1st October 2007
American College of Cardiology Foundation
American Heart Association
Summary, Abstract,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

• To provide a framework for considering cardiac risk of noncardiac surgery in a variety of patient and surgical situations
• To guide preoperative evaluation to determine the patient's current medical status
• To make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period
• To provide a clinical risk profile that the patient, primary physician, nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes
• To update the 2002 recommendations on perioperative cardiovascular evaluation and care for noncardiac surgery

TARGET POPULATION

Patients undergoing noncardiac surgery

INTERVENTIONS AND PRACTICES CONSIDERED

Risk Assessment

1. Clinical history
2. Physical examination
3. Assessment of comorbid disease (pulmonary disease, diabetes mellitus, renal impairment, hematologic disorders)
4. Ancillary studies, as needed (e.g., laboratory evaluation, chest x-ray, standard electrocardiogram [ECG])
5. Stepwise approach to perioperative cardiac assessment (clinical risk factors, prior coronary history and treatment, functional capacity, and surgery-specific risk)
6. Supplemental preoperative evaluation:
   • Resting left ventricular function
   • 12-lead ECG
   • Exercise or pharmacological stress testing
   • Myocardial perfusion imaging
   • Dobutamine stress echocardiography
   • Ambulatory ECG monitoring
   • Coronary angiography

Management

1. Perioperative therapy
   • Surgical coronary revascularization: preoperative coronary artery bypass grafting (CABG); percutaneous coronary intervention with or without stents (either bare metal or drug-eluting, with or without post-stent pharmacologic therapy [aspirin, clopidogrel]); percutaneous transluminal coronary angioplasty (PTCA)
   • Pharmacologic management: beta-blocker, alpha-2 agonist, and statin therapy; calcium channel blockers (no recommendation)
2. Management of specific cardiovascular conditions
3. Anesthetic considerations and intraoperative management
   • Anesthetic technique and agent
   • Perioperative pain management
   • Intraoperative nitroglycerin
   • Transesophageal echocardiography
   • Maintenance of body temperature
   • Intra-aortic balloon counterpulsation devices
   • Control of blood glucose concentration
4. Perioperative surveillance
   • Pulmonary artery catheters
   • ST-segment monitoring
   • Surveillance for perioperative myocardial infarction (MI)
   • Management of postoperative arrhythmias and conduction disorders
5. Postoperative and long-term management
   • Surveillance and treatment of MI
   • Cardiovascular medical therapy

MAJOR OUTCOMES CONSIDERED

• Positive and negative predictive value of tests for myocardial infarction or death
• Short- and long term cardiac outcomes, such as perioperative cardiovascular morbidity (e.g., myocardial infarction, unstable angina, congestive heart failure, ventricular tachycardia, stroke) and mortality (e.g., cardiac death)
• Economic outcomes (e.g., length of hospitalization, hospital resource use [intensive care])