Cardiovascular

CLINICAL PRACTICE GUIDELINE

2014 ACC/AHA Guideline onPerioperative CardiovascularEvaluation and Management ofPatients Undergoing Noncardiac Surgery

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DownloaThis article has been copublished in Circulation.Cardiol 2014;64:e77137.ded From: https://coThis document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Scienc

Coordinating Committee in July 2014.

The American College of Cardiology requests that this document be cited as follows: Fleisher LA, Fleischmann KE, Auerbach AD

Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thomps

Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patie

noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice GuideliVictor G. Davila-Roman, MD, FACC, FASE*yMarie D. Gerhard-Herman, MDyThomas A. Holly, MD, FACC, FASNC*kGarvan C. Kane, MD, PHD, FAHA, FASE{Joseph E. Marine, MD, FACC, FHRS#M. Timothy Nelson, MD, FACS**Crystal C. Spencer, JDyyAnnemarie Thompson, MDzzHenry H. Ting, MD, MBA, FACC, FAHAxx

and other entities may apply; see Appendix 1 for

yACC/AHA Representative. zSociety for Vascular MxACC/AHA Task Force on Practice Guidelines Liaof Nuclear Cardiology Representative. {AmericanEchocardiography Representative. #Heart Rhythm

Representative. **American College of Surgeons R

Representative/Lay Volunteer. zzAmerican SocietSociety of Cardiovascular Anesthesiologists Repre

Task Force on Performance Measures Liaison. kkSAngiography and Interventions Representative.Andrew D. Auerbach, MD, MPHyWritingCommitteeMembers*A Report of the American College of Cardiology/AmericanTask Force on Practice Guidelines

Developed in Collaboration With the American College of S

Anesthesiologists, American Society of Echocardiography, A

Heart Rhythm Society, Society for Cardiovascular Angiogra

Society of Cardiovascular Anesthesiologists, and Society of

Endorsed by the Society of Hospital Medicine

Lee A. Fleisher, MD, FACC, FAHA, ChairyKirsten E. Fleischmann, MD, MPH, FACC, Vice ChairyCopies: This document is available on the World Wide Web sites of the A

Heart Association (my.americanheart.org). For copies of this document, ple

e-mail [email protected].

Permissions: Multiple copies, modication, alteration, enhancement, and

permission of the American College of Cardiology. Requests may be co

obtainingpermission-to-re-useelsevier-material).

ntent.onlinejacc.org/ by Agim Krasniqi on 01/04/2015rgeons, American Society of

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Barry F. Uretsky, MD, FACC, FAHA, FSCAIkkDuminda N. Wijeysundera, MD, PHD,Evidence Review Committee ChairHeart Associationmerican College of Cardiology (www.cardiosource.org) and the American

ase contact the Elsevier Inc. Reprint Department via fax (212) 633-3820 or

/or distribution of this document are not permitted without the express

mpleted online via the Elsevier site (http://www.elsevier.com/authors/

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TABL

PREAM

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2.4.2. Mitra

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: https://content.onovascular Implantable Electronic5.7.2.4.3. Aortic and Mitral Regurgitation:Recommendations . . . . . . . . . . . . . . . . . . . . e88of Natriuretic Peptides inperative Risk of HF . . . . . . . . . . . . . . . e86

pathy . . . . . . . . . . . . . . . . . . . . . . . . . . . e86

art Disease: Recommendations . . . . . e87

c Stenosis: Recommendation . . . . . . . e87

l Stenosis: Recommendation . . . . . . . e88

5.4.

5.5.es: Recommendation . . . . . . . . . . . . . . e89

Vascular Disease:dations . . . . . . . . . . . . . . . . . . . . . . . . . e90

enital Heart Disease . . . . . . . . . . . . . . . e90

6. PERI

6.1.

linejacc.org/ by Agim Krasniqi on 01/04/2015Recommendations . . . . . . . . . . . . . . . . . . . . e97

.5.2. Radionuclide MPI . . . . . . . . . . . . . . . . . . . . . e98

.5.3. Dobutamine Stress Echocardiography . . . . e98

tress TestingSpecial Situations . . . . . . . . . . . . . e99

reoperative Coronary Angiography:ecommendation . . . . . . . . . . . . . . . . . . . . . . . . . . e995.5.1. Noninvasive Pharmacological Stress TestingBefore Noncardiac Surgery:harmacological Stress Testing . . . . . . . . . . . . . . . e972.2.2. Risk of HF Based on Left VentricularEjection Fraction: Preserved VersusReduced . . . . . . . . . . . . . . . . . . . . . . . . . . . . e85

2.2.3. Risk of Asymptomatic Left VentricularDysfunction . . . . . . . . . . . . . . . . . . . . . . . . . e85

2.2.4. Role

5.2. Assessment of LV Function:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . e96

5.3. Exercise Stress Testing for Myocardial Ischemiaand Functional Capacity: Recommendations . . . . e97

Cardiopulmonary Exercise Testing:1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e81

1.1. Methodology and Evidence Review . . . . . . . . . . . e81

1.2. Organization of the GWC . . . . . . . . . . . . . . . . . . . . e82

1.3. Document Review and Approval . . . . . . . . . . . . . . e82

1.4. Scope of the CPG . . . . . . . . . . . . . . . . . . . . . . . . . . e82

1.5. Denitions of Urgency and Risk . . . . . . . . . . . . . . e83

2. CLINICAL RISK FACTORS . . . . . . . . . . . . . . . . . . . . . e83

2.1. Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . e83

2.2. Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e85

2.2.1. Role of HF in Perioperative CardiacRisk Indices . . . . . . . . . . . . . . . . . . . . . . . . . e85Samuel Gidding, MD, FAHAJudith S. Hochman, MD, FACC, FAHA{{

E OF CONTENTS

BLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e79Lesley H. Curtis, PHD, FAHADavid DeMets, PHD{{Lee A. Fleisher, MD, FACC, FAHANancy M. Albert, PHD, RN, FAHABiykem Bozkurt, MD, PHD, FACC, FAHARalph G. Brindis, MD, MPH, MACCrce Members Jonathan L. Halperin, MD, FACC, FAHA, Ch

A Task Jeffrey L. Anderson, MD, FACC, FAHA, Chisher et al.

C/AHA Perioperative Clinical Practice Guideline{{Former Task Force member; current member during thewriting effort.

3. CALCULATION OF RISK TO PREDICT

PERIOPERATIVE CARDIAC MORBIDITY . . . . . . . . . e90

3.1. Multivariate Risk Indices: Recommendations . . . . e90

3.2. Inclusion of Biomarkers in MultivariableRisk Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e91

4. APPROACH TO PERIOPERATIVE

CARDIAC TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . e91

4.1. Exercise Capacity and Functional Capacity . . . . . e91

4.2. Stepwise Approach to Perioperative CardiacAssessment: Treatment Algorithm . . . . . . . . . . . . e93

5. SUPPLEMENTAL PREOPERATIVE EVALUATION . . e95

5.1. The 12-Lead Electrocardiogram:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . e95Frank W. Sellke, MD, FACC, FAHAWin-Kuang Shen, MD, FACC, FAHADuminda N. Wijeysundera, MD, PHD-Elect

Richard J. Kovacs, MD, FACC, FAHAE. Magnus Ohman, MD, FACCSusan J. Pressler, PHD, RN, FAHA

J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4

D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7OPERATIVE THERAPY . . . . . . . . . . . . . . . . . . . . e99

Coronary Revascularization Before NoncardiacSurgery: Recommendations . . . . . . . . . . . . . . . . . e100

6.3.

7.2.

7.3.

7.4. IntraoRecom

7.5. MaintRecom

7.6.

7.7.

7.8.

8. PER

8.1.

9. FUT

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Downloaded FroPerioperative Anemia Management . . . . . . . . . . e114

IOPERATIVE SURVEILLANCE . . . . . . . . . . . . . . e115Recommendations . . . . . . . . . . . . . . . . . . . . . . . . e114Hemodynamic Assist Devices: Recommendation . e113

Perioperative Use of Pulmonary Artery Catheters:SurveiRecom

URE R

m: httpperative Monitoring Techniques:mendations . . . . . . . . . . . . . . . . . . . . . . . . e113

enance of Body Temperature:mendation . . . . . . . . . . . . . . . . . . . . . . . . . e1137.1.2. Volatile General Anesthesia Versus TotalIntravenous Anesthesia: Recommendation . . e111

7.1.3. Monitored Anesthesia Care VersusGeneral Anesthesia . . . . . . . . . . . . . . . . . . . e112

Perioperative Pain Management:Recommendations . . . . . . . . . . . . . . . . . . . . . . . . e112

Prophylactic Perioperative Nitroglycerin:Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . e113Conduction Disorders . . . . . . . . . . . . . . . . . . . . . . e109

6.4. Perioperative Management of Patients WithCIEDs: Recommendation . . . . . . . . . . . . . . . . . . . e110

7. ANESTHETIC CONSIDERATION AND

INTRAOPERATIVE MANAGEMENT . . . . . . . . . . . . . . e111

7.1. Choice of Anesthetic Technique and Agent . . . . e111

7.1.1. Neuraxial Versus General Anesthesia . . . . . e111Recommendations . . . . . . . . . . . . . . . . . . . e106

6.2.6. Antiplatelet Agents: Recommendations . . e107

6.2.7. Anticoagulants . . . . . . . . . . . . . . . . . . . . . . e107

Management of Postoperative Arrhythmias and6.1.1. Timing of Elective Noncardiac Surgery inPatients With Previous PCI:Recommendations . . . . . . . . . . . . . . . . . . . e100

6.2. Perioperative Medical Therapy . . . . . . . . . . . . . . e102

6.2.1. Perioperative Beta-Blocker Therapy:Recommendations . . . . . . . . . . . . . . . . . . . e1026.2.1.1. Evidence on Efcacy of

Beta-Blocker Therapy . . . . . . . . . . . e1046.2.1.2. Titration of Beta Blockers . . . . . . . . e1046.2.1.3. Withdrawal of Beta Blockers . . . . . . e1046.2.1.4. Risks and Caveats . . . . . . . . . . . . . . e104

6.2.2. Perioperative Statin Therapy:Recommendations . . . . . . . . . . . . . . . . . . . e105

6.2.3. Alpha-2 Agonists: Recommendation . . . . e105

6.2.4. Perioperative Calcium Channel Blockers . e106

6.2.5. Angiotensin-Converting Enzyme Inhibitors:

J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4

D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7llance andManagement for Perioperative MI:mendations . . . . . . . . . . . . . . . . . . . . . . . . e115

ESEARCH DIRECTIONS . . . . . . . . . . . . . . e116

s://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e117

APPENDIX 1

Author Relationships With Industry andOther Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . e129

APPENDIX 2

Reviewer Relationships With Industry andOther Entities (Relevant) . . . . . . . . . . . . . . . . . . . . . . . e131

APPENDIX 3

Related Recommendations From Other CPGs . . . . . . e136

APPENDIX 4

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e137

PREAMBLE

The American College of Cardiology (ACC) and theAmerican Heart Association (AHA) are committed to theprevention and management of cardiovascular diseasesthrough professional education and research for clini-cians, providers, and patients. Since 1980, the ACC andAHA have shared a responsibility to translate scienticevidence into clinical practice guidelines (CPGs) withrecommendations to standardize and improve cardio-vascular health. These CPGs, based on systematicmethods to evaluate and classify evidence, provide acornerstone of quality cardiovascular care.

In response to published reports from the Institute ofMedicine (1,2) and the ACC/AHAs mandate to evaluatenew knowledge and maintain relevance at the point ofcare, the ACC/AHA Task Force on Practice Guidelines(Task Force) began modifying its methodology. Thismodernization effort is published in the 2012 Methodol-ogy Summit Report (3) and 2014 perspective article (4).The Latter recounts the history of the collaboration,changes over time, current policies, and planned initia-tives to meet the needs of an evolving health-care envi-ronment. Recommendations on value in proportion toresource utilization will be incorporated as high-qualitycomparative-effectiveness data become available (5).The relationships between CPGs and data standards,appropriate use criteria, and performance measures areaddressed elsewhere (4).

Intended UseCPGs provide recommendations appli-cable to patients with or at risk of developing cardiovas-cular disease. The focus is on medical practice in theUnited States, but CPGs developed in collaboration with

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelineother organizations may have a broader target. AlthoughCPGs may be used to inform regulatory or payer decisions,the intent is to improve quality of care and be alignedwith the patients best interest.

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Downloaded FromEvidence ReviewGuideline writing committee (GWC)members are charged with reviewing the literature;weighing the strength and quality of evidence for oragainst particular tests, treatments, or procedures; andestimating expected health outcomes when data exist. Inanalyzing the data and developing CPGs, the GWC usesevidence-based methodologies developed by the TaskForce (6). A key component of the ACC/AHA CPG method-ology is the development of recommendations on thebasis of all available evidence. Literature searches focuson randomized controlled trials (RCTs) but also includeregistries, nonrandomized comparative and descriptivestudies, case series, cohort studies, systematic reviews,and expert opinion. Only selected references are cited inthe CPG. To ensure that CPGs remain current, new dataare reviewed biannually by the GWCs and the Task Forceto determine if recommendations should be updated ormodied. In general, a target cycle of 5 years is planned forfull revision (1).

The Task Force recognizes the need for objective, in-dependent Evidence Review Committees (ERCs) toaddress key clinical questions posed in the PICOTSformat (P population; I intervention; C comparator;O outcome; T timing; S setting). The ERCs includemethodologists, epidemiologists, clinicians, and bio-statisticians who systematically survey, abstract, andassess the quality of the evidence base (3,4). Practicalconsiderations, including time and resource constraints,limit the ERCs to addressing key clinical questions forwhich the evidence relevant to the guideline topic lendsitself to systematic review and analysis when the system-atic review could impact the sense or strength of relatedrecommendations. The GWC develops recommendationson the basis of the systematic review and denotes themwith superscripted SR (i.e., SR) to emphasize supportderived from formal systematic review.

Guideline-Directed Medical TherapyRecognizing ad-vances in medical therapy across the spectrum of car-diovascular diseases, the Task Force designated the termguideline-directed medical therapy (GDMT) to repre-sent recommended medical therapy as dened mainly byClass I measuresgenerally a combination of lifestylemodication and drug- and device-based therapeutics. Asmedical science advances, GDMT evolves, and henceGDMT is preferred to optimal medical therapy. ForGDMT and all other recommended drug treatment regi-mens, the reader should conrm the dosage with productinsert material and carefully evaluate for contraindica-tions and possible drug interactions. Recommendationsare limited to treatments, drugs, and devices approved for

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelineclinical use in the United States.Class of Recommendation and Level of Evidence

Once recommendations are written, the Class of Recom-mendation (COR; i.e., the strength the GWC assigns to the

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015recommendation, which encompasses the anticipatedmagnitude and judged certainty of benet in proportionto risk) is assigned by the GWC. Concurrently, the Level ofEvidence (LOE) rates the scientic evidence supportingthe effect of the intervention on the basis of the type,quality, quantity, and consistency of data from clinicaltrials and other reports (Table 1) (4).

Relationships With Industry and Other EntitiesTheACC and AHA exclusively sponsor the work of GWCs,without commercial support, and members volunteertheir time for this activity. The Task Force makes everyeffort to avoid actual, potential, or perceived conicts ofinterest that might arise through relationships with in-dustry or other entities (RWI). All GWC members andreviewers are required to fully disclose current industryrelationships or personal interests, from 12 monthsbefore initiation of the writing effort. Management ofRWI involves selecting a balanced GWC and requires thatboth the chair and a majority of GWC members have norelevant RWI (see Appendix 1 for the denition of rele-vance). GWC members are restricted with regard towriting or voting on sections to which their RWI apply.In addition, for transparency, GWC members compre-hensive disclosure information is available as an onlinesupplement. Comprehensive disclosure information forthe Task Force is also available as an online supplement.The Task Force strives to avoid bias by selecting expertsfrom a broad array of backgrounds representing differentgeographic regions, genders, ethnicities, intellectualperspectives/biases, and scopes of clinical practice.Selected organizations and professional societies withrelated interests and expertise are invited to participateas partners or collaborators.

Individualizing Care in Patients With Associated Con-

ditions and ComorbiditiesThe ACC and AHA recognizethe complexity of managing patients with multipleconditions, compared with managing patients with asingle disease, and the challenge is compounded whenCPGs for evaluation or treatment of several coexistingillnesses are discordant or interacting (7). CPGs attempt todene practices that meet the needs of patients in most,but not all, circumstances and do not replace clinicaljudgment.

Clinical ImplementationManagement in accordancewith CPG recommendations is effective only when fol-lowed; therefore, to enhance the patients commitmentto treatment and compliance with lifestyle adjustment,clinicians should engage the patient to participate inselecting interventions on the basis of the patients in-dividual values and preferences, taking associated con-

J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4

D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7ditions and comorbidities into consideration (e.g.,shared decision making). Consequently, there are cir-cumstances in which deviations from these CPGs areappropriate.

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DownloaTABLE 1 Applying Classication of Recommendations and L

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7The recommendations in this CPG are the ofcial policyof the ACC and AHA until they are superseded by a pub-lished addendum, focused update, or revised full-text CPG.

Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines

1. INTRODUCTION

1.1. Methodology and Evidence Review

The recommendations listed in this CPG are, wheneverpossible, evidence based. In April 2013, an extensive ev-idence review was conducted, which included a literature

A recommendation with Level of Evidence B or C does not imply that the recommendationthemselves to clinical trials. Although randomized trials are unavailable, there may be a very*Data available from clinical trials or registries about the usefulness/efcacy in different subinfarction, history of heart failure, and prior aspirin use.For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B oof the treatments or strategies being evaluated.

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2l of Evidence

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelinereview through July 2013. Other selected referencespublished through May 2014 were also incorporatedby the GWC. Literature included was derived fromresearch involving human subjects, published in English,and indexed in MEDLINE (through PubMed), EMBASE,the Cochrane Library, Agency for Healthcare Research andQuality Reports, and other selected databases relevant tothis CPG. The relevant data are included in evidencetables in the Data Supplement available online. Keysearch words included but were not limited to thefollowing: anesthesia protection; arrhythmia; atrial bril-lation; atrioventricular block; bundle branch block; cardiac

is weak. Many important key clinical questions addressed in the guidelines do not lendclear clinical consensus that a particular test or therapy is useful or effective.populations, such as sex, age, history of diabetes mellitus, history of prior myocardial

nly), studies that support the use of comparator verbs should involve direct comparisons

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Downloaded Fromischemia; cardioprotection; cardiovascular implantableelectronic device; conduction disturbance; dysrhythmia;electrocardiography; electrocautery; electromagnetic in-terference; heart disease; heart failure; implantablecardioverter-debrillator; intraoperative; left ventricularejection fraction; left ventricular function; myocardialinfarction; myocardial protection; National Surgical Qual-ity Improvement Program; pacemaker; perioperative;perioperative pain management; perioperative risk; post-operative; preoperative; preoperative evaluation; surgicalprocedures; ventricular premature beats; ventriculartachycardia; and volatile anesthetics.

An independent ERC was commissioned to perform asystematic review of a key question, the results of whichwere considered by the GWC for incorporation into thisCPG. See the systematic review report published inconjunction with this CPG (8) and its respective datasupplements.

1.2. Organization of the GWC

The GWC was composed of clinicians with content andmethodological expertise, including general cardiologists,subspecialty cardiologists, anesthesiologists, a surgeon, ahospitalist, and a patient representative/lay volunteer.The GWC included representatives from the ACC, AHA,American College of Surgeons, American Society of An-esthesiologists, American Society of Echocardiography,American Society of Nuclear Cardiology, Heart RhythmSociety (HRS), Society for Cardiovascular Angiographyand Interventions, Society of Cardiovascular Anesthesi-ologists, and Society for Vascular Medicine.

1.3. Document Review and Approval

This document was reviewed by 2 ofcial reviewers eachfrom the ACC and the AHA; 1 reviewer each from theAmerican College of Surgeons, American Society of An-esthesiologists, American Society of Echocardiography,American Society of Nuclear Cardiology, HRS, Society forCardiovascular Angiography and Interventions, Society ofCardiovascular Anesthesiologists, Society of HospitalMedicine, and Society for Vascular Medicine; and 24 in-dividual content reviewers (including members of theACC Adult Congenital and Pediatric Cardiology SectionLeadership Council, ACC Electrophysiology SectionLeadership Council, ACC Heart Failure and TransplantSection Leadership Council, ACC Interventional SectionLeadership Council, and ACC Surgeons Council). Re-viewers RWI information was distributed to the GWC andis published in this document (Appendix 2).

This document was approved for publication by the

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelinegoverning bodies of the ACC and the AHA and endorsedby the American College of Surgeons, American Society ofAnesthesiologists, American Society of Echocardiography,American Society of Nuclear Cardiology, Heart Rhythm

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015Society, Society for Cardiovascular Angiography and In-terventions, Society of Cardiovascular Anesthesiologists,Society of Hospital Medicine, and Society of VascularMedicine.

1.4. Scope of the CPG

The focus of this CPG is the perioperative cardiovascularevaluation and management of the adult patient under-going noncardiac surgery. This includes preoperative riskassessment and cardiovascular testing, as well as (whenindicated) perioperative pharmacological (includinganesthetic) management and perioperative monitoringthat includes devices and biochemical markers. This CPGis intended to inform all the medical professionalsinvolved in the care of these patients. The preoperativeevaluation of the patient undergoing noncardiac surgerycan be performed for multiple purposes, including1) assessment of perioperative risk (which can be used toinform the decision to proceed or the choice of surgeryand which includes the patients perspective), 2) deter-mination of the need for changes in management, and3) identication of cardiovascular conditions or risk fac-tors requiring longer-term management. Changes inmanagement can include the decision to change medicaltherapies, the decision to perform further cardiovascularinterventions, or recommendations about postoperativemonitoring. This may lead to recommendations and dis-cussions with the perioperative team about the optimallocation and timing of surgery (e.g., ambulatory surgerycenter versus outpatient hospital, or inpatient admission)or alternative strategies.

The key to optimal management is communicationamong all of the relevant parties (i.e., surgeon, anesthe-siologist, primary caregiver, and consultants) and thepatient. The goal of preoperative evaluation is to promotepatient engagement and facilitate shared decision makingby providing patients and their providers with clear, un-derstandable information about perioperative cardiovas-cular risk in the context of the overall risk of surgery.

The Task Force has chosen to make recommendationsabout care management on the basis of available evidencefrom studies of patients undergoing noncardiac surgery.Extrapolation from data from the nonsurgical arena orcardiac surgical arena was made only when no other datawere available and the benets of extrapolating the dataoutweighed the risks.

During the initiation of the writing effort, concern wasexpressed by Erasmus University about the scienticintegrity of studies led by Poldermans (9). The GWCreviewed 2 reports from Erasmus University published on

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7the Internet (9,10), as well as other relevant articles onthis body of scientic investigation (1113). The 2012report from Erasmus University concluded that theconduct in the DECREASE (Dutch Echocardiographic

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DownloaCardiac Risk Evaluation Applying Stress Echocardiogra-phy) IV and V trials was in several respects negligent andscientically incorrect and that essential source docu-ments are lacking to make conclusions about otherstudies led by Poldermans (9). Additionally, ErasmusUniversity was contacted to ensure that the GWC had up-to-date information. On the basis of the published infor-mation, discussions between the Task Force and GWCleadership ensued to determine how best to treat anystudy in which Poldermans was the senior investigator(i.e., either the rst or last author). The Task Forcedeveloped the following framework for this document:

1. The ERC will include the DECREASE trials in thesensitivity analysis, but the systematic review reportwill be based on the published data on perioperativebeta blockade, with data from all DECREASE trialsexcluded.

2. The DECREASE trials and other derivative studies byPoldermans should not be included in the CPG datasupplements and evidence tables.

3. If nonretracted DECREASE publications and/or otherderivative studies by Poldermans are relevant to thetopic, they can only be cited in the text with a commentabout the nding compared with the current recom-mendation but should not form the basis of thatrecommendation or be used as a reference for therecommendation.

The Task Force and the GWC believe that it is crucial, for thesake of transparency, to include the nonretracted publica-tions in the text of the document. This is particularlyimportant because further investigation is occurring simul-taneously with deliberation of the CPG recommendations.Because of the availability of new evidence and the inter-national impact of the controversy about the DECREASEtrials, the ACC/AHA and European Society of Cardiology/European Society of Anesthesiology began revising theirrespective CPGs concurrently. The respective GWCs per-formed their literature reviews and analyses independentlyand then developed their recommendations. Once peer re-view of both CPGs was completed, the GWCs chose to discusstheir respective recommendations for beta-blocker therapyand other relevant issues. Any differences in recommenda-tions were discussed and clearly articulated in the text;however, the GWCs aligned a few recommendations to avoidconfusion within the clinical community, except where in-ternational practice variation was prevalent.

In developing this CPG, the GWC reviewed prior pub-lished CPGs and related statements. Table 2 lists thesepublications and statements deemed pertinent to this

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7effort and is intended for use as a resource. However,because of the availability of new evidence, the currentCPG may include recommendations that supersede thosepreviously published.

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/21.5. Denitions of Urgency and Risk

In describing the temporal necessity of operations in thisCPG, the GWC developed the following denitions byconsensus. An emergency procedure is one in which life orlimb is threatened if not in the operating room wherethere is time for no or very limited or minimal clinicalevaluation, typically within 1 to 6 weeks to allow for an evaluation and signicantchanges in management will negatively affect outcome.Most oncologic procedures would fall into this category.An elective procedure is one in which the procedure couldbe delayed for up to 1 year. Individual institutions mayuse slightly different denitions, but this frameworkcould be mapped to local categories. A low-risk procedureis one in which the combined surgical and patient char-acteristics predict a risk of a major adverse cardiac event(MACE) of death or myocardial infarction (MI) of 50 years of age andhad noncardiac surgery requiring an overnight admission,an isolated peak troponin T value of $0.02 ng/mLoccurred in 11.6% of patients. The 30-day mortality rate inthis cohort with elevated troponin T values was 1.9% (95%condence interval [CI]: 1.7% to 2.1%) (40).

Fleisher et al.

ACC/AHA Perioperative Clinical Practice GuidelineMACE after noncardiac surgery is often associated withprior CAD events. The stability and timing of a recent MIimpact the incidence of perioperative morbidity andmortality. An older study demonstrated very high

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Downloaded FromTABLE 2 Associated CPGs and Statements

Title

CPGs

Management of patients with atrial brillation

Management of valvular heart disease

Management of heart failure

Performing a comprehensive transesophageal echocardiographic examination

Management of ST-elevation myocardial infarction

Diagnosis and management of patients with stable ischemic heart disease

Focused update incorporated into the 2007 guidelines for the management of

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelinemorbidity and mortality rates in patients with unstableangina (41). A study using discharge summaries demon-strated that the postoperative MI rate decreased sub-stantially as the length of time from MI to operationincreased (0 to 30 days 32.8%; 31 to 60 days 18.7%; 61to 90 days 8.4%; and 91 to 180 days 5.9%), as didthe 30-day mortality rate (0 to 30 days 14.2%; 31to 60 days 11.5%; 61 to 90 days 10.5%; and 91 to180 days 9.9%) (42). This risk was modied by thepresence and type of coronary revascularization (coro-nary artery bypass grafting [CABG] versus percutaneouscoronary interventions [PCIs]) that occurred at the time ofthe MI (43). Taken together, the data suggest that $60days should elapse after a MI before noncardiac surgery inthe absence of a coronary intervention. A recent MI,dened as having occurred within 6 months of noncardiacsurgery, was also found to be an independent risk factor

patients with unstable angina/nonST-elevation myocardial infarction*

Red blood cell transfusion

Management of patients with peripheral artery disease:focused update and guideline

Diagnosis and treatment of hypertrophic cardiomyopathy

Coronary artery bypass graft surgery

Percutaneous coronary intervention

Perioperative transesophageal echocardiography

Management of adults with congenital heart disease

Statements

Perioperative beta blockade in noncardiac surgery: a systematic review

Basic perioperative transesophageal echocardiography examination

Practice advisory for preanesthesia evaluation

Cardiac disease evaluation and management among kidney and livertransplantation candidates

Inclusion of stroke in cardiovascular risk prediction instruments

Perioperative management of patients with implantable debrillators, pacemakersand arrhythmia monitors: facilities and patient management

*The 2012 UA/NSTEMI CPG (20) is considered policy at the time of publication of this CPG;

AABB indicates American Association of Blood Banks; AATS, American Association for ThoracAmerican Society of Echocardiography; CPG, clinical practice guideline; HRS, Heart Rhythmvascular Angiography and Interventions; SCA, Society of Cardiovascular AnesthesiologistsUA/NSTEMI, unstable angina/nonST-elevation myocardial infarction.

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015OrganizationPublication Year

(Reference)

AHA/ACC/HRS 2014 (14)

AHA/ACC 2014 (15)

ACC/AHA 2013 (16)

ASE/SCA 2013 (17)

ACC/AHA 2013 (18)

ACC/AHA/AATS/PCNA/SCAI/STS 2012 (18a)2014 (19)

ACC/AHA 2012 (20)

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7for perioperative stroke, which was associated with an8-fold increase in the perioperative mortality rate (44).

A patients age is an important consideration, giventhat adults (those $55 years of age) have a growing prev-alence of cardiovascular disease, cerebrovascular disease,and diabetes mellitus (45), which increase overall risk forMACE when they undergo noncardiac surgery. Amongolder adult patients (those >65 years of age) undergoingnoncardiac surgery, there was a higher reported incidenceof acute ischemic stroke than for those #65 years ofage (46). Age >62 years is also an independent risk factorfor perioperative stroke (44). More postoperative compli-cations, increased length of hospitalization, and inabilityto return home after hospitalization were also more pro-nounced among frail (e.g., those with impaired cogni-tion and with dependence on others in instrumentalactivities of daily living), older adults>70 years of age (47).

AABB 2012 (21)

ACC/AHA 2011 (22)2006 (23)

ACC/AHA 2011 (24)

ACC/AHA 2011 (25)

ACC/AHA/SCAI 2011 (26)

American Society of Anesthesiologists/SCA 2010 (27)

ACC/AHA 2008 (28)

ACC/AHA 2014 (8)

ASE/SCA 2013 (29)

American Society of Anesthesiologists 2012 (30)

AHA/ACC 2012 (31)

AHA/American Stroke Association 2012 (32)

HRS/American Society of Anesthesiologists 2011 (33)

however, a full, revised CPG will be published in 2014.

ic Surgery; ACC, American College of Cardiology; AHA, American Heart Association; ASE,Society; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardio-; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; and

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DownloaA history of cerebrovascular disease has been shown topredict perioperative MACE (32).

See Online Data Supplements 1 and 2 for additionalinformation on CAD and the inuence of age and sex. Anextensive consideration of CAD in the context of noncardiacsurgery, including assessment for ischemia and other as-pects, follows later in this document.

2.2. Heart Failure

Patients with clinical heart failure (HF) (active HF symp-toms or physical examination ndings of peripheraledema, jugular venous distention, rales, third heartsound, or chest x-ray with pulmonary vascular redistri-bution or pulmonary edema) or a history of HF are atsignicant risk for perioperative complications, andwidely used indices of cardiac risk include HF as an in-dependent prognostic variable (37,48,49).

The prevalence of HF is increasing steadily (50), likelybecause of aging of the population and improved survivalwith newer cardiovascular therapies. Thus, the number ofpatients with HF requiring preoperative assessment isincreasing. The risk of developing HF is higher in theelderly and in individuals with advanced cardiac disease,creating the likelihood of clustering of other risk factorsand comorbidities when HF is manifest.

2.2.1. Role of HF in Perioperative Cardiac Risk Indices

In the Original Cardiac Risk Index, 2 of the 9 independentsignicant predictors of life-threatening and fatal cardiaccomplicationsnamely, the presence of preoperativethird heart sound and jugular venous distentionwereassociated with HF and had the strongest association withperioperative MACE (48). Subsequent approaches shiftedthe emphasis to history of HF (37) and dened HF by acombination of signs and symptoms, such as history ofHF, pulmonary edema, or paroxysmal nocturnal dyspnea;physical examination showing bilateral rales or thirdheart sound gallop; and chest x-ray showing pulmonaryvascular redistribution. This denition, however, did notinclude important symptoms such as orthopnea anddyspnea on exertion (16). Despite the differences in de-nition of HF as a risk variable, changes in demographics,changes in the epidemiology of patients with cardiovas-cular comorbidities, changes in treatment strategies, andadvances in the perioperative area, population-basedstudies have demonstrated that HF remains a signicantrisk for perioperative morbidity and mortality. In a studythat used Medicare claims data, the risk-adjusted 30-daymortality and readmission rate in patients undergoing 1of 13 predened major noncardiac surgeries was 50% to

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7100% higher in patients with HF than in an elderly controlgroup without a history of CAD or HF (51,52). These resultssuggest that patients with HF who undergo major surgicalprocedures have substantially higher risks of operative

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2death and hospital readmission than do other patients. Ina population-based data analysis of 4 cohorts of 38 047consecutive patients, the 30-day postoperative mortalityrate was signicantly higher in patients with nonischemicHF (9.3%), ischemic HF (9.2%), and atrial brillation (AF)(6.4%) than in those with CAD (2.9%) (53). These nd-ings suggest that although perioperative risk-predictionmodels place greater emphasis on CAD than on HF, pa-tients with active HF have a signicantly higher risk ofpostoperative death than do patients with CAD. Further-more, the stability of a patient with HF plays a signicantrole. In a retrospective single-center cohort study of pa-tients with stable HF who underwent elective noncardiacsurgery between 2003 and 2006, perioperative mortalityrates for patients with stable HF were not higher than forthe control group without HF, but these patients withstable HF were more likely than patients without HF tohave longer hospital stays, require hospital readmission,and have higher long-term mortality rates (54). However,all patients in this study were seen in a preoperativeassessment, consultation, and treatment program; and thepopulation did not include many high-risk patients. Theseresults suggest improved perioperative outcomes for pa-tients with stable HF who are treated according to GDMT.

2.2.2. Risk of HF Based on Left Ventricular Ejection Fraction:

Preserved Versus Reduced

Although signs and/or symptoms of decompensatedHF confer the highest risk, severely decreased (29% (56). Studies havereported mixed results for perioperative risk in patientswith HF and preserved LVEF, however. In a meta-analysisusing individual patient data, patients with HF and pre-served LVEF had a lower all-cause mortality rate than didof those with HF and reduced LVEF (the risk of death didnot increase notably until LVEF fell below 40%) (57).However, the absolute mortality rate was still high inpatients with HF and preserved LVEF as compared withpatients without HF, highlighting the importance ofpresence of HF. There are limited data on perioperativerisk stratication related to diastolic dysfunction. Dia-stolic dysfunction with and without systolic dysfunctionhas been associated with a signicantly higher rate ofMACE, prolonged length of stay, and higher rates ofpostoperative HF (58,59).

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guideline2.2.3. Risk of Asymptomatic Left Ventricular Dysfunction

Although symptomatic HF is a well-established peri-operative cardiovascular risk factor, the effect of

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Downloaoxygenation, continuous-ow LV assist devices, and/orcardiac transplantation (74).

See Online Data Supplement 3 for additional informationon HF and cardiomyopathy.

2.4. Valvular Heart Disease: Recommendations

See the 2014 valvular heart disease CPG for the completeset of recommendations and specic denitions of dis-ease severity (15) and Online Data Supplement 4 foradditional information on valvular heart disease.

CLASS I

1. It is recommended that patients with clinically suspected

moderate or greater degrees of valvular stenosis or regur-

gitation undergo preoperative echocardiography if there has

been either 1) no prior echocardiography within 1 year or 2) a

signicant change in clinical status or physical examination

since last evaluation (60). (Level of Evidence: C)

2. For adults who meet standard indications for valvular

intervention (replacement and repair) on the basis of

symptoms and severity of stenosis or regurgitation, valvular

intervention before elective noncardiac surgery is effective

in reducing perioperative risk (15). (Level of Evidence: C)

Signicant valvular heart disease increases cardiac risk forpatients undergoing noncardiac surgery (37,48). Patientswith suspected valvular heart disease should undergoechocardiography to quantify the severity of stenosis orregurgitation, calculate systolic function, and estimate rightheart pressures. Evaluation for concurrent CAD is also war-ranted, with electrocardiography exercise testing, stressechocardiographic or nuclear imaging study, or coronaryangiography, as appropriate.

Emergency noncardiac surgery may occur in the pres-ence of uncorrected signicant valvular heart disease.The risk of noncardiac surgery can be minimized by1) having an accurate diagnosis of the type and severity ofvalvular heart disease, 2) choosing an anesthetic approachappropriate to the valvular heart disease, and 3) consid-ering a higher level of perioperative monitoring (e.g.,arterial pressure, pulmonary artery pressure, trans-esophageal echocardiography), as well as managing thepatient postoperatively in an intensive care unit setting.

2.4.1. Aortic Stenosis: Recommendation

CLASS IIa

1. Elevated-risk elective noncardiac surgery with appropriate

intraoperative and postoperative hemodynamic monitoring is

reasonable to perform in patients with asymptomatic severe

aortic stenosis (AS) (48,7584). (Level of Evidence: B)

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7In the Original Cardiac Risk Index, severe AS was associatedwith a perioperative mortality rate of 13%, compared with1.6% in patients without AS (48). The mechanism of MACE inpatients with AS likely arises from the anesthetic agents and

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2surgical stress that lead to an unfavorable hemodynamicstate. The occurrence of hypotension and tachycardia canresult in decreased coronary perfusion pressure, develop-ment of arrhythmias or ischemia, myocardial injury, cardiacfailure, and death.

With the recent advances in anesthetic and surgicalapproaches, the cardiac risk in patients with signicantAS undergoing noncardiac surgery has declined. In asingle, tertiary-center study, patients with moderate AS(aortic valve area: 1.0 cm2 to 1.5 cm2) or severe AS (aorticvalve area

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CLASS IIb

1. Elevated-risk elective noncardiac surgery using appropriate

intraoperative and postoperative hemodynamic monitoring

may be reasonable in asymptomatic patients with severe

mitral stenosis if valve morphology is not favorable

for percutaneous mitral balloon commissurotomy. (Level of

Evidence: C)

Patients with severe mitral stenosis are at increased risk fornoncardiac surgery and should be managed similarly to pa-tients with AS. The main goals during the perioperativeperiod are to monitor intravascular volume and to avoidtachycardia and hypotension. It is crucial to maintain intra-vascular volume at a level that ensures adequate forwardcardiac output without excessive rises in left atrial pressureand pulmonary capillary wedge pressure that could precipi-tate acute pulmonary edema.

Patients with mitral stenosis who meet standardindications for valvular intervention (open mitral com-missurotomy or percutaneous mitral balloon commissur-otomy) should undergo valvular intervention beforeelective noncardiac surgery (85). If valve anatomy is notfavorable for percutaneous mitral balloon commissur-otomy, or if the noncardiac surgery is an emergency, thennoncardiac surgery may be considered with invasive he-modynamic monitoring and optimization of loading con-ditions. There are no reports of the use of percutaneousmitral balloon commissurotomy before noncardiac sur-gery; however, this procedure has excellent outcomeswhen used during high-risk pregnancies (86,87).

2.4.3. Aortic and Mitral Regurgitation: Recommendations

CLASS IIa



is reasonable in adults with asymptomatic severe MR. (Level

of Evidence: C)



is reasonable in adults with asymptomatic severe aortic

regurgitation (AR) and a normal LVEF. (Level of Evidence: C)

Left-sided regurgitant lesions convey increased cardiac riskduring noncardiac surgery but are better tolerated than ste-notic valvular disease (88,89). AR and MR are associatedwith LV volume overload. To optimize forward cardiacoutput during anesthesia and surgery, 1) preload should bemaintained because the LV has increased size and compli-ance, and 2) excessive systemic afterload should be avoidedso as to augment cardiac output and reduce the regurgitation

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelinevolume. For patients with severe AR or MR, the LV forwardcardiac output is reduced because of the regurgitant volume.

Patients with moderate-to-severe AR and severe ARundergoing noncardiac surgery had a higher in-hospital

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015mortality rate than did case-matched controls withoutAR (9.0% versus 1.8%; p0.008) and a higher morbidityrate (16.2% versus 5.4%; p0.003), including post-operative MI, stroke, pulmonary edema, intubation >24hours, and major arrhythmia (88). Predictors of in-hospital death included depressed LVEF (ejection frac-tion [EF] 2 mg/dL),high surgical risk, and lack of preoperative cardiac medi-cations. In the absence of trials addressing perioperativemanagement, patients with moderate-to-severe AR andsevere AR could be monitored with invasive hemody-namics and echocardiography and could be admittedpostoperatively to an intensive care unit setting whenundergoing surgical procedures with elevated risk.

In a single, tertiary-center study, patients withmoderate-to-severe MR and severe MR undergoingnonemergency noncardiac surgery had a 30-day mortalityrate similar to that of propensity scorematched controlswithout MR (1.7% versus 1.1%; p0.43) (89). Patients withMR had worse primary outcomes (dened as composite of30-day death and postoperative MI, HF, and stroke) thandid patients without MR (22.2% versus 16.4%; p

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DownloaAF is the most common sustained tachyarrhythmia; itis particularly common in older patients who are likely tobe undergoing surgical procedures. Patients with a pre-operative history of AF who are clinically stable generallydo not require modication of medical management orspecial evaluation in the perioperative period, other thanadjustment of anticoagulation (Section 6.2.7). The po-tential for perioperative formation of left atrial thrombusin patients with persistent AF may need to be consideredif the operation involves physical manipulation of theheart, as in certain thoracic procedures. Ventricular ar-rhythmias, whether single premature ventricular con-tractions or nonsustained ventricular tachycardia, usuallydo not require therapy unless they result in hemodynamiccompromise or are associated with signicant structuralheart disease or inherited electrical disorders. Althoughfrequent ventricular premature beats and nonsustainedventricular tachycardia are risk factors for the develop-ment of intraoperative and postoperative arrhythmias,they are not associated with an increased risk of nonfatalMI or cardiac death in the perioperative period (94,95).However, patients who develop sustained or non-sustained ventricular tachycardia during the periopera-tive period may require referral to a cardiologist forfurther evaluation, including assessment of their ven-tricular function and screening for CAD.

High-grade cardiac conduction abnormalities, such ascomplete atrioventricular block, if unanticipated, mayincrease operative risk and necessitate temporary orpermanent transvenous pacing (96). However, patientswith intraventricular conduction delays, even in thepresence of a left or right bundle-branch block, and nohistory of advanced heart block or symptoms, rarelyprogress to complete atrioventricular block perioper-atively (97). The presence of some pre-existing conduc-tion disorders, such as sinus node dysfunction andatrioventricular block, requires caution if perioperativebeta-blocker therapy is being considered. Isolatedbundle-branch block and bifascicular block generally donot contraindicate use of beta blockers.

2.5.1. Cardiovascular Implantable Electronic Devices:

Recommendation

See Section 6.4 for intraoperative/postoperative man-agement of cardiovascular implantable electronic devices(CIEDs).

CLASS I

1. Before elective surgery in a patient with a CIED, the surgical/

procedure team and clinician following the CIED should

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7communicate in advance to plan perioperative management

of the CIED. (Level of Evidence: C)

The presence of a pacemaker or ICD has important implica-tions for preoperative, intraoperative, and postoperative

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2patient management. Collectively termed CIEDs, these de-vices include single-chamber, dual-chamber, and biven-tricular hardware congurations produced by severaldifferent manufacturers, each with different softwaredesigns and programming features. Patients with CIEDsinvariably have underlying cardiac disease that can involvearrhythmias, such as sinus node dysfunction, atrioventric-ular block, AF, and ventricular tachycardia; structural heartdisease, such as ischemic or nonischemic cardiomyopathy;and clinical conditions, such as chronic HF or inheritedarrhythmia syndromes. Preoperative evaluation of suchpatients should therefore encompass an awareness not onlyof the patients specic CIED hardware and programming,but also of the underlying cardiac condition for which thedevice was implanted. In particular, cardiac rhythm andhistory of ventricular arrhythmias should be reviewed inpatients with CIEDs.

To assist clinicians with the perioperative evaluationand management of patients with CIEDs, the HRS and theAmerican Society of Anesthesiologists jointly developedan expert consensus statement published in July 2011 andendorsed by the ACC and the AHA (33). Clinicians caringfor patients with CIEDs in the perioperative setting shouldbe familiar with that document and the consensus rec-ommendations contained within.

The HRS/American Society of Anesthesiologists expertconsensus statement acknowledges that because of thecomplexity of modern devices and the variety of in-dications for which they are implanted, the perioperativemanagement of patients with CIEDs must be individual-ized, and a single recommendation for all patients withCIEDs is not appropriate (33). Effective communicationbetween the surgical/procedure team and the clinicianfollowing the patient with a CIED in the outpatient settingis the foundation of successful perioperative managementand should take place well in advance of elective pro-cedures. The surgical/procedure team should communi-cate with the CIED clinician/team to inform them of thenature of the planned procedure and the type of electro-magnetic interference (EMI) (i.e., electrocautery) likely tobe encountered. The outpatient team should formulate aprescription for the perioperative management of theCIED and communicate it to the surgical/procedure team.

The CIED prescription can usually be made from areview of patient records, provided that patients areevaluated at least annually (for pacemakers) or semi-annually (for ICDs). In some circumstances, patients willrequire additional preoperative in-person evaluation orremote CIED interrogation. The prescription may involveperioperative CIED interrogation or reprogramming

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guideline(including changing pacing to an asynchronous modeand/or inactivating ICD tachytherapies), application of amagnet over the CIED with or without postoperativeCIED interrogation, or use of no perioperative CIED

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interrogation or intervention (98,99). Details of individualprescriptions will depend on the nature and location ofthe operative procedure, likelihood of use of monopolarelectrocautery, type of CIED (i.e., pacemaker versus ICD),

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guideline

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tion on CIEDs.

2.6. Pulmonary Vascular Disease: Recommendations

CLASS I

1. Chronic pulmonary vascular targeted therapy (i.e., phos-

phodiesterase type 5 inhibitors, soluble guanylate cyclase

stimulators, endothelin receptor antagonists, and prosta-

noids) should be continued unless contraindicated or not

tolerated in patients with pulmonary hypertension who are

undergoing noncardiac surgery. (Level of Evidence: C)

CLASS IIa

1. Unless the risks of delay outweigh the potential benets,

preoperative evaluation by a pulmonary hypertension

specialist before noncardiac surgery can be benecial for

patients with pulmonary hypertension, particularly for those

with features of increased perioperative risk (100) *. (Level

of Evidence: C)

The evidence on the role of pulmonary hypertension inperioperative mortality and morbidity in patients undergo-ing noncardiac surgery is based on observational data and ispredominantly related to Group 1 pulmonary hypertension(i.e., pulmonary arterial hypertension) (101107). However,complication rates are consistently high, with mortality ratesof 4% to 26% and morbidity rates, most notably cardiac and/or respiratory failure, of 6% to 42% (101106). A variety offactors can occur during the perioperative period that mayprecipitate worsening hypoxia, pulmonary hypertension, orRV function. In addition to the urgency of the surgery andthe surgical risk category, risk factors for perioperativeadverse events in patients with pulmonary hypertensioninclude the severity of pulmonary hypertension symptoms,the degree of RV dysfunction, and the performance ofsurgery in a center without expertise in pulmonary hyper-tension (101106). Patients with pulmonary arterial hyper-tension due to other causes, particularly with features ofincreased perioperative risk, should undergo a thoroughpreoperative risk assessment in a center with the necessary

*Features of increased perioperative risk in patients with pulmonary hyper-

tension include: 1) diagnosis of Group 1 pulmonary hypertension (i.e., pulmo-

nary arterial hypertension), 2) other forms of pulmonary hypertensionassociated with high pulmonary pressures (pulmonary artery systolic pressures

>70 mmHg) and/or moderate or greater RV dilatation and/or dysfunction and/

or pulmonary vascular resistance >3 Wood units, and 3) World Health Orga-

nization/New York Heart Association class III or IV symptoms attributable to

pulmonary hypertension (101107).

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015medical and anesthetic expertise in pulmonary hyperten-sion, including an assessment of functional capacity, hemo-dynamics, and echocardiography that includes evaluation ofRV function. Right heart catheterization can also be usedpreoperatively to conrm the severity of illness and distin-guish primary pulmonary hypertension from secondarycauses of elevated pulmonary artery pressures, such as left-sided HF. Patients should have optimization of pulmonaryhypertension and RV status preoperatively and shouldreceive the necessary perioperative management on a case-by-case basis.

See Online Data Supplement 6 for additional informa-tion on pulmonary vascular disease.

2.7. Adult Congenital Heart Disease

Several case series have indicated that performance of asurgical procedure in patients with adult congenital heartdisease (ACHD) carries a greater risk than in the normalpopulation (108113). The risk relates to the nature of theunderlying ACHD, the surgical procedure, and the ur-gency of intervention (108113). For more information,readers are referred to the specic recommendations forperioperative assessment in the ACC/AHA 2008 ACHDCPG (28). When possible, it is optimal to perform thepreoperative evaluation of surgery for patients withACHD in a regional center specializing in congenital car-diology, particularly for patient populations that appearto be at particularly high risk (e.g., those with a priorFontan procedure, cyanotic ACHD, pulmonary arterialhypertension, clinical HF, or signicant dysrhythmia).

3. CALCULATION OF RISK TO PREDICT

PERIOPERATIVE CARDIAC MORBIDITY

3.1. Multivariate Risk Indices: Recommendations

See Table 3 for a comparison of the RCRI, American Col-lege of Surgeons National Surgical Quality ImprovementProgram (NSQIP) Myocardial Infarction and Cardiac Arrest(MICA), and American College of Surgeons NSQIP SurgicalRisk Calculator. See Online Data Supplement 7 for addi-tional information on multivariate risk indices.

CLASS IIa

1. A validated risk-prediction tool can be useful in predicting

the risk of perioperative MACE in patients undergoing

noncardiac surgery (37,114,115). (Level of Evidence: B)

CLASS III: NO BENEFIT

1. For patients with a low risk of perioperative MACE, further

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7testing is not recommended before the planned operation

(34,35). (Level of Evidence: B)

Different noncardiac operations are associated with differentrisks of MACE. Operations for peripheral vascular disease are

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Downloagenerally performed among those with the highest periop-erative risk (116). The lowest-risk operations are generallythose without signicant uid shifts and stress. Plastic sur-gery and cataract surgery are associated with a very low riskof MACE (34). Some operations can have their risk loweredby taking a less invasive approach. For example, open aorticaneurysm repair has a high risk of MACE that is loweredwhen the procedure is performed endovascularly (117). Thenumber of different surgical procedures makes assigning aspecic risk of a MACE to each procedure difcult. In addi-tion, performing an operation in an emergency situation isunderstood to increase risk.

The RCRI is a simple, validated, and accepted tool toassess perioperative risk of major cardiac complications(MI, pulmonary edema, ventricular brillation or primarycardiac arrest, and complete heart block) (37). It has 6predictors of risk for major cardiac complications, only 1of which is based on the procedurenamely, Undergoingsuprainguinal vascular, intraperitoneal, or intrathoracicsurgery. A patient with 0 or 1 predictor(s) of risk wouldhave a low risk of MACE. Patients with $2 predictors ofrisk would have elevated risk.

Two newer tools have been created by the AmericanCollege of Surgeons, which prospectively collected dataon operations performed in more than 525 participatinghospitals in the United States. Data on more than 1 millionoperations have been used to create these risk calculators(114) (www.riskcalculator.facs.org).

The American College of Surgeons NSQIP MICA risk-prediction rule was created in 2011 (115), with a singlestudyalbeit large and multicenterdescribing its deri-vation and validation (http://www.surgicalriskcalculator.com/miorcardiacarrest). This tool includes adjusted ORsfor different surgical sites, with inguinal hernia as thereference group. Target complications were dened ascardiac arrest (dened as chaotic cardiac rhythmrequiring initiation of basic or advanced life support) orMI (dened as $1 of the following: documented electro-cardiographic ndings of MI, ST elevation of $1 mm in >1contiguous leads, new left bundle-branch block, new Q-wave in $2 contiguous leads, or troponin >3 times normalin setting of suspected ischemia). Using these denitionsof outcome and chart-based data collection methods, theauthors of the risk calculator derived a risk index that wasrobust in the derivation and validation stages andappeared to outperform the RCRI (which was tested in thesame dataset) in discriminative power, particularlyamong patients undergoing vascular surgery.

The American College of Surgeons NSQIP Surgical RiskCalculator uses the specic current procedural terminol-

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7ogy code of the procedure being performed to enableprocedure-specic risk assessment for a diverse group ofoutcomes (114). The procedure is dened as being anemergency case or not an emergency case. For the

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2American College of Surgeons NSQIP, to be an emergencycase, the principal operative procedure must be per-formed during the hospital admission for the diagnosisAND the surgeon and/or anesthesiologist must report thecase as emergent (118). The calculator also includes 21patient-specic variables (e.g., age, sex, body mass index,dyspnea, previous MI, functional status). From this input,it calculates the percentage risk of a MACE, death, and 8other outcomes. This risk calculator may offer the bestestimation of surgery-specic risk of a MACE and death.

Some limitations to the NSQIP-based calculator shouldbe noted: It has not been validated in an external popu-lation outside the NSQIP, and the denition of MI in-cludes only ST-segment MIs or a large troponin bump (>3times normal) that occurred in symptomatic patients. Anadditional disadvantage is the use of the American Soci-ety of Anesthesiology Physical Status Classication, acommon qualitatively derived risk score used by anes-thesiologists. This classication has poor inter-rater reli-ability even among anesthesiologists and may beunfamiliar to clinicians outside that specialty (119,120).Clinicians would also need to familiarize themselves withthe NSQIP denitions of functional status or depen-dence, concepts that are thought to be important inperioperative risk assessment algorithms but that havenot been included in multivariable risk indices to date (formore information on functional status, see Section 4).

3.2. Inclusion of Biomarkers in Multivariable Risk Models

Several studies have examined the potential utility ofincluding biomarkersmost commonly preoperative na-triuretic peptides (brain natriuretic peptide or N-terminalprobrain natriuretic peptide) and C-reactive proteininpreoperative risk indices as an approach to identify pa-tients at highest risk (64,121125). These studies and 2 sub-sequent meta-analyses suggest that biomarkers mayprovide incremental predictive value (62,66). However,most studies had signicant variation in the time frame inwhich these biomarkers were obtained, were observa-tional, did not include a control arm, and did not requirebiomarkers routinely or prospectively. Furthermore, thereare no data to suggest that targeting these biomarkersfor treatment and intervention will reduce the post-operative risk. In addition, several of these studies wereinvestigations conducted by Poldermans (121,126130).

4. APPROACH TO PERIOPERATIVE

CARDIAC TESTING

4.1. Exercise Capacity and Functional Capacity

Fleisher et al.

ACC/AHA Perioperative Clinical Practice GuidelineFunctional status is a reliable predictor of perioperativeand long-term cardiac events. Patients with reducedfunctional status preoperatively are at increased risk ofcomplications. Conversely, those with good functional

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Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guidelinestatus preoperatively are at lower risk. Moreover, inhighly functional asymptomatic patients, it is oftenappropriate to proceed with planned surgery withoutfurther cardiovascular testing.

If a patient has not had a recent exercise test beforenoncardiac surgery, functional status can usually be

NSQIP Surgical Risk Calculator

RCRI (131)

Criteria .

Creatinine $2 mg/dL

HF

.

Insulin-dependent diabetes mellitus

Intrathoracic, intra-abdominal, orsuprainguinal vascular surgery

History of cerebrovascular accident or TIA

.

.

.

.

.

.

.

.

Ischemic heart disease

.

.

.

.

.

.

.

.

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7estimated from activities of daily living (132). Functionalcapacity is often expressed in terms of metabolic equiv-alents (METs), where 1 MET is the resting or basal oxygenconsumption of a 40year-old, 70-kg man. In the periop-erative literature, functional capacity is classied asexcellent (>10 METs), good (7 METs to 10 METs),

American College ofSurgeons NSQIP MICA (115)

American College of SurgeonsNSQIP Surgical Risk Calculator (114)

Increasing age Age

Creatinine >1.5 mg/dL Acute renal failure

. HF

Partially or completely dependentfunctional status

Functional status

. Diabetes mellitus

Surgery type: Anorectal Aortic Bariatric Brain Breast Cardiac ENT Foregut/hepatopancreatobiliary Gallbladder/adrenal/appendix/

spleen Intestinal Neck Obstetric/gynecological Orthopedic Other abdomen Peripheral vascular Skin Spine Thoracic Vein Urologic

Procedure (CPT Code)

. .

. American Society of AnesthesiologistsPhysical Status Class

. Wound class

. Ascites

. Systemic sepsis

. Ventilator dependent

. Disseminated cancer

. Steroid use

. Hypertension

. Previous cardiac event

. Sex

. Dyspnea

. Smoker

. COPD

. Dialysis

. Acute kidney injury

. BMI

. Emergency case

Continued on the next page

TABLE 3 Continued

RCRI (131)American College of

Surgeons NSQIP MICA (115)American College of Surgeons

NSQIP Surgical Risk Calculator (114)

Use outside original cohort Yes No No

Sites Most often single-site studies, but ndingsconsistent in multicenter studies

Multicenter Multicenter

Outcome and risk factorascertainment

Original: research staff, multiplesubsequent studies using variety of data

collection strategies

Trained nurses, no prospective cardiacoutcome ascertainment

Trained nurses, no prospectivecardiac outcome ascertainment

Calculation method Single point per risk factor Web-based or open-sourcespreadsheet for calculation

(http://www.surgicalriskcalculator.com/miorcardiacarrest)

Web-based calculator(www.riskcalculator.facs.org)

BMI indicates body mass index; COPD, chronic obstructive pulmonary disease; CPT, current procedural terminology; ENT, ear, nose, and throat; HF, heart failure; NSQIP MICA, NationalSurgical Quality Improvement Program Myocardial Infarction Cardiac Arrest; NSQIP, National Surgical Quality Improvement Program; RCRI, Revised Cardiac Risk Index; TIA, transientischemic attack; and ., not applicable.

J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4 Fleisher et al.D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7 ACC/AHA Perioperative Clinical Practice Guideline

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available evidence and expert opinion, the rationale ofwhich is outlined throughout the CPG. The algorithmincorporates the perspectives of clinicians caring for thepatient to provide informed consent and help guideperioperative management to minimize risk. It is alsocrucial to incorporate the patients perspective withregard to the assessment of the risk of surgery or

alternative therapy and the risk of any GDMT or coro-nary and valvular interventions before noncardiac sur-gery. Patients may elect to forgo a surgical interventionif the risk of perioperative morbidity and mortality isextremely high; soliciting this information from thepatient before surgery is a key part of shared decisionmaking.

Fleisher et al. J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4

ACC/AHA Perioperative Clinical Practice Guideline D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7e94

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5. SUPPLEMENTAL PREOPERATIVE EVALUATION

See Table 5 for a summary of recommendations forsupplemental preoperative evaluation.

5.1. The 12-Lead Electrocardiogram: Recommendations

CLASS IIa

1. Preoperative resting 12-lead electrocardiogram (ECG) is

reasonable for patients with known coronary heart disease,

signicant arrhythmia, peripheral arterial disease, cerebro-

vascular disease, or other signicant structural heart disease,

except for those undergoing low-risk surgery (137139).

(Level of Evidence: B)

CLASS IIb

1. Preoperative resting 12-lead ECG may be considered for

asymptomatic patients without known coronary heart disease,

except for those undergoing low-risk surgery (37,138140).

(Level of Evidence: B)

baseline standard against which to measure changes in thepostoperative period. For both reasons, particularly thelatter, the value of the preoperative 12-lead ECG is likelyto increase with the risk of the surgical procedure, partic-ularly for patients with known coronary heart disease,arrhythmias, peripheral arterial disease, cerebrovasculardisease, or other signicant structural heart disease(137,138).

The prognostic signicance of numerous electro-cardiographic abnormalities has been identied inobservational studies, including arrhythmias (48,142),pathological Q-waves (37,142), LV hypertrophy (139,142),ST depressions (137,139,142), QTc interval prolongation(138,143), and bundle-branch blocks (140,142). However,there is poor concordance across different observationalstudies as to which abnormalities have prognostic sig-nicance and which do not; a minority of studies foundno prognostic signicance in the preoperative ECG(141,144,145). The implications of abnormalities on thepreoperative 12-lead ECG, increase with patient age and

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J A C C V O L . 6 4 , N O . 2 2 , 2 0 1 4 Fleisher et al.D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7 ACC/AHA Perioperative Clinical Practice Guideline

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1. Routine preoperative resting 12-lead ECG is not useful for

asymptomatic patients undergoing low-risk surgical pro-

cedures (35,141). (Level of Evidence: B)

In patients with established coronary heart disease, theresting 12-lead ECG contains prognostic informationrelating to short- and long-term morbidity and mortality.In addition, the preoperative ECG may provide a useful

Colors correspond to the Classes of Recommendations in Table 1. Step 1: In p

urgency of surgery. If an emergency, then determine the clinical risk factor

appropriate monitoring and management strategies based on the clinical as

symptomatic HF, VHD, or arrhythmias, see Sections 2.2, 2.4, and 2.5 for inf

elective, determine if the patient has an ACS. If yes, then refer patient for ca

NSTEMI and STEMI CPGs (18,20). Step 3: If the patient has risk factors for

combined clinical/surgical risk. This estimate can use the American College

incorporate the RCRI (131) with an estimation of surgical risk. For example, a

with multiple risk factors, would have a low risk of MACE, whereas a patient

risk of MACE (Section 3). Step 4: If the patient has a low risk of MACE (

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Recommendations

The 12-lead ECG

Preoperative resting 12-lead ECG is reasonable for patients with known coronaother signicant structural heart disease, except for low-risk surgery

Preoperative resting 12-lead ECG may be considered for asymptomatic patientlow-risk surgery

Routine preoperative resting 12-lead ECG is not useful for asymptomatic patienlow-risk surgical procedures

Assessment of LV function

It is reasonable for patients with dyspnea of unknown origin to undergo preopof LV function

It is reasonable for patients with HF with worsening dyspnea or other changepreoperative evaluation of LV function

Fleisher et al.

ACC/AHA Perioperative Clinical Practice Guideline5.2. Assessment of LV Function: Recommendations

CLASS IIa

1. It is reasonable for patients with dyspnea of unknown origin

to undergo preoperative evaluation of LV function. (Level of

Evidence: C)

2. It is reasonable for patients with HF with worsening dyspnea

or other change in clinical status to undergo preoperative

evaluation of LV function. (Level of Evidence: C)

CLASS IIb

1. Reassessment of LV function in clinically stable patients with

previously documented LVdysfunctionmay be considered if there

has been no assessment within a year. (Level of Evidence: C)


1. Routine preoperative evaluation of LV function is not

recommended (146148). (Level of Evidence: B)

Reassessment of LV function in clinically stable patients may be considered

Routine preoperative evaluation of LV function is not recommended

Exercise stress testing for myocardial ischemia and functional capacity

For patients with elevated risk and excellent functional capacity, it is reasonable toexercise testing and proceed to surgery

For patients with elevated risk and unknown functional capacity it may be reasonaexercise testing to assess for functional capacity if it will change managemen

For patients with elevated risk and moderate to good functional capacity, it may bforgo further exercise testing and proceed to surgery

For patients with elevated risk and poor or unknown functional capacity it may beperform exercise testing with cardiac imaging to assess for myocardial ischem

Routine screening with noninvasive stress testing is not useful for low-risk noncard

Cardiopulmonary exercise testing

Cardiopulmonary exercise testing may be considered for patients undergoing eleva

Noninvasive pharmacological stress testing before noncardiac surgery

It is reasonable for patients at elevated risk for noncardiac surgery with poor functto undergo either DSE or MPI if it will change management

Routine screening with noninvasive stress testing is not useful for low-risk noncard

Preoperative coronary angiography

Routine preoperative coronary angiography is not recommended

COR indicates Class of Recommendation; DSE, dobutamine stress echocardiogram; ECG, elmyocardial perfusion imaging; and N/A, not applicable.

: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2015perative Evaluation

COR LOE References

eart disease or IIa B (137139)

cept for IIb B (37,138140)

ndergoing III: No Benet B (35,141)

ive evaluation IIa C N/A

inical status to undergo IIa C N/A

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7The relationship between measures of resting LV systolicfunction (most commonly LVEF) and perioperative eventshas been evaluated in several studies of subjects beforenoncardiac surgery (56,58,146161). These studiesdemonstrate an association between reduced LV systolicfunction and perioperative complications, particularlypostoperative HF. The association is strongest in patientsat high risk for death. Complication risk is associated withthe degree of systolic dysfunction, with the greatest riskseen in patients with an LVEF at rest

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In patients who are candidates for potential solid organtransplantation, a transplantation-specic CPG has sug-gested it is appropriate to perform preoperative LV func-tion assessment by echocardiography (31).

See Online Data Supplement 10 for additional informa-tion on assessment of LV function.

5.3. Exercise Stress Testing for Myocardial Ischemia andFunctional Capacity: Recommendations

CLASS IIa

1. For patients with elevated risk and excellent (>10 METs)

functional capacity, it is reasonable to forgo further exercise

testing with cardiac imaging and proceed to surgery

(132,135,136,162,163). (Level of Evidence: B)

CLASS IIb

1. For patients with elevated risk and unknown functional

capacity, it may be reasonable to perform exercise testing to

assess for functional capacity if it will change management

(162164). (Level of Evidence: B)

2. For patients with elevated risk and moderate to good ($4

METs to 10 METs) functional capacity, it may be reasonable

to forgo further exercise testing with cardiac imaging and

proceed to surgery (132,135,136). (Level of Evidence: B)

3. For patients with elevated risk and poor (

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prole and appears safe for use in patients with bron-

for those patients undergoing any specic elevated-risk

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Downloapatients with abdominal aortic aneurysms, peripheralvascular disease, morbid obesity, and severe chronicobstructive pulmonary diseasepopulations in whichthere had previously been safety concerns (186,187,213,214,220222). Overall, a positive test result for DSE wasreported in the range of 5% to 50%. In these studies, withevent rates of 0% to 15%, the ability of a positive testresult to predict an event (nonfatal MI or death) rangedfrom 0% to 37%. The negative predictive value is invari-ably high, typically in the range of 90% to 100%. Ininterpreting these values, one must consider the overallperioperative risk of the population and the potentialresults stress imaging had on patient management.Several large studies reporting the value of DSE in theprediction of cardiac events during noncardiac surgeryfor which Poldermans was the senior author are notincluded in the corresponding data supplement table(223225); however, regardless of whether the evidenceincludes these studies, conclusions are similar.

See Online Data Supplement 15 for additional informa-tion on DSE.

5.6. Stress TestingSpecial Situations

In most ambulatory patients, exercise electrocardio-graphic testing can provide both an estimate of functionalcapacity and detection of myocardial ischemia throughchanges in the electrocardiographic and hemodynamicresponse. In many settings, an exercise stress ECG iscombined with either echocardiography or MPI. In theperioperative period, most patients undergo pharmaco-logical stress testing with either MPI or DSE.

In patients undergoing stress testing with abnormal-ities on their resting ECG that impair diagnostic inter-pretation (e.g., left bundle-branch block, LV hypertrophywith strain pattern, digitalis effect), concomitant stressimaging with echocardiography or MPI may be anappropriate alternative. In patients with left bundle-branch block, exercise MPI has an unacceptably lowspecicity because of septal perfusion defects that are notrelated to CAD. For these patients, pharmacological stressMPI, particularly with adenosine, dipyridamole, or rega-denoson, is suggested over exercise stress imaging.

In patients with indications for stress testing who areunable to perform adequate exercise, pharmacologicalstress testing with either DSE or MPI may be appropriate.There are insufcient data to support the use of dobut-amine stress magnetic resonance imaging in preoperativerisk assessment (221).

Intravenous dipyridamole and adenosine should beavoided in patients with signicant heart block, bron-

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D E C E M B E R 9 , 2 0 1 4 : e 7 7 1 3 7chospasm, critical carotid occlusive disease, or a con-dition that prevents their being withdrawn fromtheophylline preparations or other adenosine antago-nists; regadenoson has a more favorable side-effect

ded From: https://content.onlinejacc.org/ by Agim Krasniqi on 01/04/2surgery. In general, indications for preoperative coronaryangiography are similar to those identied for the nonoper-ative setting. The decreased risk of coronary computerizedtomography angiography compared with invasive angiog-raphy may encourage its use to determine preoperatively thepresence and extent of CAD. However, any additive value indecision making of coronary computed tomography angiog-raphy and calcium scoring is uncertain, given that dataare limited and involve patients undergoing noncardiacsurgery (226).

The recommendations in this CPG do not specicallyaddress the preoperative evaluation of patients for kidneyor liver transplantation because the indications for angi-ography may be different. The reader is directed to theAHA/ACC scientic statement titled Cardiac disease eval-uation and management among kidney and liver trans-plantation candidates for further recommendations (31).

See Online Data Supplement 16 for additional informa-tion on preoperative coronary angiography.chospasm. Dobutamine should be avoided in patientswith serious arrhythmias or severe hypertension. Allstress agents should be avoided in unstable patients. Inpatients in whom echocardiographic image quality isinadequate for wall motion assessment, such as thosewith morbid obesity or severe chronic obstructive lungdisease, intravenous echocardiography contrast (187,222)or alternative methods, such as MPI, may be appro-priate. An echocardiographic stress test is favored if anassessment of valvular function or pulmonary hyperten-sion is clinically important. In many instances, eitherexercise stress echocardiography/DSE or MPI may beappropriate, and local expertise may help dictate thechoice of test.

At the time of publication, evidence did not support theuse of an ambulatory ECG as the only diagnostic testto refer patients for coronary angiography, but it maybe appropriate in rare circumstances to direct medicaltherapy.

5.7. Preoperative Coronary Angiography: Recommendation


1. Routine preoperative coronary angiography is not recom-

mended. (Level of Evidence: C)

Data are insufcient to recommend the use of coronaryangiography in all patients (i.e., routine testing), includingFleisher et al.

ACC/AHA Perioperative Clinical Practice Guideline6. PERIOPERATIVE THERAPY

See Table 6 for a summary of recommendations forperioperative therapy.

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CLASS I

1. Revascularization before noncardiac surgery is recommended

in circumstances in which revascularization is indicated

according to existing CPGs (25,26). (Level of Evidence: C)

(See Table A in Appendix 3 for related recommendations.)


1. It is not recommended that routine coronary revascularization

be performed before noncardiac surgery exclusively to reduce

perioperative cardiac events (116). (Level of Evidence: B)

Patients undergoing risk stratication before elective non-cardiac procedures and whose evaluation recommendsCABG surgery should undergo coronary

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