Abstract

HomeCirculationVol. 116, No. 17ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive SummaryA 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 Search for more papers by this author , Joshua A. BeckmanJoshua A. Beckman Search for more papers by this author , Kenneth A. BrownKenneth A. Brown Search for more papers by this author , Hugh CalkinsHugh Calkins Search for more papers by this author , Elliot L. ChaikofElliot L. Chaikof Search for more papers by this author , Kirsten E. FleischmannKirsten E. Fleischmann Search for more papers by this author , William K. FreemanWilliam K. Freeman Search for more papers by this author , James B. FroehlichJames B. Froehlich Search for more papers by this author , Edward K. KasperEdward K. Kasper Search for more papers by this author , Judy R. KerstenJudy R. Kersten Search for more papers by this author , Barbara RiegelBarbara Riegel Search for more papers by this author and John F. RobbJohn F. Robb Search for more papers by this author Originally published27 Sep 2007https://doi.org/10.1161/CIRCULATIONAHA.107.185700Circulation. 2007;116:1971–1996is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 27, 2007: Previous Version 1 Preamble…1972 I. Definition of the Problem…1973 A. Purpose of These Guidelines…1973 B. Methodology and Evidence…1973 II. General Approach to the Patient…1978 A. History…1978 B. Physical Examination and Routine Laboratory Tests…1980 C. Multivariable Indices to Predict Preoperative Cardiac Morbidity…1980 D. Clinical Assessment…1980 1. Stepwise Approach to Perioperative Cardiac Assessment…1980 III. Disease-Specific Approaches…1982 A. Coronary Artery Disease…1982 1. Patients With Known CAD…1982 B. Hypertension…1982 C. Valvular Heart Disease…1982 IV. Surgery-Specific Issues…1983 V. Supplemental Preoperative Evaluation…1983 A. Assessment of LV Function…1983 B. Assessment of Risk for CAD and Assessment of Functional Capacity…1983 1. The 12-Lead ECG…1983 2. Exercise Stress Testing for Myocardial Ischemia and Functional Capacity…1983 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 …1984 3. PCI Without Stents: Coronary Balloon Angioplasty…1984 4. PCI: Bare-Metal Coronary Stents…1984 5. PCI: Drug-Eluting Stents…1984 6. Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery…1985 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…1987 4. Perioperative Calcium Channel Blockers…1987 C. Intraoperative Electromagnetic Interference With Implanted Pacemakers and Cardioverter Defibrillators…1987 VII. Anesthetic Considerations and Intraoperative Management…1987 A. Intraoperative Management…1987 B. Perioperative Pain Management…1988 VIII. Perioperative Surveillance…1988 A. Intraoperative and Postoperative Use of Pulmonary Artery Catheters…1988 B. Surveillance for Perioperative MI…1988 IX. Postoperative and Long-Term Management…1988 A. Myocardial Infarction: Surveillance and Treatment…1988 B. Long-Term Management…1989 X. Conclusions…1989 Appendix I…1989 Appendix II…1990 Appendix III…1994PreambleIt 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 GuidelinesAlice K. Jacobs, MD, FACC, FAHA Vice Chair, ACC/AHA Task Force on Practice GuidelinesI. Definition of the ProblemA. Purpose of These GuidelinesThese 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 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.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). Download figureDownload PowerPointTable 1. Applying classification of recommendations and level of evidence.RecommendationsRecommendations for Perioperative Cardiac AssessmentClass IPatients who have a need for emergency noncardiac surgery should proceed to the operating room and continue perioperative surveillance and postoperative risk stratification and risk factor management. (Level of Evidence: C)Patients with active cardiac conditions* should be evaluated and treated per ACC/AHA guidelines and, if appropriate, consider proceeding to the operating room. (Level of Evidence: B)Patients undergoing low risk surgery are recommended to proceed to planned surgery.†(Level of Evidence: B)Patients with poor (less than 4 METs) or unknown functional capacity and no clinical risk factors∥ should proceed with planned surgery.†(Level of Evidence: B)Class IIaIt is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms‡ proceed to planned surgery.§ (Level of Evidence: B)It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors∥ who are scheduled for vascular surgery consider testing if it will change management.¶(Level of Evidence: B)It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors∥ who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control.¶(Level of Evidence: B)It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors∥ who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.¶(Level of Evidence: B)Class IIbNoninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors∥ who are scheduled for intermediate risk surgery. (Level of Evidence: B)Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors∥ who are scheduled for vascular or intermediate risk surgery. (Level of Evidence: B)Recommendations for Preoperative Noninvasive Evaluation of Left Ventricular FunctionClass IIaIt is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of left ventricular (LV) function. (Level of Evidence: C)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 IIbReassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (Level of Evidence: C)Class IIIRoutine perioperative evaluation of LV function in patients is not recommended. (Level of Evidence: B)Recommendations for Preoperative Resting 12-Lead ECGClass IPreoperative 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)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 IIaPreoperative 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 IIbPreoperative 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 IIIPreoperative 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 SurgeryClass IPatients 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)Table 2. Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)ConditionExamples*According to Campeau.9†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).CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association.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 beats per minute 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)Class IIaNoninvasive 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 IIbNoninvasive 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 or vascular surgery if it will change management. (Level of Evidence: B)Class IIINoninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery. (Level of Evidence: C)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 ICoronary revascularization before noncardiac surgery is useful in patients with stable angina who have significant left main coronary artery stenosis. (Level of Evidence: A)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)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)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)Coronary revascularization before noncardiac surgery is recommended in patients with acute ST-elevation MI. (Level of Evidence: A)Class IIaIn 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)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 IIbThe 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)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 IIIIt 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)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)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 IBeta 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)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 IIaBeta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative assessment identifies coronary heart disease. (Level of Evidence: B)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)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 IIbThe 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)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 IIIBeta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)Recommendations for Statin TherapyClass IFor patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B)Class IIaFor patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B)Class IIbFor 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 AgonistsClass IIbAlpha-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 IIIAlpha-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 MonitoringClass IIbPreoperative 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 AgentsClass IIaIt 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 NitroglycerinClass IIbThe 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 EchocardiographyClass IIaThe 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 TemperatureClass IMaintenance 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 ConcentrationClass IIaIt 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 IIbThe 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 CathetersClass IIbUse 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 IIIRoutine 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 MonitoringClass IIaIntraoperative 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 IIbIntraoperative 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 MIClass IPostoperative troponin measureme