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

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 of all such that may be perceived as or conflicts of Writing members are to a relationship with industry that may be perceived as to a writing a relationship with industry they are to in The of the writing will be These are by the task to all members of the writing and and by the writing as to the for ACC/AHA writing available on the and and for of the on with Appendix I for with industry and Appendix II for peer with industry that are to these guidelines. These practice guidelines are to in clinical by a of for the management, and prevention of diseases or These guidelines to that the of most in most Clinical the and of in the area where care is These recommendations a of expert a review of the available, evidence and are to improve patient Patient to and on medical and is an important of of treatment in with these recommendations will be effective they are of patient and may affect treatment outcomes, and other every effort to the patient in with medical and these guidelines are as the basis for or the is of care and the The care of a particular patient be by the and the patient in of all of the by that are in from these guidelines are appropriate. The guidelines will be by the ACC/AHA Task Force on Practice Guidelines and will be they are or and from The and recommendations are in the of the of the American College of Cardiology and of The are in the of the as well as on the and of the and the are available from both ACC/AHA Task Force on Practice Guidelines ACC/AHA Task Force on Practice Guidelines Definition of the Problem Purpose of These Guidelines These guidelines an to those in and are for and are in the and care of a for of in a of patient and The writing that these guidelines to is and this can be in the The and for The of this is that is to the of such is of the The of is to medical to perform an of the medical recommendations the management, and of the and a clinical that the primary and and can use in treatment that may influence and be is to influence patient The of the is the care of the Methodology and Evidence The ACC/AHA to the Guidelines on Perioperative Evaluation for Noncardiac Surgery a review of the literature to since the of these guidelines in were in the and the the of and the were to the the and were in to additional members the of the formal of the recommendations in this were from the in the guidelines to a of recommendations that been written in to a such that a and from the of the document, the of the It is that this will the of the guidelines. the of an or for is of recommendations and of for Preoperative Noninvasive Evaluation of Function It is for with of to of of It is for with or with or other in clinical to of LV of of LV in with is well of III Routine of LV in is of for Preoperative 12-Lead ECG I Preoperative ECG is for with clinical are of Preoperative ECG is for with or disease are of Preoperative ECG is in with clinical are of Preoperative ECG may be in with clinical are of III Preoperative and are in of for Noninvasive Stress Testing Noncardiac Surgery I Patients with in is be and ACC/AHA of Cardiac for the Patient Evaluation and Treatment Noncardiac Surgery of Noninvasive of with or clinical and will of Noninvasive may be for with to clinical will of Noninvasive may be for with to clinical and or to are of III Noninvasive is for with clinical of Noninvasive is for of for Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or Percutaneous Coronary of the I are with the ACC/AHA for Coronary Artery Bypass I Coronary is in with have significant of Coronary is in with have is when is of Coronary is in with have disease with significant and or on of Coronary is for with or of Coronary is in with of in with is for of and in the a of or by to of is of have and procedures that the of is to all and the as as of The of is well in with of of The of is well for with an to of III It is that be in with disease of is to of or of in in or and will to be of is of with of for Beta-Blocker Medical I Beta be in are to or other ACC/AHA I of Beta be to are to the of on of Beta are for in assessment of Beta are for in assessment for as by the of clinical of Beta are for in assessment disease or as by the of clinical are or of The of is for are procedures or in assessment a clinical of The of is in with clinical are of III Beta be to have absolute to of for Statin Therapy I and for be of with or clinical use is of with clinical are procedures, may be of for Alpha-2 Agonists Alpha-2 for of may be for with CAD or clinical are of III Alpha-2 be to have to this of for Preoperative Preoperative care with a for of might be considered; however, is and be to a of selected whose is and have of for Use of Anesthetic It can be to use for the of in for of for Intraoperative The of as a to and is for those have to The for use of the and patient and that and can and of for Use of The use of or is to the of an and of for of I of in a is for most procedures other in is to of for Perioperative of It is that be the in with or are for or are and procedures with care of The of of the is in with or are procedures care of for Perioperative Use of Pulmonary Artery Catheters Use of a may be in for that are by a however, the be on patient and and practice in use and of of the data from a may of III Routine use of a in of is of for Intraoperative and Postoperative Use of Intraoperative and can be to with CAD or those with when available, to the of Intraoperative and may be in with or for CAD are of for Surveillance for Perioperative MI I Postoperative is in with ECG or of of The use of is well in are and have and of III Postoperative is in have of General Approach to the Patient on the of the patient is for or with CAD or the of or of assessment be the a assessment of and is in those of or the evidence to the of and of a in this Preoperative be to the that have the and to the of the in is an is to perform a the may to a of of an a is is important to the and that all of the are when a a been the review available patient a and perform a that includes a cardiovascular and to the and the role of the is to the of the cardiovascular and the patient is in medical the of the The may in tests or procedures, or of care tests are the information will result in a in the a in medical or or or a of the can be or The in that the may be the to the treatment of a patient with significant disease or of such The and patient be of the of the and for the It is the cardiovascular to of that and will be the overall of include with the and other as well as with the patient the The use such as for History is to the of diseases that the patient in a The to such as or significant and disease It the patient a of a or or a of and with cardiovascular with any in be of and other and is Use of and and be The to the assessment of an to perform a of been to well with by patient as to or CAD is and for may a patient a of cardiovascular disease with clinical that may from a for Physical Examination and Routine Laboratory Tests cardiovascular include an assessment of of in both and and of the and and of the for and a on the cardiovascular that may and of are with an of and in and Multivariable Indices to Predict Preoperative Cardiac Morbidity The clinical by and review of the ECG the with data to and a for the of for independent were disease as of of use of of to be to or ECG with as of or with disease of or or other or treatment for and of with the in of the The Cardiac Risk of the most Clinical Assessment the the to clinical and to be a group of that when clinical The of or of these and may result in or of the is These include or the use of the Cardiac Risk the to the with the clinical from the with the of the of is in the to the Clinical include of of or of and of MI or by ECG is as a clinical an MI as MI or the or MI or to the with evidence of important by clinical or is an the of the are for cardiovascular disease that have been to ECG other and The of might to a of CAD is the recommendations for Stepwise Approach to Perioperative Cardiac Assessment in a for are for of the cardiovascular guidelines in and studies have to of the the of this the Writing to include the of the recommendations and strength of evidence for of the Cardiac and care for on clinical cardiovascular or for of or for clinical for include or and for in this been to ACC/AHA American College of Heart of and for Perioperative Beta-Blocker Therapy on Clinical The the of or an that may for assessment or such the may by recommendations for medical and the patient have of the or clinical in to for the of or or disease to or of the been and of include MI with evidence of important by clinical or or and or in these are for to on the of the or and the of may be to to the with medical the patient these on cardiovascular in result in a in management, and be to with the the patient have will be on the basis of of any cardiovascular It is to with the with cardiovascular disease or clinical with as in the patient a can be from the to perform of this been as to to or The that can be to the the patient is or the of clinical will the for the patient clinical is to with the and in is the patient or clinical is to with the with with or to will with or clinical the is The of is to important the of may a patient with a of disease and and the most is in CAD is in a of the patient is studies that be will of may be with to have been in the to the procedures from to are data to the with the with with or cardiovascular will Cardiac Risk for Noncardiac Disease-Specific Approaches Coronary Artery Disease Patients With Known CAD with as well as those with the is the of in is the that the of to produce is the and the patient on or medical of these is an important of the and and selected is to the of Hypertension or to and or to the benefits of to optimize the of be against the of the With acting can be a of to a to in for with and and or LV or authors have and the of be to in the the patient is to the of Valvular Heart Disease be or the is the be or the been the the other in with or are for can be with a of a patient is a for may be as a to in with are for and may be in with in be of the of of disease is the be to and to the When the is the patient may from or with or are for and with or may be to of Patients with a are of of the for when they that may result in and the for The American College of on and the for procedures the is to the to the or and the of the Perioperative is for in the of with is and the of is in the or or or of the any and LV these the and of Surgery-Specific Issues are with these are most a of the in the patient or for of procedure, or or of CAD with the for the patient is The procedures have been as and disease is the for procedures with of are with of and and procedures the and are with and procedures the procedures and are in the to perform of the of evidence the of in this and be the from the procedures, on the basis of and the that these procedures the and on the and of the procedures may be with may be with and for and the to risks and the for Supplemental Preoperative Evaluation Assessment of LV Function LV been by and It is that LV to be a of Assessment of Risk for CAD and Assessment of Functional Capacity The 12-Lead ECG the a ECG and is that an ECG of is for those with disease in a ECG is Exercise Stress Testing for Myocardial Ischemia and Functional Capacity The of is to an of to the of important or and to and Noninvasive Stress Testing with or in with or been to in for are to is to the of by The of the available resources in disease is as important as the particular of with are for is to with or to to with medical treatment to perform a Perioperative Therapy Preoperative Coronary Revascularization With Coronary Artery Bypass Grafting or PCI Preoperative Coronary Artery Bypass Grafting all of the evidence the of from studies in for are that have the overall of to the of the of can be to of and will be The Artery Revascularization by and with significant from for to or The authors that in with the or of or The Cardiac Risk Evaluation Stress II to the of in with and of and MI that is a for to the of The a of for were to medical and or medical in the outcomes of or MI or the and medical a of in this to the as to the of in however, the are with the literature a of of in or The for are to those by the ACC/AHA for Coronary Artery Bypass Surgery and the data on those were Preoperative PCI of the literature that PCI is of in in those in PCI is for an in a patient a PCI with to of in those PCI Without Stents: Coronary Balloon Angioplasty of have been the basis of the available for the that the will have and the of or performing the the PCI might be for to to for of the the treatment is by a by be The of the be against the of in from the PCI: Bare-Metal Coronary Stents a is in the procedure, as in the of procedures, of may be is most in the and is of most that will result in MI or in the of in and that the of of the to to for to to for of the for when may to or is with for The and and the of of makes and are for of this to use to the of the been the can be the is It is for this that a are the patient to with be The of the be against the of in from the the of in have a the of of is significant with the of from most PCI: Drug-Eluting Stents of may and been to in the of of an for and College of Association the prevention of of in with that of the of and the of the group the procedures for is a significant of or be have an of they are of and a of for with are to procedures that of be all and the as as the of the and the use of for or that will the of is with the for PCI in the be to those by the ACC/AHA Task Force that guidelines for the use of PCI in with and is evidence to in with or with is evidence to a PCI to against MI or additional is to to PCI or a is is to against in been to Perioperative Management of Patients With Prior PCI Undergoing Noncardiac Surgery have with or or is the is is in is on expert the of and the recommendations The of to and for and in are of a of to the of with on expert be to in the for any patient that the that those have consideration be to the in any patient for the of such as in and in the or have been consideration be to of in any patient with of a The of be against the of in from the be be and the as as is evidence that or will the of of Perioperative Management in Patients Who Have Received Intracoronary Brachytherapy Intracoronary with or been in the to be as the for Percutaneous Coronary with a consideration be to in the for any patient for or those in additional or were the of or to the of The of be against the of in from the Strategy of Percutaneous Revascularization in Patients Needing Urgent Noncardiac Surgery Patients in is is in Percutaneous be in for or or CAD to PCI is the of the and the of with the in a patient to be is of or the can be or PCI with and and be the patient the in the recommendations the is to to a of and to of and with of be the of with this is with are they may as an and they can be with by PCI the is to and the of is consideration be to and with with by PCI the is or the of and the of be and is with the be Treatment for of of and Perioperative Medical Therapy Perioperative Beta-Blocker Therapy of the ACC/AHA on have been that have the efficacy of these in to the studies that of the of are the of in a to in studies that and may the of MI and in with evidence that when be to data that may be to Titration of Beta Blockers and an of absolute with the and to or The authors that can be in that are evidence that effective with be Withdrawal of Beta Blockers the of in the have for in the of in the is a I and evidence that to be the Perioperative Statin Therapy The evidence a of use on and a to the overall of and a in and that an independent of of these data are and in of of and of are Alpha-2 Agonists and a of Alpha-2 to and MI to a clinical on with or for CAD and that of and for to Perioperative Calcium Channel Blockers of in that in studies Calcium to and to and were with and Intraoperative Electromagnetic Interference With Pacemakers and Cardioverter Defibrillators It is important to be of the for and or that may the practice on this been by the American of Patients with are have to significant procedures, as well as procedures include or when the of a patient is the be to an or or a be the Implantable have treatment and on to to that the might as or is the be as from the as and in an to be to the of the is the the of the be and in the of an an be to that been to of a an on the of and a will be in a patient with a is be to be that is by the will affect the of an With of the will the and the With other the will the the is in and the will on or the with an on the is the of these with are the of the may to be to an or to Anesthetic Considerations and Intraoperative Management are to the of the care of the the use of or or and a in from the use of the a or the choice of and is to the of the care Intraoperative may be by the the for and the use of or a of these issues the will for a the Perioperative Pain Management the may be a of specifically in are with patient and effective be in the and be on issues to a patient a a Perioperative Surveillance Intraoperative and Postoperative Use of Pulmonary Artery Catheters Use of a may significant information to the care of the however, the of and the cost with and use be Practice guidelines for as well as of performing of the have been and Evidence of of use from is and a Surveillance for Perioperative MI Perioperative MI can be by clinical studies and or studies for and the the of with the of of or I the of with of of the of the to of an MI is and the frequency the basis of in be to those of cardiovascular The of a MI both and the basis of the available of is to MI with studies of with cardiovascular outcomes any the of treatment on outcomes in with an is that in are to in with the role of in with an other of MI of these issues been be Perioperative for with ECG and is in Postoperative and Long-Term Management in and and of medical have to the frequency of cardiovascular with these cardiovascular the most and most of have a MI have a in the of as as to the of are of assessment to the Myocardial Infarction: Surveillance and Treatment to in the of that in been to for the been and been a is for the treatment of a the role of and were to and and to and this that such a is and may be These procedures be on an basis in in MI is to an of the for and the benefits of be against the of the for Therapy with a and an for with or may be or the are to the review of for MI can be in the ACC/AHA Guidelines for the Management of Patients With Myocardial the Guidelines for Myocardial an important for of this in the the to the of that the of an MI a for that are by cardiovascular Patients a MI have of LV and medical be as in the ACC/AHA MI The ACC/AHA guidelines for in these of be as as Long-Term Management the of a of cardiovascular use the to cardiovascular medical the ACC/AHA Guidelines for the Management of Patients With treatment with a to a of of to and all I It is important that the care for the care of the patient be with information any cardiovascular or for CAD the Conclusions and of and the primary and the for and are the as in the is on the of and The use of both and be to those in the of such tests will affect patient for to an assessment of both and the the patient by recommendations the as well as the for and be the of medical diagnostic and American College of Cardiology Foundation Clinical and Clinical and American Heart Association