AHA/ACC 2007 executive summary


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AHA/ACC 2007 executive summary

  1. 1. Cardiovascular Anesthesiology Cardiovascular and Thoracic Education Hemostasis and Transfusion Medicine Section Editor: Charles W. Houge, Jr. Section editor: Martin J. London Section Editor: Jerrold H. Levy Special Article ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary 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 WRITING COMMITTEE MEMBERS Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC¶; Kenneth A. Brown, MD, FACC, FAHA†; Hugh Calkins, MD, FACC, FAHA‡; Elliott Chaikof, MD#; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC*; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC§; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice Chair; Cynthia D. Adams, MSN, PhD, FAHA†; Jeffrey L. Anderson, MD, FACC, FAHA††; Elliott M. Antman, MD, FACC, FAHA**; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; David P. Faxon, MD, FACC, FAHA††; Valentin Fuster, MD, PhD, FACC, FAHA††; Jonathan L. Halperin, MD, FACC, FAHA††; Loren F. Hiratzka, MD, FACC, FAHA††; Sharon A. Hunt, MD, FACC, FAHA††; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC††; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA††; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC * American Society of Echocardiography Official Representative. † American Society of Nuclear Cardiology Official Representative. ‡ Heart Rhythm Society Official Representative. § Society of Cardiovascular Anesthesiologists Official Representative. Society for Cardiovascular Angiography and Interventions Official Representative. ¶ Society for Vascular Medicine and Biology Official Representative. # Society for Vascular Surgery Official Representative. ** Immediate Past Chair. †† Task Force member during this writing effort. This document was approved by the American College of Cardiology Foundation Board of Trustees in 2007 and by the American Heart Association Science Advisory and Coordinating Committee in June 2007. When this document is cited, the American College of Cardiology Foundation and American Heart Association request that the following citation format be used: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: 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). Circulation. 2007;116:1971–1996. This article has been copublished in the October 23, 2007, issue of the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (my.americanheart.org). To purchase Circulation reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation or the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier 4431. A link to the “Permission Request Form” appears on the right side of the page. Originally published in Circulation. 2007;116:1971-1996. © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. DOI: 10.1213/01/ane.0000309024.28586.70 Vol. 106, No. 3, March 2008 685
  2. 2. TABLE OF CONTENTS VII. Anesthetic Considerations and Preamble.........................................................................686 Intraoperative Management ....................................703 I. Definition of the Problem .......................................688 A. Intraoperative Management ..................................703 A. Purpose of These Guidelines ...........................688 B. Perioperative Pain Management...........................703 B. Methodology and Evidence..............................689 VIII. Perioperative Surveillance ......................................703 II. General Approach to the Patient .........................692 A. Intraoperative and Postoperative Use of A. History..................................................................693 Pulmonary Artery Catheters.................................703 B. Physical Examination and Routine B. Surveillance for Perioperative MI ...................703 Laboratory Tests .................................................693 IX. Postoperative and Long-Term Management ....703 C. Multivariable Indices to Predict A. Myocardial Infarction: Surveillance and Preoperative Cardiac Morbidity......................694 Treatment.............................................................703 D. Clinical Assessment...........................................694 B. Long-Term Management...................................704 1. Stepwise Approach to Perioperative X. Conclusions ..............................................................704 Cardiac Assessment......................................695 Appendix I ................................................................705 III. Disease-Specific Approaches ...............................696 Appendix II...............................................................706 A. Coronary Artery Disease ..................................696 Appendix III .............................................................710 1. Patients With Known CAD ........................696 B. Hypertension .......................................................696 C. Valvular Heart Disease .....................................696 PREAMBLE IV. Surgery-Specific Issues .........................................697 It is important that the medical profession play a V. Supplemental Preoperative Evaluation ..............697 significant role in critically evaluating the use of A. Assessment of LV Function ........................................697 diagnostic procedures and therapies as they are intro- B. Assessment of Risk for CAD and duced and tested in the detection, management, or Assessment of Functional Capacity ................697 prevention of disease states. Rigorous and expert 1. The 12-Lead ECG ..........................................697 analysis of the available data documenting the abso- 2. Exercise Stress Testing for Myocardial lute and relative benefits and risks of those procedures Ischemia and Functional Capacity .............698 and therapies can produce helpful guidelines that 3. Noninvasive Stress Testing ..........................698 improve the effectiveness of care, optimize patient VI. Perioperative Therapy ..........................................698 outcomes, and favorably affect the overall cost of care A. Preoperative Coronary Revascularization by focusing resources on the most effective strategies. With Coronary Artery Bypass Grafting The American College of Cardiology (ACC) Foun- or PCI ...................................................................698 dation and the American Heart Association (AHA) 1. Preoperative Coronary Artery Bypass have jointly engaged in the production of such guide- Grafting ...........................................................698 lines in the area of cardiovascular disease since 1980. 2. Preoperative PCI ...........................................698 The ACC/AHA Task Force on Practice Guidelines, 3. PCI Without Stents: Coronary Balloon whose charge is to develop, update, or revise practice Angioplasty .....................................................698 guidelines for important cardiovascular diseases and 4. PCI: Bare-Metal Coronary Stents ................699 procedures, directs this effort. Writing committees are 5. PCI: Drug-Eluting Stents ..............................699 charged with the task of performing an assessment of 6. Perioperative Management of Patients the evidence and acting as an independent group of With Prior PCI Undergoing Noncardiac authors to develop, update, or revise written recom- Surgery.............................................................699 mendations for clinical practice. 7. Perioperative Management in Patients Who Experts in the subject under consideration have Have Received Intracoronary been selected from both organizations to examine Brachytherapy.............................................................700 subject-specific data and write guidelines. The process 8. Strategy of Percutaneous Revascularization includes additional representatives from other medi- in Patients Needing Urgent Noncardiac cal practitioner and specialty groups when appropri- Surgery.............................................................700 ate. Writing committees are specifically charged to B. Perioperative Medical Therapy ........................701 perform a formal literature review, weigh the strength 1. Perioperative Beta-Blocker Therapy ...........701 of evidence for or against a particular treatment or a. Titration of Beta Blockers ........................701 procedure, and include estimates of expected health b. Withdrawal of Beta Blockers ..................702 outcomes where data exist. Patient-specific modifiers, 2. Perioperative Statin Therapy .......................702 comorbidities, and issues of patient preference that 3. Alpha-2 Agonists............................................702 might influence the choice of particular tests or thera- 4. Perioperative Calcium Channel Blockers ..702 pies are considered, as well as frequency of follow-up C. Intraoperative Electromagnetic Interference and cost-effectiveness. When available, information With Implantable Pacemakers and Cardioverter from studies on cost will be considered; however, Defibrillators..............................................................702 review of data on efficacy and clinical outcomes will 686 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  3. 3. Table 1. Applying classification of recommendations and level of evidence. Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 687
  4. 4. constitute the primary basis for preparing recommen- ultimate judgment regarding care of a particular pa- dations in these guidelines. tient must be made by the healthcare provider and the The ACC/AHA Task Force on Practice Guidelines patient in light of all of the circumstances presented by makes every effort to avoid any actual, potential, or that patient. There are circumstances in which devia- perceived conflicts of interest that may arise as a result of tions from these guidelines are appropriate. an industry relationship or personal interest of the The guidelines will be reviewed annually by the writing committee. Specifically, all members of the writ- ACC/AHA Task Force on Practice Guidelines and ing committee, as well as peer reviewers of the docu- will be considered current unless they are updated, ment, were asked to provide disclosure statements of all revised, or sunsetted and withdrawn from distribu- such relationships that may be perceived as real or tion. The executive summary and recommendations potential conflicts of interest. Writing committee mem- are published in the October 23, 2007, issue of the bers are also strongly encouraged to declare a previous Journal of the American College of Cardiology and relationship with industry that may be perceived as October 23, 2007, issue of Circulation. The full text- relevant to guideline development. If a writing commit- guidelines are e-published in the same issue of the tee member develops a new relationship with industry journals noted above, as well as posted on the ACC during their tenure, they are required to notify guideline (www.acc.org) and AHA (www.americanheart.org) staff in writing. The continued participation of the writ- Web sites. Copies of the full text and the executive ing committee member will be reviewed. These state- summary are available from both organizations. ments are reviewed by the parent task force, reported Sidney C. Smith, Jr, MD, FACC, FAHA orally to all members of the writing committee at each Chair, ACC/AHA Task Force on Practice Guidelines meeting, and updated and reviewed by the writing Alice K. Jacobs, MD, FACC, FAHA, committee as changes occur. Please refer to the method- Vice Chair, ACC/AHA Task Force on Practice Guidelines ology manual for ACC/AHA guideline writing commit- tees, available on the ACC and AHA World Wide Web sites (http://www.acc.org/qualityandscience/ I. DEFINITION OF THE PROBLEM clinical/manual/manual_I.htm and http://circ. ahajournals.org/manual/), for further description A. Purpose of These Guidelines of the policy on relationships with industry. Please These guidelines represent an update to those pub- see Appendix I for author relationships with indus- lished in 2002 and are intended for physicians and try and Appendix II for peer reviewer relationships nonphysician caregivers who are involved in the with industry that are pertinent to these guidelines. preoperative, operative, and postoperative care of These practice guidelines are intended to assist patients undergoing noncardiac surgery. They pro- healthcare providers in clinical decision making by vide a framework for considering cardiac risk of describing a range of generally acceptable approaches noncardiac surgery in a variety of patient and surgical for the diagnosis, management, and prevention of situations. The writing committee that prepared these specific diseases or conditions. These guidelines at- guidelines strove to incorporate what is currently tempt to define practices that meet the needs of most known about perioperative risk and how this knowl- patients in most circumstances. Clinical decision mak- edge can be used in the individual patient. ing should consider the quality and availability of The tables and algorithms provide quick refer- expertise in the area where care is provided. These ences for decision making. The overriding theme of guideline recommendations reflect a consensus of this document is that intervention is rarely neces- expert opinion after a thorough review of the avail- sary to simply lower the risk of surgery unless such able, current scientific evidence and are intended to intervention is indicated irrespective of the preop- improve patient care. erative context. The purpose of preoperative evalu- Patient adherence to prescribed and agreed on ation is not to give medical clearance but rather to medical regimens and lifestyles is an important aspect perform an evaluation of the patient’s current medi- of treatment. Prescribed courses of treatment in accor- cal status; make recommendations concerning the dance with these recommendations will only be effec- evaluation, management, and risk of cardiac prob- tive if they are followed. Because lack of patient lems over the entire perioperative period; and pro- understanding and adherence may adversely affect vide a clinical risk profile that the patient, primary treatment outcomes, physicians and other healthcare physician and nonphysician caregivers, anesthesi- providers should make every effort to engage the ologist, and surgeon can use in making treatment patient in active participation with prescribed medical decisions that may influence short- and long-term regimens and lifestyles. cardiac outcomes. No test should be performed If these guidelines are used as the basis for regula- unless it is likely to influence patient treatment. The tory or payer decisions, the ultimate goal is quality of goal of the consultation is the optimal care of the care and serving the patient’s best interests. The patient. 688 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  5. 5. B. Methodology and Evidence factor* who are undergoing vascular surgical The ACC/AHA Committee to Revise the 2002 procedures. (Level of Evidence: B) Guidelines on Perioperative Cardiovascular Evalua- 2. Preoperative resting 12-lead ECG is recom- tion for Noncardiac Surgery conducted a comprehen- mended for patients with known coronary heart sive review of the literature relevant to perioperative disease, peripheral arterial disease, or cerebrovas- cardiac evaluation published since the last publication cular disease who are undergoing intermediate- of these guidelines in 2002. Literature searches were risk surgical procedures. (Level of Evidence: C) conducted in the following databases: PubMed, MED- LINE, and the Cochrane Library (including the Class IIa Cochrane Database of Systematic Reviews and the 1. Preoperative resting 12-lead ECG is reasonable Cochrane Controlled Trials Register). Searches were in persons with no clinical risk factors who are limited to the English language, the years 2002 undergoing vascular surgical procedures. through 2007, and human subjects. Related-article (Level of Evidence: B) searches were conducted in MEDLINE to find addi- Class IIb tional relevant articles. Finally, committee members 1. Preoperative resting 12-lead ECG may be rea- recommended applicable articles outside the scope of sonable in patients with at least 1 clinical risk the formal searches. factor who are undergoing intermediate-risk All of the recommendations in this guideline up- operative procedures. (Level of Evidence: B) date were converted from the tabular format used in the 2002 guidelines to a listing of recommendations Class III that has been written in full sentences to express a 1. Preoperative and postoperative resting 12-lead complete thought, such that a recommendation, even ECGs are not indicated in asymptomatic per- if separated and presented apart from the rest of the sons undergoing low-risk surgical procedures. document, would still convey the full intent of the (Level of Evidence: B) recommendation. It is hoped that this will increase the reader’s comprehension of the guidelines. Also, Recommendations for Noninvasive Stress Testing the level of evidence, either an A, B, or C, for each Before Noncardiac Surgery recommendation is now provided (Table 1). Class I 1 Patients with active cardiac conditions (Table 2) Recommendations in whom noncardiac surgery is planned should Recommendations for Preoperative Noninvasive be evaluated and treated per ACC/AHA guide- Evaluation of Left Ventricular Function lines† before noncardiac surgery. (Level of Evi- Class IIa dence: B) 1. It is reasonable for patients with dyspnea of Class IIa unknown origin to undergo preoperative 1. Noninvasive stress testing of patients with 3 or evaluation of left ventricular (LV) function. more clinical risk factors and poor functional (Level of Evidence: C) capacity (less than 4 metabolic equivalents 2. It is reasonable for patients with current or [METs]) who require vascular surgery‡ is rea- prior heart failure with worsening dyspnea or sonable if it will change management. (Level of other change in clinical status to undergo pre- Evidence: B) operative evaluation of LV function if not per- formed within 12 months. (Level of Evidence: C) Class IIb 1. Noninvasive stress testing may be considered Class IIb for patients with at least 1 to 2 clinical risk 1. Reassessment of LV function in clinically factors Gand poor functional capacity (less than stable patients with previously documented cardiomyopathy is not well established. (Level *Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovas- of Evidence: C) cular disease, diabetes mellitus, and renal insufficiency. † ACC/AHA/ESC 2006 Guidelines for the Management of Pa- Class III tients With Atrial Fibrillation,1 ACC/AHA 2005 Guideline Update 1. Routine perioperative evaluation of LV func- for the Diagnosis and Management of Chronic Heart Failure in the Adult,2 ACC/AHA Guidelines for the Management of Patients tion in patients is not recommended. (Level of With ST-Elevation Myocardial Infarction,3 ACC/AHA/ESC Guide- Evidence: B) lines for the Management of Patients With Supraventricular Ar- rhythmias,4 ACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Recommendations for Preoperative Resting 12-Lead Infarction,5 ACC/AHA 2006 Guidelines for the Management of ECG Patients With Valvular Heart Disease,6 and ACC/AHA/ESC 2006 Class I Guidelines for the Management of Patients With Ventricular Ar- rhythmias and the Prevention of Sudden Cardiac Death.7 1. Preoperative resting 12-lead ECG is recom- ‡ Vascular surgery is defined by aortic and other major vascular mended for patients with at least 1 clinical risk surgery and peripheral vascular surgery. See Table 4. Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 689
  6. 6. 4 METs) who require intermediate-risk noncar- Class IIa diac surgery if it will change management. 1. In patients in whom coronary revascularization (Level of Evidence: B) with percutaneous coronary intervention (PCI) is 2. Noninvasive stress testing may be considered appropriate for mitigation of cardiac symptoms for patients with at least 1 to 2 clinical risk and who need elective noncardiac surgery in the factors and good functional capacity (greater subsequent 12 months, a strategy of balloon an- than or equal to 4 METs) who are undergoing gioplasty or bare-metal stent placement followed vascular surgery. (Level of Evidence: B) by 4 to 6 weeks of dual-antiplatelet therapy is probably indicated. (Level of Evidence: B) Class III 2. In patients who have received drug-eluting 1. Noninvasive testing is not useful for patients coronary stents and who must undergo urgent with no clinical risk factors undergoing surgical procedures that mandate the discon- intermediate-risk noncardiac surgery. (Level tinuation of thienopyridine therapy, it is rea- of Evidence: C) sonable to continue aspirin if at all possible 2. Noninvasive testing is not useful for patients and restart the thienopyridine as soon as pos- undergoing low-risk noncardiac surgery. (Level sible. (Level of Evidence: C) of Evidence: C) Class IIb 1. The usefulness of preoperative coronary revascu- Recommendations for Preoperative Coronary Revas- larization is not well established in high-risk cularization With Coronary Artery Bypass Grafting ischemic patients (eg, abnormal dobutamine or Percutaneous Coronary Intervention stress echocardiogram with at least 5 segments of (All of the Class I indications below are consistent wall-motion abnormalities). (Level of Evidence: C) with the ACC/AHA 2004 Guideline Update for Cor- 2. The usefulness of preoperative coronary revas- onary Artery Bypass Graft Surgery.) cularization is not well established for low-risk ischemic patients with an abnormal dobuta- Class I mine stress echocardiogram (segments 1 to 4). 1. Coronary revascularization before noncardiac (Level of Evidence: B) surgery is useful in patients with stable angina who have significant left main coronary artery Class III stenosis. (Level of Evidence: A) 1. It is not recommended that routine prophylac- 2. Coronary revascularization before noncardiac tic coronary revascularization be performed in patients with stable coronary artery disease surgery is useful in patients with stable angina (CAD) before noncardiac surgery. (Level of Evi- who have 3-vessel disease. (Survival benefit is dence: B) greater when left ventricular ejection fraction is 2. Elective noncardiac surgery is not recommended less than 0.50.) (Level of Evidence: A) within 4 to 6 weeks of bare-metal coronary stent 3. Coronary revascularization before noncardiac implantation or within 12 months of drug-eluting surgery is useful in patients with stable angina coronary stent implantation in patients in whom who have 2-vessel disease with significant proxi- thienopyridine therapy or aspirin and thienopy- mal left anterior descending stenosis and either ridine therapy will need to be discontinued peri- ejection fraction less than 0.50 or demonstrable operatively. (Level of Evidence: B) ischemia on noninvasive testing. (Level of Evi- 3. Elective noncardiac surgery is not recom- dence: A) mended within 4 weeks of coronary revascu- 4. Coronary revascularization before noncardiac larization with balloon angioplasty. (Level of surgery is recommended for patients with high- Evidence: B) risk unstable angina or non–ST-segment ele- vation myocardial infarction (MI).§ (Level of Recommendations for Beta-Blocker Medical Therapy Evidence: A) Class I 5. Coronary revascularization before noncardiac 1. Beta blockers should be continued in patients surgery is recommended in patients with acute undergoing surgery who are receiving beta ST-elevation MI. (Level of Evidence: A) blockers to treat angina, symptomatic arrhyth- mias, hypertension, or other ACC/AHA Class I § High-risk unstable angina/non–ST-elevation MI patients were guideline indications. (Level of Evidence: C) identified as those with age greater than 75 years, accelerating 2. Beta blockers should be given to patients un- tempo of ischemic symptoms in the preceding 48 hours, ongoing rest pain greater than 20 minutes in duration, pulmonary edema, dergoing vascular surgery who are at high angina with S3 gallop or rales, new or worsening mitral regurgita- tion murmur, hypotension, bradycardia, tachycardia, dynamic ST- Care should be taken in applying recommendations on beta- segment change greater than or equal to 1 mm, new or presumed blocker therapy to patients with decompensated heart failure, new bundle-branch block on ECG, or elevated cardiac biomarkers, nonischemic cardiomyopathy, or severe valvular heart disease in such as troponin. the absence of coronary heart disease. 690 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  7. 7. cardiac risk owing to the finding of ischemia on Class III preoperative testing. (Level of Evidence: B) 1. Alpha-2 agonists should not be given to patients undergoing surgery who have con- Class IIa traindications to this medication. (Level of 1. Beta blockers are probably recommended for Evidence: C) patients undergoing vascular surgery in whom preoperative assessment identifies coronary Recommendation for Preoperative Intensive Care heart disease. (Level of Evidence: B) 2. Beta blockers are probably recommended for Monitoring patients in whom preoperative assessment for Class IIb vascular surgery identifies high cardiac risk, as 1. Preoperative intensive care monitoring with a defined by the presence of more than 1 clinical pulmonary artery catheter for optimization of risk factor.* (Level of Evidence: B) hemodynamic status might be considered; 3. Beta blockers are probably recommended for however, it is rarely required and should be patients in whom preoperative assessment iden- restricted to a very small number of highly tifies coronary heart disease or high cardiac risk, selected patients whose presentation is un- as defined by the presence of more than 1 clinical stable and who have multiple comorbid condi- risk factor,* who are undergoing intermediate- tions. (Level of Evidence: B) risk or vascular surgery. (Level of Evidence: B) Recommendations for Use of Volatile Anesthetic Class IIb Agents 1. The usefulness of beta blockers is uncertain Class IIa for patients who are undergoing either 1. It can be beneficial to use volatile anesthetic intermediate-risk procedures or vascular sur- agents during noncardiac surgery for the main- gery, in whom preoperative assessment iden- tenance of general anesthesia in hemodynam- tifies a single clinical risk factor.* (Level of ically stable patients at risk for myocardial Evidence: C) ischemia. (Level of Evidence: B) 2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no Recommendation for Prophylactic Intraoperative clinical risk factors who are not currently tak- Nitroglycerin ing beta blockers. (Level of Evidence: B) Class IIb 1. The usefulness of intraoperative nitroglycerin Class III as a prophylactic agent to prevent myocardial 1. Beta blockers should not be given to patients ischemia and cardiac morbidity is unclear for undergoing surgery who have absolute contrain- high-risk patients undergoing noncardiac dications to beta blockade. (Level of Evidence: C) surgery, particularly those who have required Recommendations for Statin Therapy nitrate therapy to control angina. The recom- Class I mendation for prophylactic use of nitroglycerin 1. For patients currently taking statins and sched- must take into account the anesthetic plan and uled for noncardiac surgery, statins should be patient hemodynamics and must recognize that continued. (Level of Evidence: B) vasodilation and hypovolemia can readily oc- cur during anesthesia and surgery. (Level of Class IIa Evidence: C) 1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is Recommendation for Use of Transesophageal reasonable. (Level of Evidence: B) Echocardiography Class IIa Class IIb 1. The emergency use of intraoperative or periop- 1. For patients with at least 1 clinical risk factor erative transesophageal echocardiography is who are undergoing intermediate-risk proce- reasonable to determine the cause of an acute, dures, statins may be considered. (Level of persistent, and life-threatening hemodynamic Evidence: C) abnormality. (Level of Evidence: C) Recommendations for Alpha-2 Agonists Class IIb Recommendation for Maintenance of Body 1. Alpha-2 agonists for perioperative control of Temperature hypertension may be considered for patients Class I with known CAD or at least 1 clinical risk 1. Maintenance of body temperature in a normo- factor who are undergoing surgery. (Level of thermic range is recommended for most proce- Evidence: B) dures other than during periods in which mild Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 691
  8. 8. hypothermia is intended to provide organ pro- Class IIb tection (eg, during high aortic cross-clamping). 1. Intraoperative and postoperative ST-segment (Level of Evidence: B) monitoring may be considered in patients with single or multiple risk factors for CAD who are Recommendations for Perioperative Control of undergoing noncardiac surgery. (Level of Evi- Blood Glucose Concentration dence: B) Class IIa Recommendations for Surveillance for Perioperative 1. It is reasonable that blood glucose concentra- MI tion be controlled¶ during the perioperative Class I period in patients with diabetes mellitus or 1. Postoperative troponin measurement is recom- acute hyperglycemia who are at high risk for mended in patients with ECG changes or chest myocardial ischemia or who are undergoing vas- pain typical of acute coronary syndrome. (Level cular and major noncardiac surgical procedures of Evidence: C) with planned intensive care unit admission. (Level of Evidence: B) Class IIb 1. The use of postoperative troponin measure- Class IIb ment is not well established in patients who are 1. The usefulness of strict control of blood glu- clinically stable and have undergone vascular cose concentration¶ during the perioperative and intermediate-risk surgery. (Level of Evi- period is uncertain in patients with diabetes dence: C) mellitus or acute hyperglycemia who are un- dergoing noncardiac surgical procedures with- Class III out planned intensive care unit admission. 1. Postoperative troponin measurement is not rec- (Level of Evidence: C) ommended in asymptomatic stable patients who have undergone low-risk surgery. (Level of Recommendations for Perioperative Use of Pul- Evidence: C) monary Artery Catheters Class IIb II. GENERAL APPROACH TO THE PATIENT 1. Use of a pulmonary artery catheter may be This guideline focuses on the evaluation of the patient reasonable in patients at risk for major hemo- undergoing noncardiac surgery who is at risk for peri- dynamic disturbances that are easily detected operative cardiac morbidity or mortality. In patients by a pulmonary artery catheter; however, the with known CAD or the new onset of signs or symptoms decision must be based on 3 parameters: suggestive of CAD, baseline cardiac assessment should patient disease, surgical procedure (ie, intra- be performed. In the asymptomatic patient, a more operative and postoperative fluid shifts), and extensive assessment of history and physical examina- practice setting (experience in pulmonary ar- tion is warranted in those individuals 50 years of age or tery catheter use and interpretation of results), older, because the evidence related to the determination because incorrect interpretation of the data of cardiac risk factors and derivation of a revised cardiac from a pulmonary artery catheter may cause risk index occurred in this population.8 Preoperative harm. (Level of Evidence: B) cardiac evaluation must therefore be carefully tailored to the circumstances that have prompted the evaluation Class III and to the nature of the surgical illness. In patients in 1. Routine use of a pulmonary artery catheter whom coronary revascularization is not an option, it is perioperatively, especially in patients at low often not necessary to perform a noninvasive stress test. risk of developing hemodynamic disturbances, Under other, less urgent circumstances, the preoperative is not recommended. (Level of Evidence: A) cardiac evaluation may lead to a variety of responses, including cancellation of an elective procedure. Recommendations for Intraoperative and Postopera- If a consultation is requested, then it is important to tive Use of ST-Segment Monitoring identify the key questions and ensure that all of the Class IIa perioperative caregivers are considered when provid- 1. Intraoperative and postoperative ST-segment ing a response. Once a consultation has been obtained, monitoring can be useful to monitor patients the consultant should review available patient data, with known CAD or those undergoing vascular obtain a history, and perform a physical examination surgery, with computerized ST-segment analy- that includes a comprehensive cardiovascular exami- sis, when available, used to detect myocardial nation and elements pertinent to the patient’s problem ischemia during the perioperative period. and the proposed surgery. A critical role of the (Level of Evidence: B) consultant is to determine the stability of the patient’s ¶ Blood glucose levels less than 150 mg/dL appear to be benefi- cardiovascular status and whether the patient is in cial. optimal medical condition within the context of the 692 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  9. 9. Table 2. Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B) Condition Examples Unstable coronary syndromes Unstable or severe angina* (CCS class III or IV)† Recent MI‡ Decompensated HF (NYHA functional class IV; worsening or new-onset HF) Significant arrhythmias High-grade atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR greater than 100 beats per minute at rest) Symptomatic bradycardia Newly recognized ventricular tachycardia Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF) * According to Campeau.9 † May include stable angina in patients who are unusually sedentary. ‡ The American College of Cardiology National Database Library defines recent MI as more than 7 days but less than or equal to 1 month (within 30 days). CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association. surgical illness. The consultant may recommend increased perioperative cardiovascular risk. In pa- changes in medication, suggest preoperative tests or tients with established cardiac disease, any recent procedures, or propose higher levels of care postop- change in symptoms must be ascertained. Accurate eratively. In general, preoperative tests are recom- recording of current medications used, including mended only if the information obtained will result in herbal and other nutritional supplements, and dos- a change in the surgical procedure performed, a ages is essential. Use of alcohol, tobacco, and over-the- change in medical therapy or monitoring during or counter and illicit drugs should be documented. after surgery, or a postponement of surgery until the The history should also seek to determine the cardiac condition can be corrected or stabilized. patient’s functional capacity (Table 3). An assess- The consultant must also bear in mind that the ment of an individual’s capacity to perform a spec- perioperative evaluation may be the ideal opportunity to trum of common daily tasks has been shown to effect the long-term treatment of a patient with signifi- correlate well with maximum oxygen uptake by cant cardiac disease or risk of such disease. The referring treadmill testing.10 A patient classified as high risk physician and patient should be informed of the results owing to age or known CAD but who is asymptom- of the evaluation and implications for the patient’s atic and runs for 30 minutes daily may need no prognosis. It is the cardiovascular consultant’s responsi- further evaluation. In contrast, a sedentary patient bility to ensure clarity of communication so that findings without a history of cardiovascular disease but with and impressions will be incorporated effectively into the clinical factors that suggest increased perioperative patient’s overall plan of care. This ideally would include risk may benefit from a more extensive preoperative direct communication with the surgeon, anesthesiolo- evaluation.12–15 gist, 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 B. Physical Examination and Routine Laboratory Tests surgery.” A careful cardiovascular examination should in- clude an assessment of vital signs (including mea- A. History surement of blood pressure in both arms), carotid A careful history is crucial to the discovery of pulse contour and bruits, jugular venous pressure cardiac and/or comorbid diseases that would place and pulsations, auscultation of the lungs, precordial the patient in a high surgical risk category. The history palpation and auscultation, abdominal palpation, should seek to identify serious cardiac conditions such and examination of the extremities for edema and as unstable coronary syndromes, prior angina, recent vascular integrity. or past MI, decompensated heart failure, significant Anemia imposes a stress on the cardiovascular sys- arrhythmias, and severe valvular disease (Table 2). It tem that may exacerbate myocardial ischemia and ag- should also determine whether the patient has a prior gravate heart failure.16 Hematocrits of less than 28% are history of a pacemaker or implantable cardioverter associated with an increased incidence of perioperative defibrillator (ICD) or a history of orthostatic intoler- ischemia and postoperative complications in patients ance and should identify risk factors associated with undergoing prostate and vascular surgery.16 –18 Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 693
  10. 10. Table 3. Estimated Energy Requirements for Various Activities Can you. . . Can you. . . 1 MET Take care of yourself? 4 METs Climb a flight of stairs or walk up a hill? Eat, dress, or use the toilet? Walk on level ground at 4 mph (6.4 kph)? 4™™™™™™™™™™™™™™™™™™™™™™™™™ ™™™™™™™™™™™™ Walk indoors around the house? Run a short distance? Walk a block or 2 on level ground at Do heavy work around the house like 2 to 3 mph (3.2 to 4.8 kph)? scrubbing floors or lifting or moving heavy furniture? 4 4 METs Do light work around the house like Participate in moderate recreational activities dusting or washing dishes? like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? Greater than 10 METs Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? kph indicates kilometers per hour; MET, metabolic equivalent; and mph, miles per hour. * Modified from Hlatky et al,10 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.11 C. Multivariable Indices to Predict Preoperative Cardiac of surgery unless the surgery is emergent (Table 2). Morbidity These include The basic clinical evaluation obtained by history, • Unstable coronary syndromes, physical examination, and review of the ECG usually Unstable or severe angina, provides the consultant with sufficient data to esti- Recent MI, mate cardiac risk. Lee et al.8 derived and validated a • Decompensated heart failure, “simple index” for the prediction of cardiac risk for • Significant arrhythmias, stable patients undergoing nonurgent major noncar- • Severe valvular disease. diac surgery. Six independent risk correlates were identified: ischemic heart disease (defined as history Given the increasing use of the Revised Cardiac of MI, history of positive treadmill test, use of nitro- Risk Index, the committee chose to replace the glycerin, current complaints of chest pain thought to intermediate-risk category with the clinical risk factors be secondary to coronary ischemia, or ECG with from the index, with the exclusion of the type of abnormal Q waves); congestive heart failure (defined surgery, which is incorporated elsewhere in the ap- as history of heart failure, pulmonary edema, parox- proach to the patient. Clinical risk factors include ysmal nocturnal dyspnea, peripheral edema, bilateral • history of ischemic heart disease, rales, S3, or chest radiograph with pulmonary vascular • history of compensated or prior heart failure, redistribution); cerebral vascular disease (history of • history of cerebrovascular disease, transient ischemic attack or stroke); high-risk surgery • diabetes mellitus, and (abdominal aortic aneurysm or other vascular, tho- • renal insufficiency.8 racic, abdominal, or orthopedic surgery); preoperative insulin treatment for diabetes mellitus; and preopera- A history of MI or abnormal Q waves by ECG is tive creatinine greater than 2 mg per dL. Increasing listed as a clinical risk factor, whereas an acute MI numbers of risk factors correlated with increased risk, (defined as at least 1 documented MI 7 days or less yet the risk was substantially lower than described in before the examination) or recent MI (more than 7 many of the original indices.8 The Revised Cardiac days but less than or equal to 1 month before the Risk Index has become one of the most widely used examination) with evidence of important ischemic risk indices.8 risk by clinical symptoms or noninvasive study is an active cardiac condition. This definition reflects the consensus of the ACC Cardiovascular Database D. Clinical Assessment Committee. Minor predictors are recognized mark- In the original guidelines, the committee chose to ers for cardiovascular disease that have not been segregate clinical risk factors into major, intermedi- proven to independently increase perioperative ate, and minor risk factors. There continues to be a risk, For example, advanced age (greater than 70 group of active cardiac conditions that when years), abnormal ECG (LV hypertrophy, left bundle- present indicate major clinical risk. The presence of branch block, ST-T abnormalities), rhythm other than 1 or more of these conditions mandates intensive sinus, and uncontrolled systemic hypertension. The management and may result in delay or cancellation presence of multiple minor predictors might lead to a 694 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  11. 11. 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 Table 3 for estimated MET level equivalent. ‡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 5) 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. higher suspicion of CAD but is not incorporated into the proceed to Step 3. In patients being considered for recommendations for treatment. elective noncardiac surgery, the presence of unstable coronary disease, decompensated heart failure, or severe 1. Stepwise Approach to Perioperative Cardiac arrhythmia or valvular heart disease usually leads to Assessment cancellation or delay of surgery until the cardiac Figure 1 presents in algorithmic form a framework problem has been clarified and treated appropriately. for determining which patients are candidates for Examples of unstable coronary syndromes include cardiac testing. Since publication of the perioperative previous MI with evidence of important ischemic risk cardiovascular evaluation guidelines in 2002,19 several by clinical symptoms or noninvasive study, unstable new randomized trials and cohort studies have led to or severe angina, and new or poorly controlled ischemia- modification of the original algorithm. Given the availability of this evidence, the Writing Committee mediated heart failure. Many patients in these circum- chose to include the level of the recommendations and stances are referred for coronary angiography to assess strength of evidence for many of the pathways. further therapeutic options. Depending on the results of Step 1: The consultant should determine the ur- the test or interventions and the risk of delaying gency of noncardiac surgery. In many instances, surgery, it may be appropriate to proceed to the patient- or surgery-specific factors dictate an obvious planned surgery with maximal medical therapy. strategy (eg, emergent surgery) that may not allow for Step 3: Is the patient undergoing low-risk surgery? further cardiac assessment or treatment. In such cases, In these patients, interventions based on cardiovascu- the consultant may function best by providing recom- lar testing in stable patients would rarely result in a mendations for perioperative medical management change in management, and it would be appropriate and surveillance. to proceed with the planned surgical procedure. Step 2: Does the patient have 1 of the active cardiac Step 4: Does the patient have good functional conditions or clinical risk factors listed in Table 2? If not, capacity without symptoms? In highly functional Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 695
  12. 12. Table 4. Cardiac Risk* Stratification for Noncardiac management. Other types of surgery may be associ- Surgical Procedures ated with similar risk to vascular surgery but have Risk Stratification Procedure Examples not been studied extensively. In nonvascular sur- Vascular (reported Aortic and other major vascular gery in which the perioperative morbidity related to cardiac risk often surgeryPeripheral vascular the procedures ranges from 1% to 5% (intermediate- more than 5%) surgery risk surgery), there are insufficient data to deter- Intermediate (reported Intraperitoneal and cardiac risk intrathoracic surgery mine the best strategy (proceeding with the planned generally 1% to 5%) Carotid endarterectomy surgery with tight heart rate control with beta Head and neck surgery blockade or further cardiovascular testing if it will Orthopedic surgery Prostate surgery change management). Low† (reported Endoscopic procedures cardiac risk Superficial procedure generally less than Cataract surgery III. DISEASE-SPECIFIC APPROACHES 1%) Breast surgery A. Coronary Artery Disease Ambulatory surgery 1. Patients With Known CAD *Combined incidence of cardiac death and nonfatal myocardial infarction. In patients with known CAD, as well as those with †These procedures do not generally require further preoperative cardiac testing. previously occult coronary disease, the questions be- come 1) What is the amount of myocardium in jeop- ardy? 2) What is the ischemic threshold, that is, the asymptomatic patients, management will rarely be amount of stress required to produce ischemia? 3) changed on the basis of results of any further cardio- What is the patient’s ventricular function? and 4) Is the vascular testing. It is therefore appropriate to proceed patient on his or her optimal medical regimen? Clari- with the planned surgery. In patients with known fication of these questions is an important goal of the cardiovascular disease or at least 1 clinical risk factor, preoperative history and physical examination, and perioperative heart rate control with beta blockade selected noninvasive testing is used to determine the appears appropriate as outlined in Section VI.B. patient’s prognostic gradient of ischemic response If the patient has not had a recent exercise test, during stress testing. functional status can usually be estimated from the ability to perform activities of daily living.20 For this B. Hypertension purpose, functional capacity has been classified as For stage 3 hypertension (systolic blood pressure excellent (greater than 10 METs), good (7 to 10 METs), greater than or equal to 180 mm Hg and diastolic blood moderate (4 to 7 METs), poor (less than 4 METs), or pressure greater than or equal to 110 mm Hg), the unknown. The Duke Activity Status Index (Table 3) potential benefits of delaying surgery to optimize the contains questions that can be used to estimate the effects of antihypertensive medications should be patient’s functional capacity.21 weighed against the risk of delaying the surgical Step 5: If the patient has poor functional capacity, is procedure. With rapidly acting intravenous agents, symptomatic, or has unknown functional capacity, blood pressure can usually be controlled within a then the presence of active clinical risk factors will matter of several hours. One randomized trial was determine the need for further evaluation. If the unable to demonstrate a benefit to delaying surgery in patient has no clinical risk factors, then it is appropri- chronically treated hypertensive patients who pre- sented for noncardiac surgery with diastolic blood ate to proceed with the planned surgery, and no pressure between 110 and 130 mm Hg and who had further change in management is indicated. no previous MI, unstable or severe angina pectoris, If the patient has 1 or 2 clinical risk factors, then it renal failure, pregnancy-induced hypertension, LV is reasonable either to proceed with the planned hypertrophy, previous coronary revascularization, surgery or, if appropriate, with heart rate control with aortic stenosis, preoperative dysrhythmias, conduc- beta blockade, or to consider testing if it will change tion defects, or stroke.23 management. In patients with 3 or more clinical risk Several authors have suggested withholding factors, the surgery-specific cardiac risk is important. angiotensin-converting enzyme inhibitors and angio- The surgery-specific cardiac risk (Table 4) of non- tensin receptor antagonists the morning of sur- cardiac surgery is related to 2 important factors. First, gery.24 –26 Consideration should be given to restarting the type of surgery itself may identify a patient with a angiotensin-converting enzyme inhibitors in the post- greater likelihood of underlying heart disease and operative period only after the patient is euvolemic, to higher perioperative morbidity and mortality. Per- decrease the risk of perioperative renal dysfunction. haps the most extensively studied example is vascular surgery, in which underlying CAD is present in a C. Valvular Heart Disease substantial portion of patients. If the patient is under- In symptomatic aortic stenosis, elective noncardiac going vascular surgery, recent studies suggest that surgery should generally be postponed or canceled. testing should only be considered if it will change Such patients require aortic valve replacement before 696 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  13. 13. elective but necessary noncardiac surgery. If the aortic IV. SURGERY-SPECIFIC ISSUES stenosis is severe but asymptomatic, the surgery Although different operations are associated with should be postponed or canceled if the valve has not different cardiac risks, these differences are most often been evaluated within the year. On the other hand, in a reflection of the context in which the patient under- patients with severe aortic stenosis who refuse cardiac goes surgery (stability or opportunity for adequate surgery or are otherwise not candidates for aortic preoperative preparation), surgery-specific factors (eg, valve replacement, noncardiac surgery can be per- fluid shifts, stress levels, duration of procedure, or formed with a mortality risk of approximately blood loss), or patient-specific factors (the incidence of 10%.27,28 If a patient is not a candidate for valve CAD associated with the condition for which the replacement, percutaneous balloon aortic valvulo- patient is undergoing surgery). The surgical proce- plasty may be reasonable as a bridge to surgery in dures have been classified as low risk, high risk, and hemodynamically unstable adult patients with aortic vascular. Although coronary disease is the over- stenosis who are at high risk for aortic valve replace- whelming risk factor for perioperative morbidity, pro- ment surgery and may be reasonable in adult patients cedures with different levels of stress are associated with aortic stenosis in whom aortic valve replacement with different levels of morbidity and mortality. Su- cannot be performed because of serious comorbid perficial and ophthalmologic procedures represent the conditions.6,29 lowest risk and are rarely associated with excess Significant mitral stenosis increases the risk of heart morbidity and mortality. Major vascular procedures failure. However, preoperative surgical correction of represent the highest-risk procedures and are now mitral valve disease is not indicated before noncardiac considered distinctly in the decision to perform fur- surgery, unless the valvular condition should be cor- ther evaluation because of the large body of evidence rected to prolong survival and prevent complications regarding the value of perioperative interventions in unrelated to the proposed noncardiac surgery. When this population (Figure 1). Both endovascular aortic the stenosis is severe, the patient may benefit from aneurysm repair and carotid endarterectomy should balloon mitral valvuloplasty or open surgical repair be considered within the intermediate-risk category, before high-risk surgery.30 distinct from the open vascular surgery procedures, In patients with persistent or permanent atrial on the basis of their preoperative morbidity and fibrillation who are at high risk for thromboembolism, mortality rates, but clinicians should incorporate the preoperative and postoperative therapy with intrave- similarly poor long-term survival rates that accom- nous heparin or subcutaneous low-molecular-weight pany these procedures into their decision-making heparin may be considered to cover periods of sub- processes. Within the intermediate-risk category, mor- therapeutic anticoagulation.1,31–33 bidity and mortality vary depending on the surgical Patients with a mechanical prosthetic valve are of location and extent of the procedure. Some procedures concern because of the need for endocarditis prophy- may be short, with minimal fluid shifts, whereas others may be associated with prolonged duration, laxis34 when they undergo surgery that may result in large fluid shifts, and greater potential for postopera- bacteremia and the need for careful anticoagulation tive myocardial ischemia and respiratory depression. management. The Seventh American College of Chest Therefore, the physician must exercise judgment to Physicians Consensus Conference on Antithrombotic correctly assess perioperative surgical risks and the and Thrombolytic Therapy35 recommends the fol- need for further evaluation. lowing: for patients who require minimally invasive procedures (dental work, superficial biopsies), the recommendation is to briefly reduce the international V. SUPPLEMENTAL PREOPERATIVE EVALUATION normalized ratio to the low or subtherapeutic range and resume the normal dose of oral anticoagulation A. Assessment of LV Function immediately after the procedure. Perioperative hepa- Resting LV function has been evaluated preopera- tively before noncardiac surgery by radionuclide rin therapy is recommended for patients in whom the angiography, echocardiography, and contrast ven- risk of bleeding with oral anticoagulation is high and triculography. It is noteworthy that resting LV func- the risk of thromboembolism without anticoagulation tion was not found to be a consistent predictor of is also high (mechanical valve in the mitral position; perioperative ischemic events. Bjork-Shiley valve; recent [ie, less than 1 year] throm- bosis or embolus; or 3 or more of the following risk factors: atrial fibrillation, previous embolus at any B. Assessment of Risk for CAD and Assessment of time, hypercoagulable condition, mechanical prosthe- Functional Capacity sis, and LV ejection fraction less than 30%).36 For 1. The 12-Lead ECG patients between these 2 extremes, physicians must Although the optimal time interval between obtain- assess the risk and benefit of reduced anticoagulation ing a 12-lead ECG and elective surgery is unknown, versus perioperative heparin therapy. general consensus suggests that an ECG within 30 days Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 697
  14. 14. of surgery is adequate for those with stable disease in trial39 was designed to evaluate the utility of cardiac whom a preoperative ECG is indicated. testing in patients undergoing major vascular surgery with intermediate cardiac risk factors and adequate 2. Exercise Stress Testing for Myocardial Ischemia beta-blocker therapy. A composite end point of death and Functional Capacity and nonfatal MI was assessed at 30 days after vascular The aim of supplemental preoperative testing is surgery. This study confirms that extensive cardiac to provide an objective measure of functional capac- ischemia is a risk factor for perioperative cardiac ity, to identify the presence of important preopera- events, but it was too small to assess the effect of tive myocardial ischemia or cardiac arrhythmias, revascularization. and to estimate perioperative cardiac risk and long- The DECREASE-V pilot study40 identified a high- term prognosis. risk cohort of patients scheduled for vascular surgery who were randomized to best medical therapy and 3. Noninvasive Stress Testing revascularization or best medical therapy alone before Pharmacological stress with vasodilators or adren- vascular surgery. There was no difference in the ergic stimulation in conjunction with radionuclide or echocardiographic cardiac imaging has been shown to combined outcomes of death or MI at 30 days or 1 year predict perioperative cardiac events in patients sched- between the revascularization and medical therapy uled for noncardiac surgery who are unable to exer- groups, although there was a high incidence of cardiac cise.37 Importantly, perioperative cardiac risk is directly events in this high-risk cohort. This study was not related to the extent of jeopardized viable myocardium sized to definitively answer the question as to the identified by stress cardiac imaging.37 value of preoperative revascularization in high-risk The expertise of the practitioner’s available stress patients; however, the findings are consistent with the laboratory resources in identifying severe coronary previously published literature suggesting a lack of disease is as important as the particular type of stress benefit of preoperative coronary revascularization in test ordered. For patients with unstable myocardial preventing death or MI. The indications for preopera- ischemia, who are at high risk for noncardiac surgery, tive surgical coronary revascularization, therefore, are it is usually appropriate to proceed with coronary essentially identical to those recommended by the angiography or to attempt to stabilize them with ACC/AHA 2004 Guideline Update for Coronary Ar- aggressive medical treatment rather than to perform a tery Bypass Graft Surgery and the accumulated data stress test. on which those conclusions were based.41 VI. PERIOPERATIVE THERAPY 2. Preoperative PCI A. Preoperative Coronary Revascularization With Coronary Review of the literature suggests that PCI before Artery Bypass Grafting or PCI noncardiac surgery is of no value in preventing peri- operative cardiac events, except in those patients in 1. Preoperative Coronary Artery Bypass Grafting whom PCI is independently indicated for an acute Until recently, all of the evidence regarding the coronary syndrome. However, unscheduled noncar- value of surgical coronary revascularization was de- diac surgery in a patient who has undergone a prior rived from cohort studies in patients who presented for noncardiac surgery after successful cardiac sur- PCI presents special challenges, particularly with re- gery. There are now several randomized trials that gard to management of dual-antiplatelet agents re- have assessed the overall benefit of prophylactic cor- quired in those who receive coronary stents. onary bypass surgery to lower the perioperative car- diac risk of noncardiac surgery, the results of which 3. PCI Without Stents: Coronary Balloon can be applied to specific subsets of patients and will Angioplasty be discussed later. Several retrospective series of coronary balloon The first large, randomized trial (Coronary Artery angioplasty before noncardiac surgery have been re- Revascularization Prophylaxis [CARP]) was pub- ported.42– 49 On the basis of the available literature, lished by McFalls and colleagues,38 who randomly delaying noncardiac surgery for more than 8 weeks assigned 510 patients with significant coronary artery after balloon angioplasty increases the chance that stenosis from among 5859 patients scheduled for restenosis at the angioplasty site will have occurred vascular operations to either coronary artery revascu- and theoretically increases the chances of periopera- larization before surgery or no revascularization be- tive ischemia or MI. However, performing the surgical fore surgery. The authors concluded that routine procedure too soon after the PCI procedure might also coronary revascularization in patients with stable car- be hazardous. Delaying surgery for at least 2 to 4 diac symptoms before elective vascular surgery does weeks after balloon angioplasty to allow for healing of not significantly alter the long-term outcome or short- the vessel injury at the balloon treatment site is term risk of death or MI. supported by a study by Brilakis et al.49 Daily aspirin The DECREASE (Dutch Echocardiographic Cardiac antiplatelet therapy should be continued periopera- Risk Evaluation Applying Stress Echocardiography) II tively. The risk of stopping the aspirin should be 698 ACC/AHA 2007 Perioperative Guidelines ANESTHESIA & ANALGESIA
  15. 15. weighed against the benefit of reduction in bleeding regarding the prevention of premature discontinua- complications from the planned surgery. tion of dual-antiplatelet therapy in patients with coro- nary artery stents.54 This advisory report54 concluded 4. PCI: Bare-Metal Coronary Stents that premature discontinuation of dual-antiplatelet If a coronary stent is used in the revascularization therapy markedly increases the risk of catastrophic stent procedure, as in the majority of percutaneous revas- thrombosis and death and/or MI. To eliminate the cularization procedures, further delay of noncardiac premature discontinuation of thienopyridine therapy, surgery may be beneficial. Bare-metal stent thrombo- the advisory group recommended the following: sis is most common in the first 2 weeks after stent placement and is exceedingly rare (less than 0.1% of • Elective procedures for which there is a signifi- most case series) more than 4 weeks after stent place- cant risk of perioperative or postoperative ment.50,51 Given that stent thrombosis will result in bleeding should be deferred until patients have Q-wave MI or death in the majority of patients in completed an appropriate course of thienopy- whom it occurs, and given that the risk of bare-metal ridine therapy (12 months after drug-eluting stent thrombosis diminishes after endothelialization of stent implantation if they are not at high risk of the stent has occurred (which generally takes 4 to 6 bleeding and a minimum of 1 month for bare- weeks), it appears reasonable to delay elective noncar- metal stent implantation). diac surgery for 4 to 6 weeks to allow for at least • For patients treated with drug-eluting stents who partial endothelialization of the stent, but not for more are to undergo subsequent procedures that man- than 12 weeks, when restenosis may begin to occur. date discontinuation of thienopyridine therapy, A thienopyridine (ticlopidine or clopidogrel) is aspirin should be continued if at all possible and generally administered with aspirin for 4 weeks after the thienopyridine restarted as soon as possible bare-metal stent placement. The thienopyridines and after the procedure because of concerns about aspirin inhibit platelet aggregation and reduce stent late-stent thrombosis. thrombosis but increase the risk of bleeding. Rapid endothelialization of bare-metal stents makes late Given the above reports and recommendations, the thrombosis rare, and thienopyridines are rarely use of drug-eluting stents for coronary revasculariza- needed for more than 4 weeks after implantation of tion before imminent or planned noncardiac surgery bare-metal stents. For this reason, delaying surgery 4 that will necessitate the discontinuation of dual- to 6 weeks after bare-metal stent placement allows antiplatelet agents is not recommended. proper thienopyridine use to reduce the risk of coro- In patients with stable CAD, the indications for PCI nary stent thrombosis; then, after the thienopyridine in the preoperative setting should be identical to those has been discontinued, the noncardiac surgery can be developed by the joint ACC/AHA Task Force that performed. However, once the thienopyridine is provided guidelines for the use of PCI in patients with stopped, its effects do not diminish immediately. It is stable angina and asymptomatic ischemia.55 There is for this reason that some surgical teams request a no evidence to support prophylactic preoperative percu- 1-week delay after thienopyridines are discontinued taneous revascularization in patients with asymptomatic before the patient proceeds to surgery. In patients ischemia or stable angina, particularly with drug-eluting with bare-metal stents, daily aspirin antiplatelet stents. Similarly, there is little evidence to show how therapy should be continued perioperatively. The risk long a more distant PCI (ie, months to years before of stopping the aspirin should be weighed against the noncardiac surgery) protects against perioperative MI benefit of reduction in bleeding complications from or death. Because additional coronary restenosis is the planned surgery. In the setting of noncardiac unlikely to occur more than 8 to 12 months after PCI surgery in patients who have recently received a (whether or not a stent is used), it is reasonable to bare-metal stent, the risk of stopping dual-antiplatelet expect ongoing protection against untoward perioper- agents prematurely (within 4 weeks of implantation) ative ischemic complications in currently asymptom- is significant compared with the risk of major bleeding atic, active patients who had been symptomatic before from most commonly performed surgeries. complete percutaneous coronary revascularization more than 8 to 12 months previously. 5. PCI: Drug-Eluting Stents Thrombosis of drug-eluting stents may occur late 6. Perioperative Management of Patients With and has been reported up to 1.5 years after implanta- Prior PCI Undergoing Noncardiac Surgery tion, particularly in the context of discontinuation of For patients who have undergone successful coro- antiplatelet agents before noncardiac surgery.52,53 In nary intervention with or without stent placement January 2007, an AHA/ACC/Society for Cardiovas- before planned or unplanned noncardiac surgery, cular Angiography and Interventions (SCAI)/ there is uncertainty regarding how much time should American College of Surgeons (ACS)/American Dia- pass before the noncardiac procedure is performed. betes Association (ADA) science advisory was issued One approach is outlined in Figure 2, which is based Vol. 106, No. 3, March 2008 © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. 699