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ACC/AHA GUIDELINE

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

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

Lee A. Fleisher, MD, FACC, FAHA, Chair, WRITING COMMITTEE MEMBER, Joshua A. Beckman, MD, FACC, WRITING COMMITTEE MEMBER^¶, Kenneth A. Brown, MD, FACC, FAHA, WRITING COMMITTEE MEMBER, Hugh Calkins, MD, FACC, FAHA, WRITING COMMITTEE MEMBER, Elliott L. Chaikof, MD, WRITING COMMITTEE MEMBER^#, Kirsten E. Fleischmann, MD, MPH, FACC, WRITING COMMITTEE MEMBER, William K. Freeman, MD, FACC, WRITING COMMITTEE MEMBER_^*, James B. Froehlich, MD, MPH, FACC, WRITING COMMITTEE MEMBER, Edward K. Kasper, MD, FACC, WRITING COMMITTEE MEMBER, Judy R. Kersten, MD, FACC, WRITING COMMITTEE MEMBER, Barbara Riegel, DNSc, RN, FAHA, WRITING COMMITTEE MEMBER, John F. Robb, MD, FACC, WRITING COMMITTEE MEMBER^||, Sidney C. Smith, Jr, MD, FACC, FAHA, Chair, ACC/AHA TASK FORCE MEMBER, Alice K. Jacobs, MD, FACC, FAHA, Vice Chair, ACC/AHA TASK FORCE MEMBER, Cynthia D. Adams, MSN, PhD, FAHA, ACC/AHA TASK FORCE MEMBER, Jeffrey L. Anderson, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Elliott M. Antman, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER_^*, Christopher E. Buller, MD, FACC, ACC/AHA TASK FORCE MEMBER, Mark A. Creager, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Steven M. Ettinger, MD, FACC, ACC/AHA TASK FORCE MEMBER, David P. Faxon, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Valentin Fuster, MD, PhD, FACC, FAHA, FESC, ACC/AHA TASK FORCE MEMBER, Jonathan L. Halperin, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Loren F. Hiratzka, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Sharon A. Hunt, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Bruce W. Lytle, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Rick Nishimura, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Joseph P. Ornato, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Richard L. Page, MD, FACC, FAHA, ACC/AHA TASK FORCE MEMBER, Barbara Riegel, DNSc, RN, FAHA, ACC/AHA TASK FORCE MEMBER, Lynn G. Tarkington, RN, ACC/AHA TASK FORCE MEMBER and Clyde W. Yancy, MD, FACC, ACC/AHA TASK FORCE MEMBER

	Table of Contents

Top Table of Contents Preamble 1. Definition of the... 2. General Approach to... 3. Disease-Specific Approaches 4. Surgery-Specific Issues 5. Supplemental Preoperative... 6. Implications of Guidelines... 7. Perioperative Therapy 8. Anesthetic Considerations and... 9. Perioperative Surveillance 10. Postoperative and Long-Term... 11. Conclusions 12. Cardiac Risk of... Staff Appendix References

Preamble......e161

1 Definition of the Problem......e162

1.1 Purpose of These Guidelines......e162

1.2 Methodology and Evidence......e162

1.3 Epidemiology......e162

1.4 Practice Patterns......e162

1.5 Financial Implications......e164

2 General Approach to the Patient......e164

2.1 Role of the Consultant......e164

2.2 History......e165

2.3 Physical Examination......e165

2.4 Comorbid Diseases......e166

2.4.1 Pulmonary Disease......e166

2.4.2 Diabetes Mellitus......e166

2.4.3 Renal Impairment......e166

2.4.4 Hematologic Disorders......e167

2.5 Ancillary Studies......e167

2.6 Multivariable Indices to Predict Preoperative Cardiac Morbidity......e167

2.7 Clinical Assessment......e168

2.7.1 Stepwise Approach to Perioperative Cardiac Assessment......e168

3 Disease-Specific Approaches......e171

3.1 Coronary Artery Disease......e171

3.1.1 Patients With Known CAD ......e171

3.1.2 Influence of Age and Gender......e171

3.2 Hypertension......e171

3.3 Heart Failure......e172

3.4 Cardiomyopathy......e173

3.5 Valvular Heart Disease......e173

3.6 Arrhythmias and Conduction Defects......e174

3.7 Implanted Pacemakers and ICDs ......e174

3.8 Pulmonary Vascular Disease and Congenital Heart Disease......e174

4 Surgery-Specific Issues......e175

4.1 Urgency......e175

4.2 Surgical Risk......e175

5 Supplemental Preoperative Evaluation......e178

5.1 Assessment of LV Function......e178

5.2 Assessment of Risk for CAD and Assessment of Functional Capacity......e179

5.2.1 The 12-Lead ECG......e179

5.2.2 Exercise Stress Testing for Myocardial Ischemia and Functional Capacity......e179

5.2.3 Noninvasive Stress Testing......e181

5.2.3.1 Radionuclide Myocardial Perfusion Imaging Methods......e181

5.2.3.2 Dobutamine Stress Echocardiography......e184

5.2.3.3 Stress Testing in the Presence of Left Bundle-Branch Block......e186

5.2.4 Ambulatory ECG Monitoring......e186

5.3 Recommendations: If a Test Is Indicated, Which Test?......e186

6 Implications of Guidelines and Other Risk Assessment Strategies for Costs and Outcomes......e187

7 Perioperative Therapy......e188

7.1 Preoperative Coronary Revascularization With CABG or Percutaneous Coronary Intervention......e188

7.1.1 Rationale for Surgical Coronary Revascularization......e189

7.1.2 Preoperative CABG......e189

7.1.3 Preoperative PCI......e191

7.1.4 PCI Without Stents: Coronary Balloon Angioplasty......e193

7.1.5 PCI: Bare-Metal Coronary Stents......e194

7.1.6 PCI: DES......e195

7.1.7 Stent Thrombosis and DES......e196

7.1.8 Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery......e199

7.1.9 Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy......e199

7.1.10 Risks Associated With Perioperative Antiplatelet Agents......e200

7.1.11 Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery......e201

7.2 Perioperative Medical Therapy......e201

7.2.1 Perioperative Beta-Blocker Therapy......e201

7.2.1.1 Evidence on Efficacy of Beta-Blocker Therapy......e203

7.2.1.2 Titration of Beta Blockers......e206

7.2.1.3 Withdrawal of Beta Blockers......e206

7.2.2 Perioperative Statin Therapy......e206

7.2.3 Alpha-2 Agonists......e208

7.2.4 Perioperative Calcium Channel Blockers......e209

7.3 Prophylactic Valvular Intervention Before Noncardiac Surgery......e209

7.4 Perioperative Arrhythmias and Conduction Disturbances......e209

7.5 Intraoperative Electromagnetic Interference With Implanted Pacemakers and ICDs......e210

7.6 Preoperative Intensive Care......e211

7.7 Venothromboembolism/Peripheral Arterial Disease......e211

8 Anesthetic Considerations and Intraoperative Management......e212

8.1 Choice of Anesthetic Technique and Agent......e212

8.2 Perioperative Pain Management......e214

8.3 Prophylactic Intraoperative Nitroglycerin......e214

8.4 Use of TEE......e215

8.5 Maintenance of Body Temperature......e215

8.6 Intra-Aortic Balloon Counterpulsation Device......e215

8.7 Perioperative Control of Blood Glucose Concentration......e216

9 Perioperative Surveillance......e216

9.1 Intraoperative and Postoperative Use of PACs......e216

9.2 Intraoperative and Postoperative Use of ST-Segment Monitoring......e218

9.3 Surveillance for Perioperative MI......e219

9.4 Postoperative Arrhythmias and Conduction Disorders......e221

10 Postoperative and Long-Term Management......e221

10.1 MI: Surveillance and Treatment......e221

10.2 Long-Term Management......e222

11 Conclusions......e223

12 Cardiac Risk of Noncardiac Surgery: Areas in Need of Further Research......e223

Appendix I......e224

Appendix II......e225

Appendix III......e229

References......e229

	Preamble

Top Table of Contents Preamble 1. Definition of the... 2. General Approach to... 3. Disease-Specific Approaches 4. Surgery-Specific Issues 5. Supplemental Preoperative... 6. Implications of Guidelines... 7. Perioperative Therapy 8. Anesthetic Considerations and... 9. Perioperative Surveillance 10. Postoperative and Long-Term... 11. Conclusions 12. Cardiac Risk of... Staff Appendix References

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

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

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

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

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

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

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

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

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

	1. Definition of the Problem

Top Table of Contents Preamble 1. Definition of the... 2. General Approach to... 3. Disease-Specific Approaches 4. Surgery-Specific Issues 5. Supplemental Preoperative... 6. Implications of Guidelines... 7. Perioperative Therapy 8. Anesthetic Considerations and... 9. Perioperative Surveillance 10. Postoperative and Long-Term... 11. Conclusions 12. Cardiac Risk of... Staff Appendix References

 
1.1 Purpose of These Guidelines.   These 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 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.

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.

1.4 Practice Patterns.   There 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 Implications.   The 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 Patient

Top Table of Contents Preamble 1. Definition of the... 2. General Approach to... 3. Disease-Specific Approaches 4. Surgery-Specific Issues 5. Supplemental Preoperative... 6. Implications of Guidelines... 7. Perioperative Therapy 8. Anesthetic Considerations and... 9. Perioperative Surveillance 10. Postoperative and Long-Term... 11. Conclusions 12. Cardiac Risk of... Staff Appendix References

 
This guideline focuses on the evaluation of the patient undergoing noncardiac surgery who is at risk for perioperative cardiac morbidity or mortality. In patients with known 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 Consultant.   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. 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 History.   A 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.

The general appearance provides invaluable evidence regarding the patient's overall status. Cyanosis, pallor, dyspnea during conversation or with minimal activity, Cheyne-Stokes respiration, poor nutritional status, obesity, skeletal deformities, tremor, and anxiety are just a few of the clues of underlying disease or CAD that can be recognized by the skilled physician.

In patients with acute HF, rales and chest X-ray evidence of pulmonary congestion correlate well with elevated pulmonary venous pressure. However, in patients with chronic HF, these findings may be absent. An elevated jugular venous pressure or a positive hepatojugular reflux are more reliable signs of hypervolemia in these patients (15,16). Peripheral edema is not a reliable indicator of chronic HF unless the jugular venous pressure is elevated or the hepatojugular test is positive.

An examination of the carotid and other arterial pulses is essential. The presence of associated vascular disease should heighten suspicion of occult CAD. Cardiac auscultation will often provide useful clues to underlying cardiac disease. When present, a third heart sound at the apical area suggests a failing left ventricle (LV), but its absence is not a reliable indicator of good ventricular function (16). If a murmur is present, the clinician will need to decide whether or not it represents significant valvular disease. Detection of significant aortic stenosis is of particular importance because this lesion poses a higher risk for noncardiac surgery (17). Significant mitral stenosis or regurgitation increases the risk of HF. Aortic regurgitation and mitral regurgitation may be minimal, yet they predispose the patient to infective endocarditis should bacteremia occur after surgery. Recommendations for endocarditis prophylaxis have been published elsewhere (18) (see Section 3.5 Valvular Heart Disease).

2.4 Comorbid Diseases.   The consultant must evaluate the cardiovascular system within the framework of the patient's overall health. Associated conditions often heighten the risk of anesthesia and may complicate cardiac management. The most common of these conditions are discussed below.

2.4.1 Pulmonary Disease
The presence of either obstructive or restrictive pulmonary disease places the patient at increased risk of developing perioperative respiratory complications. Hypoxemia, hypercapnia, acidosis, and increased work of breathing can all lead to further deterioration of an already compromised cardiopulmonary system. If significant pulmonary disease is suspected by history or physical examination, determination of functional capacity, response to bronchodilators, and/or evaluation for the presence of carbon dioxide retention through arterial blood gas analysis may be justified. If there is evidence of infection, appropriate antibiotics are critical. Steroids and bronchodilators may be indicated, although the risk of producing arrhythmia or myocardial ischemia by beta agonists must be considered. Recommendations for preoperative chest radiographs can be found elsewhere (19).

2.4.2 Diabetes Mellitus
A variety of metabolic diseases may accompany cardiac disease. Diabetes mellitus is the most common. Its presence should heighten suspicion of CAD, particularly because CAD and myocardial ischemia are more likely in patients with diabetes mellitus (20–22). Lee et al identified insulin therapy for diabetes mellitus as a significant risk factor for cardiac morbidity (4). Older patients with diabetes mellitus are more likely to develop HF postoperatively than those without diabetes mellitus even after adjustment for treatment with angiotensin-converting enzyme (ACE) inhibitors (23). Management of blood glucose levels in the perioperative period may be difficult. Fragile patients with diabetes mellitus need careful treatment with adjusted doses or infusions of short-acting insulin based on frequent blood sugar determinations. Historically, it has been acceptable to maintain relatively high glucose levels perioperatively to avoid the attendant risks of hypoglycemic episodes; however, aggressive perioperative glucose control in coronary bypass surgery patients by a continuous, intravenous insulin infusion was found to be superior to intermittent subcutaneous insulin administration in significantly reducing postoperative wound infection (24). A similar benefit is less well established but may be found in noncardiac surgery (25). A discussion of the perioperative management of blood glucose concentration can be found in Section 8.7.

2.4.3 Renal Impairment
Azotemia is commonly associated with cardiac disease and is associated with an increased risk of cardiovascular events. Maintenance of adequate intravascular volume for renal perfusion during diuresis of a patient with HF is often challenging. Excessive diuresis in combination with initiation of ACE inhibitors or angiotensin receptor blockers may result in an increase in blood urea nitrogen and serum creatinine concentrations. In patients with known vascular disease, a small increase in blood urea nitrogen and creatinine may suggest the presence of renal artery stenosis. However, small increases in blood urea nitrogen and serum creatinine concentrations are not an indication to discontinue these drugs, because they have been shown to improve survival in patients with HF due to systolic dysfunction. Preexisting renal disease (preoperative serum creatinine levels 2 mg per dL or greater or reduced glomerular filtration rate) has been identified as a risk factor for postoperative renal dysfunction and increased long-term morbidity and mortality compared with patients without renal disease (26,27). In coronary artery bypass patients who are more than 70 years old, preoperative creatinine levels greater than 2.6 mg per dL place the patient at much greater risk for chronic dialysis postoperatively than creatinine levels below 2.6 mg per dL (28). Intuitively, one might extrapolate these findings to those older patients with comparable creatinine levels who undergo major noncardiac surgical procedures. One large study has shown that a preoperative creatinine level greater than 2 mg per dL is a significant, independent risk factor for cardiac complications after major noncardiac surgery (4).

Creatinine clearance, another indicator of renal function, has been used to predict postoperative complications (29,30). Creatinine clearance incorporates serum creatinine, age, and weight to provide a more accurate assessment of renal function than serum creatinine alone. Kertai and colleagues evaluated 852 subjects undergoing major vascular surgery and demonstrated an increase in mortality as both serum creatinine increased and creatinine clearance decreased, with creatinine clearance providing a more accurate assessment (29). To date, there has been no validation of this relationship by other investigators or in a prospective study. The AHA, in a scientific statement, advocated use of the Modification in Diet in Renal Disease equation to calculate glomerular filtration rate to determine kidney function (27).

2.4.4 Hematologic Disorders
Anemia imposes a stress on the cardiovascular system that may exacerbate myocardial ischemia and aggravate HF (31). Preoperative transfusion, when used appropriately in patients with advanced CAD and/or HF, may reduce perioperative cardiac morbidity. However, with current concern about transfusion reaction, clerical error, or transmission of communicable disease through the use of blood products, a conservative approach with respect to transfusion is warranted. Hematocrits less than 28% are associated with an increased incidence of perioperative ischemia and postoperative complications in patients undergoing prostate and vascular surgery (31–33). In the VA National Surgical Quality Improvement Program database, mild degrees of preoperative anemia or polycythemia were associated with an increased risk of 30-day postoperative mortality and cardiac events in older, mostly male veterans undergoing major noncardiac surgery (34). The adjusted risk of 30-day postoperative mortality and cardiac morbidity begins to rise when hematocrit levels decrease to less than 39% or exceed 51%.

Polycythemia, thrombocytosis, and other conditions that increase viscosity and hypercoagulability may increase the risk of thromboembolism or hemorrhage. Appropriate steps to reduce these risks should be considered and tailored to the individual patient's particular circumstances. Current guidelines are available that address perioperative transfusion practices (35).

2.5 Ancillary Studies.   The consultant should review all pertinent available laboratory data. In the present era of cost containment, the laboratory data available may be minimal. Therefore, the consultant may require additional tests such as blood chemistries and a chest x-ray on the basis of history and physical examination. Blood levels of cardiac drugs should be obtained only when there are specific indications, such as changes in renal function, a recent change in dose, or symptoms that suggest toxicity.

The ECG is frequently obtained as part of a preoperative evaluation in all patients over a specific age or undergoing a specific set of procedures. Section 5.2.1 identifies the indications for a preoperative ECG based on the available evidence. An abnormal ECG report is often the reason that consultation is requested, but if not previously done, an ECG should be obtained as part of the consultation. Metabolic and electrolyte disturbances, medications, intracranial disease, and pulmonary disease, among other things, can alter the ECG. Conduction disturbances, such as right bundle-branch block or first-degree atrioventricular block, may lead to concern but usually do not justify further workup. The same is often true of asymptomatic ventricular arrhythmias, even in the presence of structural heart disease (36,37). On the other hand, subtle ECG clues can point to a clinically silent condition of major importance.

2.6 Multivariable Indices to Predict Preoperative Cardiac Morbidity.   The basic clinical evaluation obtained by history, physical examination, and review of the ECG usually provides the consultant with sufficient data to estimate cardiac risk. In an attempt to codify those clinical and laboratory factors that influence outcome, numerous investigators have developed risk indices over the past 25 years based on multivariable analyses (17,38–47). Although some authors have suggested a scoring system that assigns more weight to some factors than others and sums these to arrive at a composite risk (17,45,47), most recent articles have suggested simpler criteria (4,38–44). Lee et al derived and validated a "simple index" for the prediction of cardiac risk for stable patients undergoing nonurgent major noncardiac surgery (4). Six independent risk correlates were identified: ischemic heart disease (defined as history of MI, history of positive treadmill test, use of nitroglycerin, current complaints of chest pain thought to be secondary to coronary ischemia, or ECG with abnormal Q waves); congestive HF (defined as history of HF, pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, bilateral rales, S₃, or X-ray with pulmonary vascular redistribution); cerebral vascular disease (history of transient ischemic attack or stroke); high-risk surgery (abdominal aortic aneurysm or other vascular, thoracic, abdominal, or orthopedic surgery); preoperative insulin treatment for diabetes mellitus; and preoperative creatinine greater than 2 mg per dL. Increasing numbers of risk factors correlated with increased risk, yet the risk was substantially lower than described in many of the original indices (4). These improvements in outcome most likely reflect selection bias with respect to who presents for elective surgery, advances in surgical technique and anesthesia, and advances in the management of CAD both perioperatively and in general. The Revised Cardiac Risk Index has become one of the most widely used risk indices (4).

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

• unstable coronary syndromes,

unstable or severe angina,

recent MI,

• decompensated HF,

• significant arrhythmias, and

• severe valvular disease.

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

• history of ischemic heart disease,

• history of compensated or prior HF,

• history of cerebrovascular disease,

• diabetes mellitus, and

• renal insufficiency (4).

A history of MI or abnormal Q waves by ECG is listed as a clinical risk factor, whereas an acute MI (defined as at least 1 documented MI 7 days or less before the examination) or recent MI (more than 7 days but less than or equal to 1 month before the examination) with evidence of important ischemic risk by clinical symptoms or noninvasive study is an active cardiac condition. This definition reflects the consensus of the ACC Cardiovascular Database Committee. In this way, the separation of MI into the traditional 3- and 6-month intervals has been avoided (17,48). Current management of MI provides for risk stratification during convalescence (49). If a recent stress test does not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there are no adequate clinical trials on which to base firm recommendations, it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgery.

Minor predictors are recognized markers for cardiovascular disease that have not been proven to increase perioperative risk independently, for example, advanced age (greater than 70 years), abnormal ECG (LV hypertrophy, left bundle-branch block, ST-T abnormalities), rhythm other than sinus, and uncontrolled systemic hypertension. The presence of multiple minor predictors might lead to a higher suspicion of CAD but is not incorporated into the recommendations for treatment.

2.7.1 Stepwise Approach to Perioperative Cardiac Assessment
Recommendations for Perioperative Cardiac Assessment
   Class I

1 Patients 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)

2 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)

3 Patients undergoing low risk surgery are recommended to proceed to planned surgery.(Level of Evidence: B)

4 Patients with poor (less than 4 METs) or unknown functional capacity and no clinical risk factorsshould proceed with planned surgery.(Level of Evidence: B)

   Class IIa

1 It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptomsproceed to planned surgery.^||(Level of Evidence: B)

2 It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factorswho are scheduled for vascular surgery consider testing if it will change management.^¶(Level of Evidence: B)

3 It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factorswho are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control.^¶(Level of Evidence: B)

4 It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factorswho are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.^¶(Level of Evidence: B)

   Class IIb

1 Noninvasive 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 factorswho are scheduled for intermediate risk surgery. (Level of Evidence: B)

2 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 factorswho are scheduled for vascular or intermediate risk surgery. (Level of Evidence: B)

Figure 1 presents, in algorithmic form, a framework for determining which patients are candidates for cardiac testing. The clinician must consider several interacting variables and give them appropriate weight. Since publication of the perioperative cardiovascular evaluation guidelines in 2002 (50), several new randomized trials and cohort studies have led to modification of the original algorithm. Given the availability of this evidence, the writing committee chose to include the level of the recommendations and strength of evidence for each of the pathways.

View larger version (13K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical conditions. See Class III recommendations in Section 5.2.3. Noninvasive Stress Testing. See Table 3 for estimated MET level equivalent. Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management. ||Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperative beta blockade (see Table 12) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent.

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

Step 3: Is the patient undergoing low-risk surgery? Many procedures are associated with a combined morbidity and mortality rate less than 1% (see Section 4), even in high-risk patients. Additionally, mortality on the day of surgery, for most ambulatory surgical procedures, is actually lower than mortality on day 30, which suggests that the incremental risk of ambulatory surgery is negligible or may be protective (51). Therefore, interventions based on cardiovascular testing in stable patients would rarely result in a change in management, and it would be appropriate to proceed with the planned surgical procedure.

Step 4: Does the patient have a functional capacity greater than or equal to 4 METs, without symptoms? Functional status has been shown to be reliable for perioperative and long-term prediction of cardiac events (52–56). In highly functional asymptomatic patients, management will rarely be changed based on the results of any further cardiovascular testing. It is therefore appropriate to proceed with the planned surgery. In patients with known cardiovascular disease or at least 1 clinical risk factor, perioperative heart rate control with beta blockade appears appropriate as outlined in Section 7.2.

If the patient has not had a recent exercise test, functional status can usually be estimated from the ability to perform activities of daily living (55). Functional capacity can be expressed as metabolic equivalents (METs); the resting or basal oxygen consumption (VO ₂) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min, or 1 MET. For this purpose, functional capacity has been classified as excellent (greater than 10 METs), good (7 to 10 METs), moderate (4 to 6 METs), poor (less than 4 METs), or unknown. Multiples of the baseline MET values provide a uniform terminology across different exercise protocols to express aerobic demands for specific activities. Maximum and submaximum levels of work differ per unit of time according to the exercise protocol used. Thus, 6 minutes of a Naughton protocol is not equivalent to 6 minutes on a standard Bruce protocol in terms of work performed and energy expended. The predicted MET level for a certain activity is influenced by the degree of conditioning and genetic predisposition. Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities (55). In 1 series of 600 consecutive patients undergoing major noncardiac procedures, perioperative myocardial ischemia and cardiovascular events were more common in patients who reported poor exercise tolerance (inability to walk 4 blocks or climb 2 flights of stairs), even after adjustment for baseline characteristics known to be associated with increased risk (55). The likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked (P=0.006) or flights of stairs that could be climbed (P=0.01). Examples of leisure activities associated with less than 4 METs are slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at a speed of approximately 2 to 3 mph. Activities that require more than 4 METs include moderate cycling, climbing hills, ice skating, roller blading, skiing, singles tennis, and jogging. The Duke Activity Status Index contains questions that can be used to estimate the patient's functional capacity (11,52). Use of the Duke Activity Status Index or other activity scales (53) and knowledge of the METs levels required for physical activities, as listed above and described in Table 3, provide the clinician with a relatively easy set of questions to estimate whether a patient's functional capacity will be less than or greater than 4 METs. At activity levels less than 4 METs, specific questions to establish risk gradients are less reliable. Furthermore, a clinical questionnaire only estimates functional capacity and does not provide as objective a measurement as exercise treadmill testing or arm ergometry. Other activity scales have been advocated, including the Specific Activity Scale (57).

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

If the patient has 1 or 2 clinical risk factors, then it is reasonable to either proceed with the planned surgery, with heart rate control with beta blockade, or consider testing if it will change management. Two studies in vascular surgery patients with 1 to 2 clinical risk factors were unable to demonstrate any difference in outcome in the group who proceeded with the planned surgery with good medical management or tight heart rate control, but there are circumstances in which the clinician may change aspects of care based on the results of the test (58,59).

In patients with 3 or more clinical risk factors, the surgery-specific cardiac risk is important. The surgery-specific cardiac risk (Table 4) of noncardiac surgery is related to 2 important factors. First, the type of surgery itself may identify a patient with a greater likelihood of underlying heart disease and higher perioperative morbidity and mortality. Perhaps the most extensively studied example is vascular surgery, in which underlying CAD is present in a substantial portion of patients. If the patient is undergoing vascular surgery, testing should only be considered if it will change management. Other types of surgery may be associated with similar risk to vascular surgery but have not been studied extensively. For nonvascular surgery, the degree of hemodynamic cardiac stress dictates the surgery-specific risk. Depending on the noncardiac surgical procedure, it may be associated with profound alterations in heart rate, blood pressure, vascular volume, pain, bleeding, clotting tendencies, oxygenation, neurohumoral activation, and other perturbations. The intensity of these coronary and myocardial stressors helps determine the likelihood of perioperative cardiac events. The perioperative morbidity related to the procedures ranges from 1% to 5%. In these patients who are considered ready to undergo intermediate-risk surgery, there are insufficient data to determine the best strategy (proceeding with the planned surgery with tight heart rate control with beta blockade or further cardiovascular testing if it will change management).