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Guidelines: Perioperative Cardiovascular Evaluation for Noncardiac Surgery

The ACC and AHA have updated the 1996 guidelines with new, evidence-based recommendations.

Sponsoring Organizations: The American College of Cardiology and the American Heart Association

Background and Purpose: Cardiac-related complications of elective surgery account for significant morbidity and mortality (an estimated 1 million perioperative MIs in the U.S. annually). In this update of the 1996 recommendations, new data (from 160 relevant articles) are integrated into concise, evidence-based guidelines for evaluating and assessing perioperative risk, for optimizing appropriate perioperative testing and/or intervention, and for adjusting care -- all aimed at decreasing perioperative and long-term risk.

Key Points:

1. Since 1996, the expert-opinion-based algorithm for perioperative cardiac-risk assessment has proved to be successful and cost-effective. The authors strongly recommend using this stepwise approach, which remains virtually unchanged in the new guidelines (see Figure 1 of the guidelines).

2. Clinical evaluation to determine a patient's likelihood of significant coronary artery disease and to define specific risk categories remains the basis of cardiac-risk assessment.

3. To further refine risk assessment, noninvasive testing should be used selectively. Decisions about stress testing should be based on clinical markers of risk, on the patient's functional capacity (using history), and on the cardiovascular stress expected from surgery. New recommendations about when to use which tests appear in section V of the guidelines.

4. In general, indications for perioperative coronary angiography are similar to angiography indications for the nonoperative setting.

5. Coronary revascularization is rarely necessary simply to lower surgery risk, unless such intervention is indicated for other reasons.

6. For patients who undergo successful percutaneous coronary intervention before planned noncardiac surgery, there is uncertainty about the appropriate timing of surgery. However, the guideline authors cite retrospective-study results that show a high stent-thrombosis rate for elective surgery performed within 2 weeks of stent placement. Therefore, delaying surgery 2 to 4 weeks after stent placement seems prudent.

7. Patients with implanted pacemakers or cardioverter-defibrillators should have their devices evaluated before and after surgery. The new guidelines concisely summarize several general recommendations for clinicians and surgeons.

8. Prophylactic beta-blockade should be used in high-risk patients who are not already taking beta-blockers and for whom coronary revascularization is not a serious consideration.

9. The authors emphasize that perioperative evaluation is a unique opportunity to identify patients with cardiac risk factors and to initiate appropriate predischarge therapy -- and not just to focus on "medical clearance" for surgery.

Comment: These comprehensive guidelines provide clinicians with a quick reference for optimal decision making about the cardiac risks of noncardiac surgery. The best event-free-survival/cost-effectiveness ratio can be expected with coronary-angiography referral for high-risk patients, selective stress testing for intermediate-risk patients, and no further pre-surgery workup (beyond initial assessment) for low-risk patients.

— Beat J. Meyer, MD

Published in Journal Watch Cardiology March 22, 2002

Citation(s):

Eagle KA et al. ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). 2002. http://www.acc.org/clinical/guidelines/perio/update/pdf/perio_update.pdf