Abstract

TABLE OF CONTENTS Preamble 686 Definition of the Problem 688 Purpose of These Guidelines 688 Methodology and Evidence 689 General Approach to the Patient 692 History 693 Physical Examination and Routine Laboratory Tests 693 Multivariable Indices to Predict Preoperative Cardiac Morbidity 694 Clinical Assessment 694 Stepwise Approach to Perioperative Cardiac Assessment 695 Disease-Specific Approaches 696 Coronary Artery Disease 696 Patients With Known CAD 696 Hypertension 696 Valvular Heart Disease 696 Surgery-Specific Issues 697 Supplemental Preoperative Evaluation 697 Assessment of LV Function 697 Assessment of Risk for CAD and Assessment of Functional Capacity 697 The 12-Lead ECG 697 Exercise Stress Testing for Myocardial Ischemia and Functional Capacity 698 Noninvasive Stress Testing 698 Perioperative Therapy 698 Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or PCI 698 Preoperative Coronary Artery Bypass Grafting 698 Preoperative PCI 698 PCI Without Stents: Coronary Balloon Angioplasty 698 PCI: Bare-Metal Coronary Stents 699 PCI: Drug-Eluting Stents 699 Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery 699 Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy 700 Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery 700 Perioperative Medical Therapy 701 Perioperative Beta-Blocker Therapy 701 Titration of Beta Blockers 701 Withdrawal of Beta Blockers 702 Perioperative Statin Therapy 702 Alpha-2 Agonists 702 Perioperative Calcium Channel Blockers 702 Intraoperative Electromagnetic Interference With Implantable Pacemakers and Cardioverter Defibrillators 702 Anesthetic Considerations and Intraoperative Management 703 Intraoperative Management 703 Perioperative Pain Management 703 Perioperative Surveillance 703 Intraoperative and Postoperative Use of Pulmonary Artery Catheters 703 Surveillance for Perioperative MI 703 Postoperative and Long-Term Management 703 Myocardial Infarction: Surveillance and Treatment 703 Long-Term Management 704 Conclusions 704 Appendix I 705 Appendix II 706 Appendix III 710 Preamble 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 might 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 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).Table 1: Applying classification of recommendations and level of evidence.Recommendations Recommendations for Preoperative Noninvasive Evaluation of Left Ventricular Function Class IIa It 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 IIb Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (Level of Evidence: C Class III Routine perioperative evaluation of LV function in patients is not recommended. (Level of Evidence: B) Recommendations for Preoperative Resting 12-Lead ECG Class I 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) 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 Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (Level of Evidence: B) Class IIb 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 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 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) Table 2: Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)Class IIa 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 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors Gand poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B) 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 Noninvasive 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 I Coronary 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 IIa 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) 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 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) 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 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) 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 I 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) 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 Beta 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 IIb 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) 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 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 For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B) Class IIa For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B) Class IIb 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 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 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 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 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 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 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 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 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 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 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 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 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 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 Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome. (Level of Evidence: C) Class IIb 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 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 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.12–15Table 3: Estimated Energy Requirements for Various ActivitiesB. 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