Abstract

HomeCirculationVol. 120, No. 212009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/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 toSupplementary MaterialsFree AccessReview ArticlePDF/EPUB2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac SurgeryA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 2007 WRITING COMMITTEE MEMBERS Lee A. Fleisher, 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 2007 WRITING COMMITTEE MEMBERS , 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 published2 Nov 2009https://doi.org/10.1161/CIRCULATIONAHA.109.192690Circulation. 2009;120:e169–e276Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 2, 2009: Previous Version 1 Preamble (UPDATED)…e1711. Introduction/Definition of the Problem (UPDATED)…e172 1.1. Methodology and Evidence Review (UPDATED)…e172 1.2. Organization of Committee and Relationships With Industry and Other Entities (NEW)…e173 1.3. Document Review and Approval (UPDATED)…e173 1.4. Epidemiology…e173 1.5. Practice Patterns…e173 1.6. Financial Implications…e1742. General Approach to the Patient…e175 2.1. Role of the Consultant…e175 2.2. History…e175 2.3. Physical Examination…e176 2.4. Comorbid Diseases…e177 2.4.1. Pulmonary Disease…e177 2.4.2. Diabetes Mellitus…e177 2.4.3. Renal Impairment…e177 2.4.4. Hematologic Disorders…e177 2.5. Ancillary Studies…e178 2.6. Multivariable Indices to Predict Preoperative Cardiac Morbidity…e178 2.7. Clinical Assessment…e178 2.7.1. Stepwise Approach to Perioperative Cardiac Assessment…e1793. Disease-Specific Approaches…e181 3.1. Coronary Artery Disease…e181 3.1.1. Patients With Known CAD…e181 3.1.2. Influence of Age and Gender…e182 3.2. Hypertension…e182 3.3. Heart Failure…e183 3.4. Cardiomyopathy…e183 3.5. Valvular Heart Disease…e184 3.6. Arrhythmias and Conduction Defects…e185 3.7. Implanted Pacemakers and ICDs…e185 3.8. Pulmonary Vascular Disease and Congenital Heart Disease…e1854. Surgery-Specific Issues…e185 4.1. Urgency…e186 4.2. Surgical Risk…e1865. Supplemental Preoperative Evaluation…e189 5.1. Assessment of LV Function…e189 5.2. Assessment of Risk for CAD and Assessment of Functional Capacity…e189 5.2.1. The 12-Lead ECG…e189 5.2.2. Exercise Stress Testing for Myocardial Ischemia and Functional Capacity…e190 5.2.3. Noninvasive Stress Testing…e192 5.2.3.1. Radionuclide Myocardial Perfusion Imaging Methods…e192 5.2.3.2. Dobutamine Stress Echocardiography…e195 5.2.3.3. Stress Testing in the Presence of Left Bundle-Branch Block…e197 5.2.4. Ambulatory ECG Monitoring…e197 5.3. Recommendations: If a Test Is Indicated, Which Test?…e1986. Implications of Guidelines and Other Risk Assessment Strategies for Costs and Outcomes…e1997. Perioperative Therapy…e200 7.1. Preoperative Coronary Revascularization With CABG or Percutaneous Coronary Intervention…e200 7.1.1. Rationale for Surgical Coronary Revascularization…e200 7.1.2. Preoperative CABG…e200 7.1.3. Preoperative PCI…e203 7.1.4. PCI Without Stents: Coronary Balloon Angioplasty…e203 7.1.5. PCI: Bare-Metal Coronary Stents…e206 7.1.6. PCI: DES…e207 7.1.7. Stent Thrombosis and DES…e207 7.1.8. Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery…e210 7.1.9. Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy…e211 7.1.10. Risks Associated With Perioperative Antiplatelet Agents…e211 7.1.11. Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery…e212 7.2. Perioperative Medical Therapy (UPDATED)…e213 7.2.1. Recommendations for Perioperative Beta-Blocker Therapy (UPDATED)…e213 7.2.1.1. Evidence on Efficacy of Beta-Blocker Therapy (UPDATED)…e214 7.2.1.1.1. Recent Data Regarding Perioperative Beta-Blocker Therapy (NEW)…e218 7.2.1.2. Titration of Beta Blockers (UPDATED)…e219 7.2.1.3. Withdrawal of Beta Blockers (UPDATED)…e220 7.2.1.4. Risks and Caveats (NEW)…e220 7.2.1.5. Summary (NEW)…e221 7.2.2. Perioperative Statin Therapy…e221 7.2.3. Alpha-2 Agonists…e223 7.2.4. Perioperative Calcium Channel Blockers…e224 7.3. Prophylactic Valvular Intervention Before Noncardiac Surgery…e224 7.4. Perioperative Arrhythmias and Conduction Disturbances…e224 7.5. Intraoperative Electromagnetic Interference With Implanted Pacemakers and ICDs…e225 7.6. Preoperative Intensive Care…e226 7.7. Venothromboembolism/Peripheral Arterial Disease…e2268. Anesthetic Considerations and Intraoperative Management…e227 8.1. Choice of Anesthetic Technique and Agent…e227 8.2. Perioperative Pain Management…e229 8.3. Prophylactic Intraoperative Nitroglycerin…e229 8.4. Use of TEE…e230 8.5. Maintenance of Body Temperature…e230 8.6. Intra-Aortic Balloon Counterpulsation Device…e230 8.7. Perioperative Control of Blood Glucose Concentration…e2319. Perioperative Surveillance…e231 9.1. Intraoperative and Postoperative Use of PACs…e231 9.2. Intraoperative and Postoperative Use of ST-Segment Monitoring…e233 9.3. Surveillance for Perioperative MI…e234 9.4. Postoperative Arrhythmias and Conduction Disorders…e23610. Postoperative and Long-Term Management…e236 10.1. MI: Surveillance and Treatment…e237 10.2. Long-Term Management…e23711. Conclusions…e23812. Cardiac Risk of Noncardiac Surgery: Areas in Need of Further Research…e238References…e239Appendix 1. 2007 Author Relationships With Industry and Other Entities…e253Appendix 2. 2007 Peer Reviewer Relationships With Industry and Other Entities…e253Appendix 3. 2007 Abbreviations List…e259Appendix 4. 2009 Author Relationships With Industry and Other Entities (NEW)…e259Appendix 5. 2009 Peer Reviewer Relationships With Industry and Other Entities (NEW)…e260Appendix 6. 2009 Summary Table (NEW)…e263Preamble (UPDATED)It is essential 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 production of clinical practice guidelines can provide a foundation for a variety of other applications such as performance measures, appropriateness use criteria, clinical decision support tools, and quality improvement tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines is charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and directs this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update, or revise recommendations for clinical practice.Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against particular treatments or procedures, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of tests or therapies are considered as well as the frequency of follow-up and cost-effectiveness. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.The ACCF/AHA Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all such relationships that might be perceived as relevant to the writing effort. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. These statements are reviewed by the parent task force, reviewed by all members in conjunction with each conference call and/or meeting of the writing committee, updated as changes occur and ultimately published as an appendix to the document. Please refer to the methodology manual for ACCF/AHA Guideline Writing Committees for further description of the relationships with industry and other entities policy.1 See Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry pertinent to this guideline.These practice guidelines produced are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions. (See Appendix 3 for a list of abbreviations frequently used in this document.) Clinicians should consider the quality and availability of expertise in the area where care is provided. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The 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 upon medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles.If these guidelines are used as the basis for regulatory or payer decisions, the goal should be quality of care and the patient's best interest. 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. Consequently, there are circumstances in which deviations from these guidelines are appropriate.The guidelines will be reviewed annually by the ACCF/AHA Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution. The executive summary and recommendations are published in the October 23, 2007, issues of the Journal of the American College of Cardiology and Circulation. The full-text guidelines are e-published in the same issue of these journals and posted on the ACC (www.acc.org) and AHA (my.americanheart.org) World Wide Web sites. Copies of the full-text guidelines and the executive summary are available from both organizations.This document is a republication of the "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery",2 revised to incorporate updated recommendations and text from the "2009 ACCF/AHA Focused Update on Perioperative Beta Blockade".3 Recommendations have been updated with new information that has emerged from clinical trials or other ACCF/AHA guideline or consensus documents. For easy reference, this online-only version denotes sections that have been updated.Alice K. Jacobs, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice GuidelinesSidney C. Smith, Jr., MD, FACC, FAHA Immediate Past Chair, ACCF/AHA Task Force on Practice Guidelines1. Introduction/Definition of the Problem (UPDATED)The 2007 full-text 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.1.1. Methodology and Evidence Review (UPDATED)The 2007 guidelines writing committee 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 ACCF/AHA Task Force on Practice Guidelines, the committee revised the guidelines text and recommendations.For the 2009 focused update,3 late-breaking clinical trials presented at the 2008 annual scientific meetings of the ACC, AHA, and European Society of Cardiology, as well as selected other data through June 2009, were reviewed by the standing guideline writing committee along with the parent task force and other experts to identify those trials and other key data that may impact guideline recommendations. Recent trial data and other clinical information were considered important enough to prompt a focused update of the "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery".2 This update addresses predominantly the prophylactic use of beta blockers perioperatively to minimize cardiac risk, but it does not cover other legitimate uses of beta blockers (e.g., as an adjunct in anesthetic regimens, for intraoperative control of heart rate or blood pressure, or to achieve heart rate control in common perioperative arrhythmias such as atrial fibrillation).When considering the new data for this focused update, the writing group faced the task of weighing evidence from studies enrolling large numbers of subjects outside North America. While noting that practice patterns and the rigor applied to data collection, as well as the genetic make-up of subjects, may influence the observed magnitude of a treatment's effect, the writing group believed the data were relevant to formulation of recommendations for perioperative management in North America. The reasons for this decision include the following: 1) The use of detailed protocol-driven management strategies likely reduced treatment variability among sites; and 2) it may be impractical to expect that the thousands of patients undergoing noncardiac surgery who are needed to meet the estimated sample size for contemporary clinical trials would be enrolled exclusively at North American sites.To provide clinicians with a comprehensive set of data, whenever possible, the exact event rates in various treatment arms of clinical trials are presented to permit calculation of the absolute risk difference and number needed to treat (NNT) or harm. The relative treatment effects are described either as odds ratio (OR), relative risk (RR), or hazard ratio (HR), depending on the format in the original publication.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*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level.1.2. Organization of Committee and Relationships With Industry and Other Entities (NEW)For the 2009 focused update, all members of the 2007 Perioperative Guideline Writing Committee were invited to participate; those who agreed (referred to as the 2009 Focused Update Writing Group) were required to disclose all relationships with industry and other entities relevant to the data under consideration (see Appendix 4). Each recommendation required a confidential vote by the writing group members before and after external review of the document. Any writing group member with a relationship with industry relevant to the recommendation was recused from voting on that recommendation. The committee included representatives from the American Society of Echocardiography (ASE), Heart Rhythm Society (HRS), Society of Cardiovascular Anesthesiologists (SCA), Society for Cardiac Angiography and Interventions (SCAI), Society for Vascular Medicine (SVM), and Society for Vascular Surgery (SVS).1.3. Document Review and Approval (UPDATED)The 2007 guidelines were approved for publication by the governing bodies of the ACCF and the AHA and have been officially endorsed by the ASE, American Society of Nuclear Cardiology (ASNC), HRS, SCA, SCAI, SVM, and SVS.The 2009 focused update was reviewed by 2 official reviewers nominated by the ACCF and 2 official reviewers nominated by the AHA, as well as 2 reviewers each from the ASE, ASNC, HRS, SCA, SCAI, SVM, and the SVS, and 8 individual content reviewers from the ACCF Cardiac Catheterization Committee and the ACCF Interventional Council. All information on reviewer relationships with industry was collected and distributed to the writing group and is published in this document (Appendix 5).The 2009 focused update was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the ASE, ASNC, HRS, SCA, SCAI, SVM, and the SVS.1.4. 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.1.5. 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.1.6. 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 i