoperative intensive care monitoring with a pulmonary artery catheter for optimization of hemodynamic status might be considered; however, it is rarely required and should be restricted to a very small number of highly selected patients whose presentation is unstable and who have multiple comorbid conditions. (Level of Evidence: B)
   

Recommendations for Use of Volatile Anesthetic Agents

Class IIa

1. It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. (Level of Evidence: B)
   

Recommendation for Prophylactic Intraoperative Nitroglycerin

Class IIb

1. The usefulness of intraoperative nitroglycerin as a prophylactic agent to prevent myocardial ischemia and cardiac morbidity is unclear for high-risk patients undergoing noncardiac surgery, particularly those who have required nitrate therapy to control angina. The recommendation for prophylactic use of nitroglycerin must take into account the anesthetic plan and patient hemodynamics and must recognize that vasodilation and hypovolemia can readily occur during anesthesia and surgery. (Level of Evidence: C)
   

Recommendation for Use of Transesophageal Echocardiography

Class IIa

1. The emergency use of intraoperative or perioperative transesophageal echocardiography is reasonable to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality. (Level of Evidence: C)
   

Recommendation for Maintenance of Body Temperature

Class I

1. Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (eg, during high aortic cross-clamping). (Level of Evidence: B)
   

Recommendations for Perioperative Control of Blood Glucose Concentration

Class IIa

1. It is reasonable that blood glucose concentration be controlled^¶ during the perioperative period in patients with diabetes mellitus or acute hyperglycemia who are at high risk for myocardial ischemia or who are undergoing vascular and major noncardiac surgical procedures with planned intensive care unit admission. (Level of Evidence: B)
   

Class IIb

1. The usefulness of strict control of blood glucose concentration^¶ during the perioperative period is uncertain in patients with diabetes mellitus or acute hyperglycemia who are undergoing noncardiac surgical procedures without planned intensive care unit admission. (Level of Evidence: C)
   

Recommendations for Perioperative Use of Pulmonary Artery Catheters

Class IIb

1. Use of a pulmonary artery catheter may be reasonable in patients at risk for major hemodynamic disturbances that are easily detected by a pulmonary artery catheter; however, the decision must be based on 3 parameters: patient disease, surgical procedure (ie, intraoperative and postoperative fluid shifts), and practice setting (experience in pulmonary artery catheter use and interpretation of results), because incorrect interpretation of the data from a pulmonary artery catheter may cause harm. (Level of Evidence: B)
   

Class III

1. Routine use of a pulmonary artery catheter perioperatively, especially in patients at low risk of developing hemodynamic disturbances, is not recommended. (Level of Evidence: A)
   

Recommendations for Intraoperative and Postoperative Use of ST-Segment Monitoring

Class IIa

1. Intraoperative and postoperative ST-segment monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, with computerized ST-segment analysis, when available, used to detect myocardial ischemia during the perioperative period. (Level of Evidence: B)
   

Class IIb

1. Intraoperative and postoperative ST-segment monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery. (Level of Evidence: B)
   

Recommendations for Surveillance for Perioperative MI

Class I

1. Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome. (Level of Evidence: C)
   

Class IIb

1. The use of postoperative troponin measurement is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery. (Level of Evidence: C)
   

Class III

1. Postoperative troponin measurement is not recommended in asymptomatic stable patients who have undergone low-risk surgery. (Level of Evidence: C)
   

	II. General Approach to the Patient

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
This guideline focuses on the evaluation of the patient undergoing noncardiac surgery who is at risk for perioperative cardiac morbidity or mortality. In patients with known CAD or the new onset of signs or symptoms suggestive of CAD, baseline cardiac assessment should be performed. In the asymptomatic patient, a more extensive assessment of history and physical examination is warranted in those individuals 50 years of age or older, because the evidence related to the determination of cardiac risk factors and derivation of a revised cardiac risk index occurred in this population.⁸ Preoperative cardiac evaluation must therefore be carefully tailored to the circumstances that have prompted the evaluation and to the nature of the surgical illness. In patients in whom coronary revascularization is not an option, it is often not necessary to perform a noninvasive stress test. Under other, less urgent circumstances, the preoperative cardiac evaluation may lead to a variety of responses, including cancellation of an elective procedure.

If a consultation is requested, then it is important to identify the key questions and ensure that all of the perioperative caregivers are considered when providing a response. Once a consultation has been obtained, the consultant should review available patient data, obtain a history, and perform a physical examination that includes a comprehensive cardiovascular examination and elements pertinent to the patient’s problem and the proposed surgery. A critical role of the consultant is to determine the stability of the patient’s cardiovascular status and whether the patient is in optimal medical condition within the context of the surgical illness. The consultant may recommend changes in medication, suggest preoperative tests or procedures, or propose higher levels of care postoperatively. In general, preoperative tests are recommended only if the information obtained will result in a change in the surgical procedure performed, a change in medical therapy or monitoring during or after surgery, or a postponement of surgery until the cardiac condition can be corrected or stabilized.

The consultant must also bear in mind that the perioperative evaluation may be the ideal opportunity to effect the long-term treatment of a patient with significant cardiac disease or risk of such disease. The referring physician and patient should be informed of the results of the evaluation and implications for the patient’s prognosis. It is the cardiovascular consultant’s responsibility to ensure clarity of communication so that findings and impressions will be incorporated effectively into the patient’s overall plan of care. This ideally would include direct communication with the surgeon, anesthesiologist, and other physicians, as well as frank discussion directly with the patient and, if appropriate, the family. The consultant should not use phrases such as "clear for surgery."

A. History
A careful history is crucial to the discovery of cardiac and/or comorbid diseases that would place the patient in a high surgical risk category. The history should seek to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent or past MI, decompensated heart failure, significant arrhythmias, and severe valvular disease (Table 2). It should also determine whether the patient has a prior history of a pacemaker or implantable cardioverter defibrillator (ICD) or a history of orthostatic intolerance and should identify risk factors associated with increased perioperative cardiovascular risk. In patients with established cardiac disease, any recent change in symptoms must be ascertained. Accurate recording of current medications used, including herbal and other nutritional supplements, and dosages is essential. Use of alcohol, tobacco, and over-the-counter and illicit drugs should be documented.

The history should also seek to determine the patient’s functional capacity (Table 3). An assessment of an individual’s capacity to perform a spectrum of common daily tasks has been shown to correlate well with maximum oxygen uptake by treadmill testing.¹⁰ A patient classified as high risk owing to age or known CAD but who is asymptomatic and runs for 30 minutes daily may need no further evaluation. In contrast, a sedentary patient without a history of cardiovascular disease but with clinical factors that suggest increased perioperative risk may benefit from a more extensive preoperative evaluation.^12–15

B. Physical Examination and Routine Laboratory Tests
A careful cardiovascular examination should include an assessment of vital signs (including measurement of blood pressure in both arms), carotid pulse contour and bruits, jugular venous pressure and pulsations, auscultation of the lungs, precordial palpation and auscultation, abdominal palpation, and examination of the extremities for edema and vascular integrity.

Anemia imposes a stress on the cardiovascular system that may exacerbate myocardial ischemia and aggravate heart failure.¹⁶ Hematocrits of less than 28% are associated with an increased incidence of perioperative ischemia and postoperative complications in patients undergoing prostate and vascular surgery.^16–18

C. Multivariable Indices to Predict Preoperative Cardiac Morbidity
The basic clinical evaluation obtained by history, physical examination, and review of the ECG usually provides the consultant with sufficient data to estimate cardiac risk. Lee et al.⁸ derived and validated a "simple index" for the prediction of cardiac risk for stable patients undergoing nonurgent major noncardiac surgery. Six independent risk correlates were identified: ischemic heart disease (defined as history of MI, history of positive treadmill test, use of nitroglycerin, current complaints of chest pain thought to be secondary to coronary ischemia, or ECG with abnormal Q waves); congestive heart failure (defined as history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, bilateral rales, S₃, or chest radiograph with pulmonary vascular redistribution); cerebral vascular disease (history of transient ischemic attack or stroke); high-risk surgery (abdominal aortic aneurysm or other vascular, thoracic, abdominal, or orthopedic surgery); preoperative insulin treatment for diabetes mellitus; and preoperative creatinine greater than 2 mg per dL. Increasing numbers of risk factors correlated with increased risk, yet the risk was substantially lower than described in many of the original indices.⁸ The Revised Cardiac Risk Index has become one of the most widely used risk indices.⁸

D. Clinical Assessment
In the original guidelines, the committee chose to segregate clinical risk factors into major, intermediate, and minor risk factors. There continues to be a group of active cardiac conditions that when present indicate major clinical risk. The presence of 1 or more of these conditions mandates intensive management and may result in delay or cancellation of surgery unless the surgery is emergent (Table 2). These include

• unstable coronary syndromes,

      unstable or severe angina,
  

      recent MI,
  

  
  
• decompensated heart failure,
  
• significant arrhythmias, and
  
• severe valvular disease.
  

Given the increasing use of the Revised Cardiac Risk Index, the committee chose to replace the intermediate-risk category with the clinical risk factors from the index, with the exclusion of the type of surgery, which is incorporated elsewhere in the approach to the patient. Clinical risk factors include

• history of heart disease,
  
• history of compensated or prior heart failure,
  
• history of cerebrovascular disease,
  
• diabetes mellitus, and
  
• renal insufficiency.⁸
  

A history of MI or abnormal Q waves by ECG is listed as a clinical risk factor, whereas an acute MI (defined as at least 1 documented MI 7 days or less 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 an active cardiac condition. This definition reflects the consensus of the ACC Cardiovascular Database Committee. Minor predictors are recognized markers for cardiovascular disease that have not been proven to independently increase perioperative risk, for example, advanced age (greater than 70 years), abnormal ECG (LV hypertrophy, left bundle-branch block, ST-T abnormalities), rhythm other than sinus, and uncontrolled systemic hypertension. The presence of multiple minor predictors might lead to a higher suspicion of CAD but is not incorporated into the recommendations for treatment.

1. Stepwise Approach to Perioperative Cardiac Assessment
Figure 1 presents in algorithmic form a framework for determining which patients are candidates for cardiac testing. Since publication of the perioperative cardiovascular evaluation guidelines in 2002,¹⁹ several new randomized trials and cohort studies have led to modification of the original algorithm. Given the availability of this evidence, the Writing Committee chose to include the level of the recommendations and strength of evidence for many of the pathways.

View larger version (13K): [in this window] [in a new window]   Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical conditions. See Table 3 for estimated MET level equivalent. Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. Consider perioperative beta blockade (see Table 5) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent.

Step 1: The consultant should determine the urgency of noncardiac surgery. In many instances, patient- or surgery-specific factors dictate an obvious strategy (eg, emergent surgery) that may not allow for further cardiac assessment or treatment. In such cases, the consultant may function best by providing recommendations for perioperative medical management and surveillance.

Step 2: Does the patient have 1 of the active cardiac conditions or clinical risk factors listed in Table 2? If not, proceed to Step 3. In patients being considered for elective noncardiac surgery, the presence of unstable coronary disease, decompensated heart failure, or severe arrhythmia or valvular heart disease usually leads to cancellation or delay of surgery until the cardiac problem has been clarified and treated appropriately. Examples of unstable coronary syndromes include previous MI with evidence of important ischemic risk by clinical symptoms or noninvasive study, unstable or severe angina, and new or poorly controlled ischemia-mediated heart failure. Many patients in these circumstances are referred for coronary angiography to assess further therapeutic options. Depending on the results of the test or interventions and the risk of delaying surgery, it may be appropriate to proceed to the planned surgery with maximal medical therapy.

Step 3: Is the patient undergoing low-risk surgery? In these patients, interventions based on cardiovascular testing in stable patients would rarely result in a change in management, and it would be appropriate to proceed with the planned surgical procedure.

Step 4: Does the patient have good functional capacity without symptoms? In highly functional asymptomatic patients, management will rarely be changed on the basis of results of any further cardiovascular testing. It is therefore appropriate to proceed with the planned surgery. In patients with known cardiovascular disease or at least 1 clinical risk factor, perioperative heart rate control with beta blockade appears appropriate as outlined in Section VI.B.

If the patient has not had a recent exercise test, functional status can usually be estimated from the ability to perform activities of daily living.²⁰ For this purpose, functional capacity has been classified as excellent (greater than 10 METs), good (7 to 10 METs), moderate (4 to 7 METs), poor (less than 4 METs), or unknown. The Duke Activity Status Index (Table 3) contains questions that can be used to estimate the patient’s functional capacity.²¹

Step 5: If the patient has poor functional capacity, is symptomatic, or has unknown functional capacity, then the presence of active clinical risk factors will determine the need for further evaluation. If the patient has no clinical risk factors, then it is appropriate to proceed with the planned surgery, and no further change in management is indicated.

If the patient has 1 or 2 clinical risk factors, then it is reasonable either to proceed with the planned surgery or, if appropriate, with heart rate control with beta blockade, or to consider testing if it will change management. In patients with 3 or more clinical risk factors, the surgery-specific cardiac risk is important.

The surgery-specific cardiac risk (Table 4) of noncardiac surgery is related to 2 important factors. First, the type of surgery itself may identify a patient with a greater likelihood of underlying heart disease and higher perioperative morbidity and mortality. Perhaps the most extensively studied example is vascular surgery, in which underlying CAD is present in a substantial portion of patients. If the patient is undergoing vascular surgery, recent studies suggest that testing should only be considered if it will change management. Other types of surgery may be associated with similar risk to vascular surgery but have not been studied extensively. In nonvascular surgery in which the perioperative morbidity related to the procedures ranges from 1% to 5% (intermediate-risk surgery), there are insufficient data to determine the best strategy (proceeding with the planned surgery with tight heart rate control with beta blockade or further cardiovascular testing if it will change management).

	III. Disease-Specific Approaches

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
A. Coronary Artery Disease
1. Patients With Known CAD
In patients with known CAD, as well as those with previously occult coronary disease, the questions become 1) What is the amount of myocardium in jeopardy? 2) What is the ischemic threshold, that is, the amount of stress required to produce ischemia? 3) What is the patient’s ventricular function? and 4) Is the patient on his or her optimal medical regimen? Clarification of these questions is an important goal of the preoperative history and physical examination, and selected noninvasive testing is used to determine the patient’s prognostic gradient of ischemic response during stress testing.

B. Hypertension
For 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), the potential benefits of delaying surgery to optimize the effects of antihypertensive medications should be weighed against the risk of delaying the surgical procedure. With rapidly acting intravenous agents, blood pressure can usually be controlled within a matter of several hours. One randomized trial was unable to demonstrate a benefit to delaying surgery in chronically treated hypertensive patients who presented for noncardiac surgery with diastolic blood pressure between 110 and 130 mm Hg and who had no previous MI, unstable or severe angina pectoris, renal failure, pregnancy-induced hypertension, LV hypertrophy, previous coronary revascularization, aortic stenosis, preoperative dysrhythmias, conduction defects, or stroke.²³

Several authors have suggested withholding angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists the morning of surgery.^24–26 Consideration should be given to restarting angiotensin-converting enzyme inhibitors in the postoperative period only after the patient is euvolemic, to decrease the risk of perioperative renal dysfunction.

C. Valvular Heart Disease
In symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery. If the aortic stenosis is severe but asymptomatic, the surgery should be postponed or canceled if the valve has not been evaluated within the year. On the other hand, in patients with severe aortic stenosis who refuse cardiac surgery or are otherwise not candidates for aortic valve replacement, noncardiac surgery can be performed with a mortality risk of approximately 10%.^27,28 If a patient is not a candidate for valve replacement, percutaneous balloon aortic valvuloplasty may be reasonable as a bridge to surgery in hemodynamically unstable adult patients with aortic stenosis who are at high risk for aortic valve replacement surgery and may be reasonable in adult patients with aortic stenosis in whom aortic valve replacement cannot be performed because of serious comorbid conditions.^6,29

Significant mitral stenosis increases the risk of heart failure. However, preoperative surgical correction of mitral valve disease is not indicated before noncardiac surgery, unless the valvular condition should be corrected to prolong survival and prevent complications unrelated to the proposed noncardiac surgery. When the stenosis is severe, the patient may benefit from balloon mitral valvuloplasty or open surgical repair before high-risk surgery.³⁰

In patients with persistent or permanent atrial fibrillation who are at high risk for thromboembolism, preoperative and postoperative therapy with intravenous heparin or subcutaneous low-molecular-weight heparin may be considered to cover periods of subtherapeutic anticoagulation.^1,31–33

Patients with a mechanical prosthetic valve are of concern because of the need for endocarditis prophylaxis³⁴ when they undergo surgery that may result in bacteremia and the need for careful anticoagulation management. The Seventh American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy³⁵ recommends the following: for patients who require minimally invasive procedures (dental work, superficial biopsies), the recommendation is to briefly reduce the international normalized ratio to the low or subtherapeutic range and resume the normal dose of oral anticoagulation immediately after the procedure. Perioperative heparin therapy is recommended for patients in whom the risk of bleeding with oral anticoagulation is high and the risk of thromboembolism without anticoagulation is also high (mechanical valve in the mitral position; Bjork-Shiley valve; recent [ie, less than 1 year] thrombosis or embolus; or 3 or more of the following risk factors: atrial fibrillation, previous embolus at any time, hypercoagulable condition, mechanical prosthesis, and LV ejection fraction less than 30%).³⁶ For patients between these 2 extremes, physicians must assess the risk and benefit of reduced anticoagulation versus perioperative heparin therapy.

	IV. Surgery-Specific Issues

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
Although different operations are associated with different cardiac risks, these differences are most often a reflection of the context in which the patient undergoes surgery (stability or opportunity for adequate preoperative preparation), surgery-specific factors (eg, fluid shifts, stress levels, duration of procedure, or blood loss), or patient-specific factors (the incidence of CAD associated with the condition for which the patient is undergoing surgery). The surgical procedures have been classified as low risk, high risk, and vascular. Although coronary disease is the overwhelming risk factor for perioperative morbidity, procedures with different levels of stress are associated with different levels of morbidity and mortality. Superficial and ophthalmologic procedures represent the lowest risk and are rarely associated with excess morbidity and mortality. Major vascular procedures represent the highest-risk procedures and are now considered distinctly in the decision to perform further evaluation because of the large body of evidence regarding the value of perioperative interventions in this population (Figure 1). Both endovascular aortic aneurysm repair and carotid endarterectomy should be considered within the intermediate-risk category, distinct from the open vascular surgery procedures, on the basis of their preoperative morbidity and mortality rates, but clinicians should incorporate the similarly poor long-term survival rates that accompany these procedures into their decision-making processes. Within the intermediate-risk category, morbidity and mortality vary depending on the surgical location and extent of the procedure. Some procedures may be short, with minimal fluid shifts, whereas others may be associated with prolonged duration, large fluid shifts, and greater potential for postoperative myocardial ischemia and respiratory depression. Therefore, the physician must exercise judgment to correctly assess perioperative surgical risks and the need for further evaluation.

	V. Supplemental Preoperative Evaluation

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
A. Assessment of LV Function
Resting LV function has been evaluated preoperatively before noncardiac surgery by radionuclide angiography, echocardiography, and contrast ventriculography. It is noteworthy that resting LV function was not found to be a consistent predictor of perioperative ischemic events.

B. Assessment of Risk for CAD and Assessment of Functional Capacity
1. The 12-Lead ECG
Although the optimal time interval between obtaining a 12-lead ECG and elective surgery is unknown, general consensus suggests that an ECG within 30 days of surgery is adequate for those with stable disease in whom a preoperative ECG is indicated.

2. Exercise Stress Testing for Myocardial Ischemia and Functional Capacity
The aim of supplemental preoperative testing is to provide an objective measure of functional capacity, to identify the presence of important preoperative myocardial ischemia or cardiac arrhythmias, and to estimate perioperative cardiac risk and long-term prognosis.

3. Noninvasive Stress Testing
Pharmacological stress with vasodilators or adrenergic stimulation in conjunction with radionuclide or echocardiographic cardiac imaging has been shown to predict perioperative cardiac events in patients scheduled for noncardiac surgery who are unable to exercise.³⁷ Importantly, perioperative cardiac risk is directly related to the extent of jeopardized viable myocardium identified by stress cardiac imaging.³⁷

The expertise of the practitioner’s available stress laboratory resources in identifying severe coronary disease is as important as the particular type of stress test ordered. For patients with unstable myocardial ischemia, who are at high risk for noncardiac surgery, it is usually appropriate to proceed with coronary angiography or to attempt to stabilize them with aggressive medical treatment rather than to perform a stress test.

	VI. Perioperative Therapy

Top Introduction Preamble I. Definition of the... II. General Approach to... III. Disease-Specific Approaches IV. Surgery-Specific Issues V. Supplemental Preoperative... VI. Perioperative Therapy VII. Anesthetic Considerations... VIII. Perioperative Surveillance IX. Postoperative and Long-Term... X. Conclusions Staff References

 
A. Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or PCI
1. Preoperative Coronary Artery Bypass Grafting
Until recently, all of the evidence regarding the value of surgical coronary revascularization was derived from cohort studies in patients who presented for noncardiac surgery after successful cardiac surgery. There are now several randomized trials that have assessed the overall benefit of prophylactic coronary bypass surgery to lower the perioperative cardiac risk of noncardiac surgery, the results of which can be applied to specific subsets of patients and will be discussed later.

The first large, randomized trial (Coronary Artery Revascularization Prophylaxis [CARP]) was published by McFalls and colleagues,³⁸ who randomly assigned 510 patients with significant coronary artery stenosis from among 5859 patients scheduled for vascular operations to either coronary artery revascularization before surgery or no revascularization before surgery. The authors concluded that routine coronary revascularization in patients with stable cardiac symptoms before elective vascular surgery does not significantly alter the long-term outcome or short-term risk of death or MI.

The DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) II trial³⁹ was designed to evaluate the utility of cardiac testing in patients undergoing major vascular surgery with intermediate cardiac risk factors and adequate beta-blocker therapy. A composite end point of death and nonfatal MI was assessed at 30 days after vascular surgery. This study confirms that extensive cardiac ischemia is a risk factor for perioperative cardiac events, but it was too small to assess the effect of revascularization.

The DECREASE-V pilot study⁴⁰ identified a high-risk cohort of patients scheduled for vascular surgery who were randomized to best medical therapy and revascularization or best medical therapy alone before vascular surgery. There was no difference in the combined outcomes of death or MI at 30 days or 1 year between the revascularization and medical therapy groups, although there was a high incidence of cardiac events in this high-risk cohort. This study was not sized to definitively answer the question as to the value of preoperative revascularization in high-risk patients; however, the findings are consistent with the previously published literature suggesting a lack of benefit of preoperative coronary revascularization in preventing death or MI. The indications for preoperative surgical coronary revascularization, therefore, are essentially identical to those recommended by the ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery and the accumulated data on which those conclusions were based.⁴¹

2. Preoperative PCI
Review of the literature suggests that PCI before noncardiac surgery is of no value in preventing perioperative cardiac events, except in those patients in whom PCI is independently indicated for an acute coronary syndrome. However, unscheduled noncardiac surgery in a patient who has undergone a prior PCI presents special challenges, particularly with regard to management of dual-antiplatelet agents required in those who receive coronary stents.

3. PCI Without Stents: Coronary Balloon Angioplasty
Several retrospective series of coronary balloon angioplasty before noncardiac surgery have been reported.^42–49 On the basis of the available literature, delaying noncardiac surgery for more than 8 weeks after balloon angioplasty increases the chance that restenosis at the angioplasty site will have occurred and theoretically increases the chances of perioperative ischemia or MI. However, performing the surgical procedure too soon after the PCI procedure might also be hazardous. Delaying surgery for at least 2 to 4 weeks after balloon angioplasty to allow for healing of the vessel injury at the balloon treatment site is supported by a study by Brilakis et al.⁴⁹ Daily aspirin antiplatelet therapy should be continued perioperatively. The risk of stopping the aspirin should be weighed against the benefit of reduction in bleeding complications from the planned surgery.

4. PCI: Bare-Metal Coronary Stents
If a coronary stent is used in the revascularization procedure, as in the majority of percutaneous revascularization procedures, further delay of noncardiac surgery may be beneficial. Bare-metal stent thrombosis is most common in the first 2 weeks after stent placement and is exceedingly rare (less than 0.1% of most case series) more than 4 weeks after stent placement.^50,51 Given that stent thrombosis will result in Q-wave MI or death in the majority of patients in whom it occurs, and given that the risk of bare-metal stent thrombosis diminishes after endothelialization of the stent has occurred (which generally takes 4 to 6 weeks), it appears reasonable to delay elective noncardiac surgery for 4 to 6 weeks to allow for at least partial endothelialization of the stent, but not for more than 12 weeks, when restenosis may begin to occur.

A thienopyridine (ticlopidine or clopidogrel) is generally administered with aspirin for 4 weeks after bare-metal stent placement. The thienopyridines and aspirin inhibit platelet aggregation and reduce stent thrombosis but increase the risk of bleeding. Rapid endothelialization of bare-metal stents makes late thrombosis rare, and thienopyridines are rarely needed for more than 4 weeks after implantation of bare-metal stents. For this reason, delaying surgery 4 to 6 weeks after bare-metal stent placement allows proper thienopyridine use to reduce the risk of coronary stent thrombosis; then, after the thienopyridine has been discontinued, the noncardiac surgery can be performed. However, once the thienopyridine is stopped, its effects do not diminish immediately. It is for this reason that some surgical teams request a 1-week delay after thienopyridines are discontinued before the patient proceeds to surgery. In patients with bare-metal stents, daily aspirin antiplatelet therapy should be continued perioperatively. The risk of