ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary

Abstract

Table of Contents I. Introduction A. Development of Guidelines B. General Approach C. Preoperative Clinical Evaluation II. Further Preoperative Testing to Assess Coronary Risk A. Clinical Markers B. Functional Capacity C. Surgery-Specific Risk III. Management of Specific Preoperative Cardiovascular Conditions A. Hypertension B. Valvular Heart Disease C. Myocardial Disease D. Arrhythmias and Conduction Abnormalities E. Implantable Pacemakers or ICDs IV. Supplemental Preoperative Evaluation A. Resting Left Ventricular Function B. 12-Lead ECG C. Exercise or Pharmacological Stress Testing D. Coronary Angiography V. Perioperative Therapy or Previous Coronary Revascularization A. Coronary Artery Bypass Grafting B. Percutaneous Coronary Intervention VI. Perioperative Medical Therapy VII. Anesthetic Considerations and Intraoperative Management A. Anesthetic Agent B. Perioperative Pain Management C. Intraoperative Nitroglycerin D. Transesophageal Echocardiography E. Perioperative Maintenance of Body Temperature VIII. Perioperative Surveillance A. Pulmonary Artery Catheters B. Intraoperative and Postoperative ST-Segment Monitoring C. Surveillance for Perioperative MI IX. Postoperative and Long-Term Management References I. Introduction These guidelines represent an update of those published in 1996 and are intended for physicians 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 overriding theme of these guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. The purpose of preoperative evaluation is not simply 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, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. The goal of the consultation is to identify the most appropriate testing and treatment strategies to optimize care of the patient, provide assessment of both short- and long-term cardiac risk, and avoid unnecessary testing in this era of cost containment. A. Development of Guidelines These guidelines are based on an update of a Medline, EMBASE, Cochrane library, and Best Evidence search of the English literature from 1995 through 2000, a review of selected journals, and the expert opinions of 12 committee members representing various disciplines of cardiovascular care, including general cardiology, interventional cardiology, noninvasive testing, vascular medicine, vascular surgery, anesthesiology, and arrhythmia management. As a result of these searches, more than 400 relevant new articles were identified. In addition, draft guidelines were submitted for critical review and amendment to the executive officers representing the American College of Cardiology (ACC) and the American Heart Association (AHA). A large proportion of the data used to develop these guidelines are based on observational or retrospective studies or knowledge of management of cardiovascular disorders in the nonoperative setting. Although the collective body of knowledge about the identification of high- and low-risk patients by perioperative clinical and noninvasive evaluation is substantial, the number of prospective or randomized studies that have been performed to establish the value of different treatments on perioperative outcomes is small. The ACC/AHA classifications of evidence used in this report to summarize the indication for a particular therapy or treatment are as follows: Class I: Conditions for which there is evidence and/or general agreement that a given procedure/therapy is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy. Class IIa: Weight of evidence/opinion is in favor of usefulness/ efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/ opinion. Class III: Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in some cases may be harmful. Two versions of the full-text guidelines are available on the World Wide Web sites of both the American College of Cardiology (http://www.acc.org) and the American Heart Association (http://www.americanheart.org); one version highlights the updated material (deleted text in strikeout and new text in red), and the other fully incorporates the changes. This document was approved for publication by the governing bodies of the ACC and the AHA, will be reviewed annually by the Task Force, and will be considered current unless the Task Force revises or withdraws them from distribution. B. General Approach The preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and to the nature of the surgical illness (e.g., acute surgical emergency) as opposed to urgent or elective cases. Successful perioperative evaluation and treatment of cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon. In general, indications for further cardiac testing and treatments are the same as those in the nonoperative setting, but their timing is dependent on such factors as the urgency of noncardiac surgery, the patient’s risk factors, and specific surgical considerations. Coronary revascularization before noncardiac surgery to enable the patient to “get through” the noncardiac procedure is appropriate only for a small subset of patients at very high risk. Preoperative testing should be limited to circumstances in which the results will affect patient treatment and outcomes. A conservative approach to the use of expensive tests and treatments is recommended. C. Preoperative Clinical Evaluation The initial history, physical examination, and electrocardiogram (ECG) assessment should focus on identification of potentially serious cardiac disorders, including coronary artery disease (CAD) [e.g., prior myocardial infarction (MI) and angina pectoris], heart failure (HF), symptomatic arrhythmias, presence of pacemaker or implantable cardioverter defibrillator (ICD), or a history of orthostatic intolerance (1). The presence of anemia may also place a patient at higher perioperative risk (2–4). In addition to identifying the presence of pre-existing manifested heart disease, it is essential to define disease severity, stability, and prior treatment. Other factors that help determine cardiac risk include functional capacity, age, comorbid conditions (e.g., diabetes mellitus, peripheral vascular disease, renal dysfunction, and chronic pulmonary disease), and type of surgery (vascular procedures and prolonged, complicated thoracic, abdominal, and head and neck procedures are considered higher risk). Numerous risk indices have been developed over the past 25 years on the basis of multivariate analyses (5–14). In addition to the presence of CAD and HF, a history of cerebrovascular disease, preoperative elevated creatinine greater than 2 mg per deciliter, insulin treatment for diabetes mellitus, and high-risk surgery have all been associated with increased perioperative cardiac morbidity. Despite these risk indices, there was consensus among the committee members to place clinical risk factors into 3 categories of predictors (see Section II-A). II. Further Preoperative Testing to Assess Coronary Risk Which patients are most likely to benefit from preoperative coronary assessment and treatment? The lack of adequately controlled or randomized clinical trials to define the optimal evaluation strategy led to the proposed algorithm based on collected observational data and expert opinion (see Fig. 1). Since publication of the guidelines in 1996, several studies have suggested that this stepwise approach to the assessment of CAD is both efficacious and cost-effective.Figure 1: Stepwise approach to preoperative cardiac assessment. Steps are discussed in text. *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.A stepwise bayesian strategy that relies on assessment of clinical markers, prior coronary evaluation and treatment, functional capacity, and surgery-specific risk is outlined in Figure 1. A framework for determining which patients are candidates for cardiac testing is presented in algorithmic form. Successful use of the algorithm requires an appreciation of the different levels of risk attributable to certain clinical circumstances, levels of functional capacity, and types of surgery. These are defined below, after which the algorithm is reviewed step by step. A. Clinical Markers The major clinical predictors (Table 1) of increased perioperative cardiovascular risk are a recent unstable coronary syndrome such as an acute MI (documented MI less than 7 days previously), recent MI (more than 7 days but less than 1 month before surgery), unstable or severe angina, evidence of a large ischemic burden by clinical symptoms or noninvasive testing, decompensated HF, significant arrhythmias (high-grade atrioventricular block, symptomatic arrhythmias in the presence of underlying heart disease, or supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease.Table 1: Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Heart Failure, Death)Intermediate predictors of increased risk are mild angina pectoris, a more remote prior MI (more than 1 month before planned surgery), compensated HF, preoperative creatinine greater than or equal to 2.0 mg per deciliter, and diabetes mellitus. Minor predictors of risk are advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled systemic hypertension. A history of MI or abnormal Q waves by ECG is listed as an intermediate predictor, whereas an acute MI (defined as at least 1 documented MI less than or equal to 7 days 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 a major predictor. 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 (6,15). Current management of MI provides for risk stratification during convalescence (16). 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. B. Functional Capacity Functional capacity can be expressed in metabolic equivalent (MET) levels (Table 2). Multiples of the baseline MET value can be used to express aerobic demands for specific activities. Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities (17–19). The Duke Activity Status Index and other activity scales provide the clinician with a set of questions to determine a patient’s functional capacity (20–22). Energy expenditures for activities such as eating, dressing, walking around the house, and dishwashing range from 1 to 4 METs. Climbing a flight of stairs, walking on level ground at 6.4 km per hour, running a short distance, scrubbing floors, or playing a game of golf represents 4 to 10 METs. Strenuous sports such as swimming, and 10 Energy for Surgery-Specific Risk cardiac risk of noncardiac surgery is to 2 important the type of surgery and the of stress associated with the The and of coronary and myocardial can be in the likelihood of perioperative cardiac for surgery. risk for noncardiac surgery can be as and low (Table surgery major surgery, in the and other major vascular peripheral vascular and procedures associated with large and/or procedures include and surgery, head and neck surgery, surgery, and surgery. procedures include and surgery, and for to the algorithm presented in Figure 1. 1 is the urgency of noncardiac not for preoperative cardiac Postoperative risk stratification may be appropriate for some patients who have not such an assessment 2 the patient coronary revascularization in the past If and clinical has of further cardiac testing is not necessary 3 the patient a coronary evaluation in the past 2 If coronary risk was adequately and the were it is not necessary to testing unless the patient has a or new symptoms of coronary the 4 the patient have an unstable coronary syndrome or a major clinical of elective noncardiac surgery is the presence of unstable coronary disease, decompensated HF, symptomatic arrhythmias, and/or severe valvular heart disease to cancellation or delay of surgery the has been and the patient have intermediate clinical predictors of The presence or of prior MI by history or ECG, angina pectoris, compensated or prior HF, preoperative creatinine greater than or equal to 2 mg per deciliter, and/or diabetes to further clinical risk for perioperative coronary of functional capacity and level of surgery-specific risk a approach to identify patients most likely to benefit from further noninvasive 6 major but with intermediate predictors of clinical risk and or functional capacity can surgery with likelihood of perioperative or further noninvasive testing is considered for patients with functional capacity or functional capacity but surgery, for patients with 2 or more intermediate predictors of risk. 7 surgery is for patients with major intermediate predictors of clinical risk and or functional capacity or testing may be considered on an basis for patients clinical but with functional capacity who are those with several clinical predictors of risk who are to vascular surgery. The results of noninvasive testing can be used to determine the for preoperative testing and treatment. In some patients with documented the risk of coronary intervention or cardiac surgery may approach or the risk of the proposed noncardiac surgery. This approach may be it the patient’s long-term some a careful of and functional to a to to coronary III. Management of Specific Preoperative Cardiovascular Conditions A. Hypertension 3 greater than or equal to and greater than or equal to should be controlled before surgery. In such of an can be over several days to weeks of preoperative treatment. If surgery is more can be that in a of or to be of preoperative treatment through the perioperative is B. Valvular Heart Disease for evaluation and treatment of valvular heart disease are to those in the setting. are associated with risk of perioperative or and or before noncardiac surgery to lower cardiac risk disease is and may be with medical therapy and disease can be with or after noncardiac surgery. Medical therapy and are appropriate a delay of several weeks or before noncardiac surgery may have severe may include severe valvular with ventricular in which is limited that during perioperative is C. Myocardial Disease and are associated with an increased of perioperative Management is at preoperative and postoperative medical therapy and of is useful for from or postoperative D. Arrhythmias and Conduction Abnormalities The presence of an arrhythmia or cardiac should a careful evaluation for underlying disease, or metabolic Therapy should be for symptomatic or significant arrhythmias, to an underlying and to the for therapy and cardiac are to those in the nonoperative setting. ventricular and/or ventricular have not been associated with an increased risk of MI or cardiac in the perioperative and or treatment in the perioperative is not E. Implantable Pacemakers or ICDs The type and of evaluation of a pacemaker or on the urgency of the surgery, a pacemaker has or is or the between and and pacemaker should be before surgery and on IV. Supplemental Preoperative Evaluation Specific recommendations for preoperative evaluation must be to patient and The may be appropriate in specific assessment of ventricular stress testing, stress testing, ECG and coronary In most the test of is ECG testing, which can both provide an of functional capacity and myocardial through in the ECG and In patients with important on their ECG (e.g., block, ventricular with or other such as or myocardial should be testing are given A. Resting Left Ventricular Function Resting ventricular has not been to be a of perioperative ischemic for Preoperative Evaluation of Left Ventricular Function Class with current or controlled evaluation has documented severe ventricular dysfunction, preoperative testing may not be Class with prior and patients with of Class As a test of ventricular in patients prior B. 12-Lead ECG The ECG does not identify increased perioperative risk in patients undergoing low-risk surgery, but certain ECG are clinical predictors of increased perioperative and long-term cardiovascular risk in and high-risk patients for Preoperative 12-Lead ECG Class of or ischemic equivalent in or high-risk patients for an or high-risk Class with diabetes mellitus. Class 1. with prior coronary more than years or more than years with 2 or more risk for cardiac Class As a test in undergoing low-risk C. Exercise or Pharmacological Stress Testing for Exercise or Pharmacological Stress Testing Class of patients with intermediate of assessment of patients undergoing initial evaluation for or evaluation of with significant in clinical of of myocardial before coronary Evaluation of of medical assessment after an acute coronary syndrome recent evaluation Class Evaluation of capacity assessment is Class of CAD patients with high or low those with less than 1 those or those with ECG for ventricular of in high-risk the initial after coronary intervention Class stress testing, of patients with ECG that adequate ventricular greater than 1 or likely to or for of or of in D. Coronary Angiography for Coronary Angiography in Perioperative Evaluation Class I: or CAD Evidence for high risk of based on noninvasive test to adequate medical angina, or noncardiac surgery. noninvasive test results in patients at high clinical risk undergoing surgery. Class of intermediate clinical and planned vascular surgery testing should be considered to large on noninvasive testing but high-risk and lower ventricular noninvasive test results in patients at intermediate clinical risk undergoing high-risk noncardiac surgery. noncardiac surgery from acute Class Perioperative or angina and planned low-risk or surgery. Class noncardiac surgery with CAD and no high-risk results on noninvasive after coronary revascularization with capacity than or equal to 7 angina with ventricular and no high-risk noninvasive test for coronary revascularization to medical severe ventricular (e.g., ventricular less than or to for or renal less than years as of evaluation for unless noninvasive testing high risk for V. Perioperative Therapy or Previous Coronary Revascularization A. Coronary Artery Bypass Grafting for coronary artery before noncardiac surgery are to those reviewed in the ACC/AHA guidelines for is rarely indicated simply to “get a patient through” noncardiac surgery. In patients in the Coronary Artery the cardiac risk associated with noncardiac the and head and neck was in those patients who prior undergoing elective noncardiac procedures who are to have high-risk coronary and in long-term likely be by should revascularization before a noncardiac elective surgical procedure of high or intermediate risk (Table B. Percutaneous Coronary Intervention are no controlled trials perioperative cardiac after noncardiac surgery for patients with preoperative medical small observational have suggested that cardiac is in patients who have before noncardiac surgery studies have also a number of from including in some further data are indications for in the perioperative are to those in the ACC/AHA guidelines for use of in general is should between and noncardiac surgery for at least 1 after to for of the has If a coronary is a delay of at least 2 weeks and 4 to 6 weeks should before noncardiac surgery to 4 weeks of therapy and of the to be or VI. Perioperative Medical Therapy recent trials have the of medical therapy before surgery on cardiac Two trials of have been performed perioperative cardiac and the other 6-month with perioperative trials have the of cardiac in the subset of patients with CAD undergoing vascular surgery are very randomized trials of medical therapy before noncardiac surgery to perioperative cardiac and not provide data from which to firm or are to the on of MI or cardiac and on the of ECG to Current that perioperative and may the risk of MI and in high-risk should be days or weeks before elective surgery, with the to a heart between and per Perioperative treatment with may have on myocardial and cardiac this is an in which further be for Perioperative Medical Therapy Class in the recent past to symptoms of angina or patients with symptomatic arrhythmias or hypertension. patients at high cardiac risk to the of on preoperative testing who are undergoing vascular surgery. Class preoperative assessment coronary disease, or major risk factors for coronary Class perioperative of or CAD or major risk factors for Class to to VII. Anesthetic Considerations and Intraoperative Management A. Anesthetic Agent and have cardiac that should be considered in the perioperative appears to be no one the of and is to the of the care which will the for postoperative cardiovascular myocardial and level of the of in which is by have that use of this the of general or but no studies have established to can to increased stress and/or myocardial B. Perioperative Pain Management and/or is a for postoperative studies that management to a in postoperative and C. Intraoperative Nitroglycerin are data about the of in patients at high risk Nitroglycerin should be used only the of other in use have been D. Transesophageal Echocardiography are data on the value of to in cardiac in noncardiac surgical patients to that the value of this for risk is small Guidelines for appropriate use of have been published by the American of and the of Cardiovascular E. Perioperative Maintenance of Body Temperature randomized a of perioperative cardiac in patients who were in a of with care VIII. Perioperative Surveillance A. Pulmonary Artery Catheters Although very studies that have been patient outcomes after treatment with or pulmonary artery 3 are important in benefit risk of pulmonary artery disease severity, of surgery, and The of is a primary most likely to benefit from perioperative use of a pulmonary artery to be those with a recent MI complicated by HF, those with significant CAD who are undergoing procedures associated with significant and those with or ventricular dysfunction, and/or valvular disease who are undergoing high-risk B. Intraoperative and Postoperative ST-Segment Monitoring Intraoperative and postoperative myocardial are predictors of perioperative MI in patients at high risk who noncardiac surgery postoperative is a significant of long-term risk of MI and cardiac in patients at low risk who noncardiac surgery, may and is not associated with evidence that use of in selected patients at high risk may for myocardial C. Surveillance for Perioperative MI studies have the optimal for a perioperative Clinical postoperative ECG and of the of have been most of such as or have also been to be of value In patients with or CAD who are undergoing high-risk at after surgery, and on the 2 days after surgery to be A risk can be based on the of the presence or of new ECG and and of of cardiac is for patients at high risk and those with ECG, or evidence of cardiovascular IX. Postoperative and Long-Term Management Despite optimal perioperative management, some patients will have perioperative which is associated with a to patients who a symptomatic perioperative MI as a result of coronary should be considered after the risks have been Pharmacological therapy with should be as as and a and may also be Perioperative MI a high risk for cardiac who acute MI in the perioperative should careful medical evaluation for residual and ventricular is also appropriate to risk in the large number of elective surgery patients in cardiovascular are during preoperative Although the of surgery is as a specific high-risk most of the patients who have or CAD during their preoperative will not have during elective noncardiac surgery. the preoperative cardiac risk has been by clinical or noninvasive testing, most patients will benefit from to lower or the basis of expert the goal should be to lower the level to less than mg per per