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2014 ACC/AHA Guideline |
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2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery |
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Classification of Recommendations : |
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Class I: |
Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. |
Class II: |
Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. |
IIa: |
Weight of evidence/opinion is in favor of usefulness/efficacy |
IIb: |
Usefulness/efficacy is less well established by evidence/opinion. |
Class III: |
Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful. |
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Level of Evidence |
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Level of Evidence A |
Data derived from multiple randomized clinical trials |
Level of Evidence B |
Data derived from a single randomized trial, or non-randomized studies |
Level of Evidence C |
Consensus opinion of experts |
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Note: A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important key clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. |
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Stepwise Approach to Perioperative Cardiac Assessment for CAD : |
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GDMT-Guideline Determined Medical Therapy, ACS- Acute Coronary Syndrome, MACE- major adverse cardiac event, MET- metabolic equivalent, NB- No Benefit, CPG- clinical practice guideline, HF- heart failure, VHD- valvular heart disease, STEMI- ST-elevation myocardial infarction, UA/NSTEMI- unstable angina/non–ST-elevation myocardial infarction. |
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Step 1:
In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment. |
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Step 2:
If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs |
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Step 3:
If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. |
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Step 4:
If the patient has a low risk of MACE (<1%) , then no further testing is needed, and the patient may proceed to surgery. |
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Step 5:
If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI (Duke Activity Status Index). If the patient has moderate, good, or excellent functional capacity (≥4 METs), then proceed to surgery without further evaluation. |
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Step 6:
If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (e.g., decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (e.g., radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT. |
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Step 7:
If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (e.g., radiation therapy for cancer) or palliation. |
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Summary of Recommendations for Supplemental Preoperative Evaluation: |
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Recommendations |
COR |
LOE |
The 12-lead ECG |
Preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease, except for low-risk surgery |
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IIa |
B |
Preoperative resting 12-lead ECG may be considered for asymptomatic patients, except for low-risk surgery |
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IIb |
B |
Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures |
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III: No Benefit |
B |
Assessment of LV function |
It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function |
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IIa |
C |
It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function |
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IIa |
C |
Reassessment of LV function in clinically stable patients may be considered |
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IIb |
C |
Routine preoperative evaluation of LV function is not recommended |
III: No Benefit |
B |
Exercise stress testing for myocardial ischemia and functional capacity |
For patients with elevated risk and excellent functional capacity, it is reasonable to forgo further exercise testing and proceed to surgery |
IIa |
B |
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 |
IIb |
B |
For patients with elevated risk and moderate to good functional capacity, it may be reasonable to forgo further exercise testing and proceed to surgery |
IIb |
B |
For patients with elevated risk and poor or unknown functional capacity it may be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia |
IIb |
C |
Routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery |
III: No Benefit |
B |
Cardiopulmonary exercise testing |
Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures |
IIb |
B |
Noninvasive pharmacological stress testing before noncardiac surgery |
It is reasonable for patients at elevated risk for noncardiac surgery with poor functional capacity to undergo either DSE or MPI if it will change management |
IIa |
B |
Routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery |
III: No Benefit |
B |
Preoperative coronary angiography |
Routine preoperative coronary angiography is not recommended |
III: No Benefit |
C |
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Definitions of Urgency and Risk: |
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An emergency procedure is one in which life or limb is threatened if not in the operating room where there is time for no or very limited or minimal clinical evaluation, typically within <6 hours. |
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An urgent procedure is one in which there may be time for a limited clinical evaluation, usually when life or limb is threatened if not in the operating room, typically between 6 and 24 hours. |
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A time-sensitive procedure is one in which a delay of >1 to 6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome. Most oncologic procedures would fall into this category. |
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An elective procedure is one in which the procedure could be delayed for up to 1 year. |
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A low-risk procedure is one in which the combined surgical and patient characteristics predict a risk of a major adverse cardiac event (MACE) of death or myocardial infarction (MI) of <1%. Selected examples of low-risk procedures include cataract and plastic surgery. |
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Procedures with a risk of MACE of ≥1% are considered elevated risk. |
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Proposed Algorithm for Antiplatelet Management in Patients With PCI and Noncardiac Surgery: |
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ASA indicates aspirin; ASAP, as soon as possible; BMS, bare-metal stent; DAPT, dual antiplatelet therapy; DES, drugeluting stent; and PCI, percutaneous coronary intervention. |
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Summary of Recommendations for Perioperative Therapy: |
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Recommendations |
COR |
LOE |
Coronary revascularization before noncardiac surgery |
Revascularization before noncardiac surgery is recommended when indicated by existing CPGs |
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I |
C |
Coronary revascularization is not recommended before noncardiac surgery exclusively to reduce perioperative cardiac events. |
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III: No Benefit |
B |
Timing of elective noncardiac surgery in patients with previous PCI |
Noncardiac surgery should be delayed after PCI |
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I |
C: 14 d after balloon angioplasty B: 30 d after BMS implantation |
Noncardiac surgery should be delayed 365 d after DES implantation |
I |
B |
A consensus decision as to the relative risks of discontinuation or continuation of antiplatelet therapy can be useful |
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IIa |
C |
Elective noncardiac surgery after DES implantation may be considered after 180 d |
IIb* |
B |
Elective noncardiac surgery should not be performed in patients in whom DAPT will need to be discontinued perioperatively within 30 d after BMS implantation or within 12 mo after DES implantation |
III: Harm |
B |
Elective noncardiac surgery should not be performed within 14 d of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively |
III: Harm |
C |
Perioperative beta-blocker therapy |
Continue beta blockers in patients who are on beta blockers chronically |
I |
B SR† |
Guide management of beta blockers after surgery by clinical circumstances |
IIa |
B SR† |
In patients with intermediate- or high-risk preoperative tests, it may be reasonable to begin beta blockers |
IIb |
C SR† |
In patients with ≥3 RCRI factors, it may be reasonable to begin beta blockers before surgery |
IIb |
B SR† |
Initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit in those with a long-term indication but no other RCRI risk factors. |
IIb |
B SR† |
It may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably >1 d before surgery.
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IIb |
B SR† |
Beta-blocker therapy should not be started on the d of surgery
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III: Harm |
B SR† |
Perioperative statin therapy |
Continue statins in patients currently taking statins |
IIa |
B |
Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery
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I |
B |
Perioperative initiation of statins may be considered in patients with a clinical risk factor who are undergoing elevated-risk procedures
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IIb |
C |
Alpha-2 agonists |
Alpha-2 agonists are not recommended for prevention of cardiac events |
III: No Benefit |
B |
ACE inhibitors |
Continuation of ACE inhibitors or ARBs is reasonable perioperatively |
IIa |
B |
If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively |
IIa |
C |
Antiplatelet agents |
Continue DAPT in patients undergoing urgent noncardiac surgery during the first 4 to 6 wk after BMS or DES implantation, unless the risk of bleeding outweighs the benefit of stent thrombosis prevention.
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I |
C |
In patients with stents undergoing surgery that requires discontinuation P2Y12 inhibitors, continue aspirin and restart the P2Y12 platelet receptor–inhibitor as soon as possible after surgery. |
I |
C |
Management of perioperative antiplatelet therapy should be determined by consensus of treating clinicians and the patient. |
I |
C |
In patients undergoing nonemergency/nonurgent noncardiac surgery without prior coronary stenting, it may be reasonable to continue aspirin when the risk of increased cardiac events outweighs the risk of increased bleeding. |
IIb |
B |
Initiation or continuation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting. |
III: No Benefit |
B
C: If risk of
ischemic events
outweighs risk
of surgical
bleeding |
Perioperative management of patients with CIEDs |
Patients with ICDs should be on a cardiac monitor continuously during the entire period of inactivation, and external defibrillation equipment should be available. Ensure that ICDs are reprogrammed to active therapy.
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I |
C |
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ACE indicates angiotensin-converting-enzyme; ARB, angiotensin-receptor blocker; BMS, bare-metal stent; CIED,cardiovascular implantable electronic device; COR, Class of Recommendation; CPG, clinical practice guideline; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; ERC, Evidence Review Committee; ICD, implantable cardioverterdefibrillator;LOE, Level of Evidence; N/A, not applicable; PCI, percutaneous coronary intervention; RCRI, Revised Cardiac Risk Index; and SR, systematic review. |
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Summary of Recommendations for Anesthetic Consideration and Intraoperative Management: |
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Recommendations |
COR |
LOE |
Volatile general anesthesia versus total intravenous anesthesia |
Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable for patients undergoing noncardiac surgery
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IIa |
A |
Perioperative pain management |
Neuraxial anesthesia for postoperative pain relief can be effective to reduce MI in patients undergoing abdominal aortic surgery |
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IIa |
B |
Preoperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with hip fracture
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IIb |
B |
Prophylactic intraoperative nitroglycerin |
Prophylactic intravenous nitroglycerin is not effective in reducing myocardial ischemia in patients undergoing noncardiac surgery |
III: No Benefit |
B |
Intraoperative monitoring techniques |
Emergency use of perioperative TEE in patients with hemodynamic instability is reasonable in patients undergoing noncardiac surgery if expertise is readily available
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IIa |
C |
Routine use of intraoperative TEE during noncardiac surgery is not Recommended.
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III: No Benefit
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C |
Maintenance of body temperature |
Maintenance of normothermia may be reasonable to reduce perioperative cardiac events |
IIb |
B |
Hemodynamic assist devices |
Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the setting of acute severe cardiac dysfunction |
IIb |
C |
Perioperative use of pulmonary artery catheters |
The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics cannot be corrected before surgery
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IIb |
C |
Routine use of pulmonary artery catheterization is not recommended
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III: No Benefit |
A |
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COR indicates Class of Recommendation; LOE, Level of Evidence; MI, myocardial infarction; N/A, not applicable; and TEE, transesophageal echocardiogram. |
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Source : |
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Lee A. Fleisher, MD, 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2014;():. doi:10.1016/j.jacc.2014.07.944 |