HomeCirculationVol. 116, No. 17ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac SurgeryA 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) Lee A. Fleisher, WRITING COMMITTEE:, MD, FACC, FAHA, Chair, Joshua A. Beckman, MD, FACC, Kenneth A. Brown, MD, FACC, FAHA, Hugh Calkins, MD, FACC, FAHA, Elliot L. 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 and John F. Robb, MD, FACC Lee A. FleisherLee A. Fleisher , Joshua A. BeckmanJoshua A. Beckman , Kenneth A. BrownKenneth A. Brown , Hugh CalkinsHugh Calkins , Elliot L. ChaikofElliot L. Chaikof , Kirsten E. FleischmannKirsten E. Fleischmann , William K. FreemanWilliam K. Freeman , James B. FroehlichJames B. Froehlich , Edward K. KasperEdward K. Kasper , Judy R. KerstenJudy R. Kersten , Barbara RiegelBarbara Riegel and John F. RobbJohn F. Robb Originally published27 Sep 2007https://doi.org/10.1161/CIRCULATIONAHA.107.185699Circulation. 2007;116:e418–e500is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 27, 2007: Previous Version 1 Preamble…e420 1. Definition of the Problem…e421 1.1. Purpose of These Guidelines…e421 1.2. Methodology and Evidence…e421 1.3. Epidemiology…e421 1.4. Practice Patterns…e421 1.5. Financial Implications…e423 2. General Approach to the Patient…e423 2.1. Role of the Consultant…e423 2.2. History…e424 2.3. Physical Examination…e424 2.4. Comorbid Diseases…e425 2.4.1. Pulmonary Disease…e425 2.4.2. Diabetes Mellitus…e425 2.4.3. Renal Impairment…e425 2.4.4. Hematologic Disorders…e426 2.5. Ancillary Studies…e426 2.6. Multivariable Indices to Predict Preoperative Cardiac Morbidity…e426 2.7. Clinical Assessment…e427 2.7.1. Stepwise Approach to Perioperative Cardiac Assessment…e427 3. Disease-Specific Approaches…e430 3.1. Coronary Artery Disease…e430 3.1.1. Patients With Known CAD …e430 3.1.2. Influence of Age and Gender…e430 3.2. Hypertension…e430 3.3. Heart Failure…e431 3.4. Cardiomyopathy…e432 3.5. Valvular Heart Disease…e432 3.6. Arrhythmias and Conduction Defects…e433 3.7. Implanted Pacemakers and ICDs …e433 3.8. Pulmonary Vascular Disease and Congenital Heart Disease…e433 4. Surgery-Specific Issues…e434 4.1. Urgency…e434 4.2. Surgical Risk…e434 5. Supplemental Preoperative Evaluation…e437 5.1. Assessment of LV Function…e437 5.2. Assessment of Risk for CAD and Assessment of Functional Capacity…e438 5.2.1. The 12-Lead ECG…e438 5.2.2. Exercise Stress Testing for Myocardial Ischemia and Functional Capacity…e438 5.2.3. Noninvasive Stress Testing…e440 5.2.3.1. Radionuclide Myocardial Perfusion Imaging Methods…e440 5.2.3.2. Dobutamine Stress Echocardiography…e443 5.2.3.3. Stress Testing in the Presence of Left Bundle-Branch Block…e445 5.2.4. Ambulatory ECG Monitoring…e445 5.3. Recommendations: If a Test Is Indicated, Which Test?…e446 6. Implications of Guidelines and Other Risk Assessment Strategies for Costs and Outcomes…e446 7. Perioperative Therapy…e447 7.1. Preoperative Coronary Revascularization With CABG or Percutaneous Coronary Intervention…e447 7.1.1. Rationale for Surgical Coronary Revascularization…e448 7.1.2. Preoperative CABG …e448 7.1.3. Preoperative PCI …e450 7.1.4. PCI Without Stents: Coronary Balloon Angioplasty…e452 7.1.5. PCI: Bare-Metal Coronary Stents…e453 7.1.6. PCI: DES…e454 7.1.7. Stent Thrombosis and DES…e455 7.1.8. Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery…e457 7.1.9. Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy…e458 7.1.10. Risks Associated With Perioperative Antiplatelet Agents…e458 7.1.11. Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery…e459 7.2. Perioperative Medical Therapy…e460 7.2.1. Perioperative Beta-Blocker Therapy…e460 7.2.1.1. Evidence on Efficacy of Beta-Blocker Therapy…e461 7.2.1.2. Titration of Beta Blockers…e464 7.2.1.3. Withdrawal of Beta Blockers…e465 7.2.2. Perioperative Statin Therapy…e465 7.2.3. Alpha-2 Agonists…e467 7.2.4. Perioperative Calcium Channel Blockers…e467 7.3. Prophylactic Valvular Intervention Before Noncardiac Surgery…e467 7.4. Perioperative Arrhythmias and Conduction Disturbances…e468 7.5. Intraoperative Electromagnetic Interference With Implanted Pacemakers and ICDs…e468 7.6. Preoperative Intensive Care…e469 7.7. Venothromboembolism/Peripheral Arterial Disease…e470 8. Anesthetic Considerations and Intraoperative Management…e471 8.1. Choice of Anesthetic Technique and Agent…e471 8.2. Perioperative Pain Management…e472 8.3. Prophylactic Intraoperative Nitroglycerin…e473 8.4. Use of TEE…e473 8.5. Maintenance of Body Temperature…e473 8.6. Intra-Aortic Balloon Counterpulsation Device…e474 8.7. Perioperative Control of Blood Glucose Concentration…e474 9. Perioperative Surveillance…e474 9.1. Intraoperative and Postoperative Use of PACs…e476 9.2. Intraoperative and Postoperative Use of ST-Segment Monitoring…e476 9.3. Surveillance for Perioperative MI…e477 9.4. Postoperative Arrhythmias and Conduction Disorders…e479 10. Postoperative and Long-Term Management…e479 10.1. MI: Surveillance and Treatment…e479 10.2. Long-Term Management…e480 11. Conclusions…e481 12. Cardiac Risk of Noncardiac Surgery: Areas in Need of Further Research…e481Appendix I…e482Appendix II…e483Appendix III…e487PreambleIt 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 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 GuidelinesAlice K. Jacobs, MD, FACC, FAHA Vice Chair, ACC/AHA Task Force on Practice Guidelines1. Definition of the Problem1.1. Purpose of These GuidelinesThese guidelines 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.1.2. Methodology and EvidenceThe 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.Major search topics included perioperative risk, cardiac risk, noncardiac surgery, intraoperative risk, postoperative risk, risk stratification, cardiac complication, cardiac evaluation, perioperative care, preoperative evaluation, preoperative assessment, and intraoperative complications. Additional searches cross-referenced these topics with the following subtopics: troponin, myocardial infarction (MI), myocardial ischemia, Duke activity status index, functional capacity, dobutamine, adenosine, venous thrombosis, thromboembolism, warfarin, percutaneous transluminal coronary angioplasty (PTCA), stent, adrenergic beta agonists, echocardiography, anticoagulant, beta blocker, coronary artery bypass surgery, valve, diabetes mellitus, wound infection, blood sugar control, normothermia, body temperature changes, body temperature regulation, hypertension, pulmonary hypertension, anemia, aspirin, arrhythmia, implantable defibrillator, artificial pacemaker, pulmonary artery catheters, Swan-Ganz catheter, and platelet aggregation inhibitors.As a result of these searches, more than 400 relevant, new articles were identified and reviewed by the committee for the revision of these guidelines. Using evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, the committee revised the guidelines text and recommendations.All of the recommendations in this guideline revision 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.The schema for classification of recommendations and level of evidence are summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of treatment effect and an estimate of the certainty of the treatment effect. Download figureDownload PowerPointTable 1. Applying classification of recommendations and level of evidence.1.3. EpidemiologyThe prevalence of cardiovascular disease increases with age, and it is estimated that the number of persons older than 65 years in the United States will increase 25% to 35% over the next 30 years.1 Coincidentally, this is the same age group in which the largest number of surgical procedures is performed.2 Thus, it is conceivable that the number of noncardiac surgical procedures performed in older persons will increase from the current 6 million to nearly 12 million per year, and nearly one fourth of these—major intra-abdominal, thoracic, vascular, and orthopedic procedures—have been associated with significant perioperative cardiovascular morbidity and mortality.1.4. Practice PatternsThere are few reliable data available regarding 1) how often a family physician, general internist, physician extender, specialist, or surgeon performs a preoperative evaluation on his or her own patient without a formal cardiovascular consultation and 2) how often a formal preoperative consultation is requested from either a generalist or a subspecialist such as a cardiologist for different types of surgical procedures and different categories of patients. The actual patterns of practice with regard to the practitioner performing the evaluation and utilization of testing varies widely, suggesting the need to determine which practices lead to the best clinical and economic outcomes.3 There is an important need to determine the relative cost-effectiveness of different strategies of perioperative evaluation. In many institutions, patients are evaluated in an anesthesia preoperative evaluation setting. If sufficient information about the patient’s cardiovascular status is available, the symptoms are stable, and further evaluation will not influence perioperative management, a formal consultation may not be required or obtained. This is facilitated by communication between anesthesia personnel and physicians responsible for the patient’s cardiovascular care.1.5. Financial ImplicationsThe financial implications of risk stratification cannot be ignored. The need for better methods of objectively measuring cardiovascular risk has led to the development of multiple noninvasive techniques in addition to established invasive procedures. Although a variety of strategies to assess and lower cardiac risk have been developed, their aggregate cost has received relatively little attention. Given the striking practice variation and high costs associated with many evaluation strategies, the development of practice guidelines based on currently available knowledge can serve to foster more efficient approaches to perioperative evaluation.2. General Approach to the PatientThis 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 coronary artery disease (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.4 Preoperative cardiac evaluation must therefore be carefully tailored to the circumstances that have prompted the evaluation and to the nature of the surgical illness. Given an acute surgical emergency, preoperative evaluation might have to be limited to simple and critical tests, such as a rapid assessment of cardiovascular vital signs, volume status, hematocrit, electrolytes, renal function, urine analysis, and ECG. Only the most essential tests and interventions are appropriate until the acute surgical emergency is resolved. A more thorough evaluation can be conducted after surgery. 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.2.1. Role of the ConsultantIf 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. Several studies suggest that such an approach is not always taken. A multiple-choice survey regarding the purposes and utility of cardiology consultations was sent to randomly selected New York metropolitan area anesthesiologists, surgeons, and cardiologists.5 There was substantial disagreement on the importance and purposes of a cardiology consultation; for instance, intraoperative monitoring, “clearing the patient for surgery,” and advising as to the safest type of anesthesia were regarded as important by most cardiologists and surgeons but as unimportant by anesthesiologists. In addition, the charts of 55 consecutive patients aged more than 50 years who received preoperative cardiology consultations were examined to determine the stated purpose of the consultation, recommendations made, and concordance by surgeons and anesthesiologists with cardiologists’ recommendations. Of the cardiology consultations, 40% contained no recommendations other than “proceed with case,” “cleared for surgery,” or “continue current medications.” A review of 146 medical consultations suggests that the majority of such consultations give little advice that truly impacts either perioperative management or outcome of surgery.6 In only 5 consultations (3.4%) did the consultant identify a new finding; 62 consultations (42.5%) contained no recommendations.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. The consultant must not rely solely on the question that he or she has been asked to answer but must provide a comprehensive evaluation of the patient’s risk. The consultation may have been requested for an ECG anomaly, chest pain, or arrhythmia that may have been thought to be indicative of CAD but that the consultant may determine is noncardiac in origin or benign, therefore requiring no further evaluation. In contrast, the consultation may lead to a suspicion of previously unsuspected CAD or heart failure (HF) in a patient scheduled for an elective procedure, which justifies a more extensive evaluation.7–9 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 postoperative care. In some instances, an additional diagnostic cardiac evaluation is necessary on the basis of the results of the initial preoperative test. 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. Before suggesting an additional test, the consultant should feel confident that the information will have the potential to affect treatment. Redundancy should be avoided.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. The consultant can also assist in planning for follow-up, such as suggesting additional therapies known to reduce long-term cardiovascular risk or setting up an office appointment. It is the cardiovascular consultant’s responsibility to ensure clarity of communication, such 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.” As is expected for good medical care in general, clear documentation in the medical record is appropriate.2.2. HistoryA 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 HF, 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. Modifiable risk factors for coronary heart disease (CHD) should be recorded, along with evidence of associated diseases, such as peripheral vascular disease, cerebrovascular disease, diabetes mellitus, renal impairment, and chronic pulmonary disease. 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. Table 2. Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)ConditionExamplesCCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association.*According to Campeau.10†May include “stable” angina in patients who are unusually sedentary.‡The American College of Cardiology National Database Library defines recent MI as more than 7 days but less than or equal to 1 month (within 30 days).Unstable coronary syndromesUnstable or severe angina* (CCS class III or IV)†Recent MI‡Decompensated HF (NYHA functional class IV; worsening or new-onset HF)Significant arrhythmiasHigh-grade atrioventricular blockMobitz II atrioventricular blockThird-degree atrioventricular heart blockSymptomatic ventricular arrhythmiasSupraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR greater than 100 bpm at rest)Symptomatic bradycardiaNewly recognized ventricular tachycardiaSevere valvular diseaseSevere aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)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.11 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.8,9,13,14 The preoperative consultation may represent the first careful cardiovascular evaluation for the patient in years or, in some instances, ever. For example, inquiry regarding symptoms suggestive of angina or anginal equivalents such as dyspnea or HF may establish or suggest these diagnoses for the first time. Table 3. Estimated Energy Requirements for Various Activitieskph indicates kilometers per hour; MET, metabolic equivalent; and mph, miles per hour.*Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.121 METCan you … Take care of yourself? 4 METsCan you… Climb a flight of stairs or walk up a hill?Eat, dress, or use the toilet?Walk on level ground at 4 mph (6.4 kph)?Walk indoors around the house?Run a short distance?Walk a block or 2 on level ground at 2 to 3 mph (3.2 to 4.8 kph)?Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?4 METsDo light work around the house like dusting or washing dishes?Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
