periop guideline hand book

8/9/2019 Periop Guideline Hand Book

1/24

PerioperativeCardiovascular

ACC/AHAPocket

GuidelineUpdate


2/24


3/24

C om

p e t en c e

©2002 American College of Cardiology Foundationand American Heart Association, Inc.

The following material was adapted from theACC/AH A Gui deli ne Update for Peri operati ve Cardi ovascular Evaluati on for Noncardiac Surgery.For a copy of the executive summary, (J Am CollCardiol 2002;39:542-53, Circulation 2002;105:1257-68) and full report, visit our Web sites athttp://www.acc.org or http://www.americanheart.orgor call the ACC Resource Center at 1-800-253-4636,

ext. 694.

Contents Purpose and Approach . . . . . . . . . . . . . . . . . . . . . 4

Preoperative Clinical Evaluation . . . . . . . . . . . . 5

Furt her Preoperat ive Test ingto Assess Coronary Risk . . . . . . . . . . . . . . . . . . . 6

Methods of Assessing Cardiac Risk . . . . . . . . . 18

Management of SpecificPreoperative Cardiovascular Conditions . . . . . 29

Preoperative Coronary Revascularization . . . . 34

Anesthet ic Considerationsand Intraoperat ive Management . . . . . . . . . . . 37

Perioperative Surveillance . . . . . . . . . . . . . . . . 40

Postoperative Therapyand Long-Term Mana geme nt . . . . . . . . . . . . . . . 44

E v al u a t i on

A s s e s s m en t

M an a g em en t

R ev a s c ul ar i z a t i on

A n e s t h e t i c

S ur v ei l l an c e

P o s t o p er a t i v e


4/24

54

E v al u a t i on

Purpose of These Guidelines

These guidelines are intended for physiciansinvolved in the preoperative, operative, and post-

operative care of patients undergoing noncardiacsurgery. They provide a framework for consideringcardiac risk of noncardiac surgery in a variety of patient and operative situations. They strive toincorporate what is currently known about peri-operative risk and how this knowledge can be usedto treat individual patients. The methods used todevelop these guidelines are described in the fulltext of the guidelines that appear on the WorldWide Web sites of the ACC (www.acc.org) andAHA (www.americanheart.org) .

General Approach

Successful perioperative evaluation and treatmentof cardiac patients undergoing noncardiac surgeryrequires careful teamwork and communication

between patient, primary care physician, anesthe-siologist, surgeon, and the medical consultant. Ingeneral, indications for further cardiac testing andtreatments are the same as those in the nonopera-tive setting, but their timing is dependent on suchfactors as the urgency of noncardiac surgery, thepatient’s risk factors, and specific surgical considera-tions. Coronary revascularization before noncardiac

surgery to enable the patient to “get through” the noncardiacprocedure is appropriate only for a small subset of patientsat very high risk. Preoperative testing should be limited tocircumstances in which the results will affect patient treatmentand outcomes. A conservative approach to the use of expen-sive tests and treatments is recommended.

Preoperative Clinical Evaluation

The initial history, physical examination, and electrocardio-graphic (ECG) assessment should focus on the identificationof potentially serious cardiac disorders, including coronary

artery disease (CAD) (eg, prior myocardial infarction [MI],angina pectoris), heart failure (HF), and electrical instability(symptomatic arrhythmias).

In addition to identifying the presence of preexisting mani-fested heart disease, it is essential to define disease severi ty,stability, and prior treatment . Other factors that helpdetermine cardiac risk include■ functional capacity■ age■ comorbid conditions (eg, diabetes mellitus, peripheral

vascular disease, renal dysfunction, chronic pulmonarydisease)

■ type of surgery (vascular procedures and prolongedcomplicated thoracic, abdominal, and head and neckprocedures are considered higher risk)


5/24

76

E v al u a t i on E

v a l u a t i o n

Furt her Preoperat ive Test ing

to Assess Coronary Risk

Coronary heart disease is the most frequent causeof perioperative cardiac mortality and morbidity afternoncardiac surgery. A common question concerningnoncardiac surgery is which patients are most likelyto benefit from preoperative coronary assessmentand treatment?The lack of adequately controlledor randomized clinical trials to define the optimalevaluation strategy has led to the proposed algorithmbased on collected observational data and expertopinion. A step-wise Bayesian strategy that relieson assessment of clinical markers, prior coronaryevaluation and treatment, functional capacity, andsurgery-specific risk is outlined below and correlateswith the information in Tables 1-3 and Figure 1 ,which presents in algorithmic form a framework fordetermining which patients are candidates for cardiactesting. Table 1 outlines clinical predictors of periop-erative risk. Table 2 presents a validated method for

assessing functional capacity. Table 3 stratifies riskof various types of noncardiac surgeries. For clarity,categories have been established as “black andwhite,” but it is recognized that individual patientproblems occur in “shades of gray.” The clinicianmust consider several interacting variables and weighthem appropriately. Furthermore, there are no ade-quate controlled or randomized clinical trials tohelp define the process.

Table 1Clinical Predictors of IncreasedPerioperative Cardiovascular Risk(Myocardial Infarction, Heart Failure, Death)

Major

Unstable coronary syndromes■ Acute or recent myocardial infarction*with evidence of important ischemicrisk by clinical symptoms or noninvasivestudy■ Unstable or severe † angina (CanadianCardiovascular Society Class III or IV) ‡

Decompensated heart failure

Significant arrhythmias such as■ High-grade atrioventricular block■ Symptomatic ventricular arrhythmiasin the presence of underlying heartdisease■ Supraventricular arrhythmiaswith uncontrolled ventricular rate

Severe valvular disease

*The Ameri can College of Cardiology National Database Library defines recentmyocardial i nfarction as greater than 7 days but less than or equal to 1 month(30 days); acute MI is wi thi n 7 days.

†May include “stable” angina in patients who are unusually sedentary.‡Campeau L. Grading of angina pectori s. Ci rculation 1976;54:522-523.

Intermediate

Mild angina pectoris (CanadianCardiovascular Society Class I or II)

Prior myocardial infarctionby history or pathological Q-waves

Compensated or prior heart failure

Diabetes mellitus(particularly insulin-dependent)

Renal insufficiency

Minor

Advanced age

Abnormal electrocardiogram(left ventricular hypertrophy, leftbundle branch block, ST-T abnormalities)

Rhythm other than sinus(eg, atrial fibrillation)

Low functional capacity(eg, inability to climb one flightof stairs with a bag of groceries)

History of stroke

Uncontrolled systemic hypertension


6/24

98

E v al u a t i on E

v a l u a t i o n

Tabl e 2Estimat ed Energy Requirementsfor Various Activities

1 MET Can you take careof yourself?

Eat, dress, or usethe toilet?

Walk indoors aroundthe house?

Walk a block or two onlevel ground at 2-3 mphor 3.2- 4.8 km/h?

4 METs Do light work aroundthe house like dustingor washing dishes?

MET indicates metaboli c equivalent.

Adapted from the Duke Acti vit y Status Index (Hl atky M A, Boineau RE, Higginbotham MB, Lee KL, M ark DB, Cali ff RM , Cobb FR, Pryor DB. A brief self-admini steredquesti onnaire to determi ne functional capacity [t he Duke Activity Status Index]. Am J Cardiol. 1989;64:651-654) and AH A Exercise Standards (Fl etcher GF, Balady G,Froeli cher VF, Hart ley LH, H askell WL, Pollock M L. Exercise standards: a statementfor healthcare professionals from the Ameri can Heart Associati on. Ci rculat ion 1995; 91:580-615).

4 METs Climb a flight of stairs or walkup a hill?

Walk on level ground at 4 mphor 6.4 km/h?

Run a short distance?

Do heavy work around the houselike scrubbing floors or lifting ormoving heavy furniture?

Participate in moderaterecreational activities likegolf, bowling, dancing, doublestennis, or throwing a baseballor football?

>1 0 M ETs Participate in strenuous sportslike swimming, singles tennis,football, basketball, or skiing?

▼

▼

Table 3Cardiac Event Risk * Stratification forNoncardiac Surgical Procedures

High(Reported cardiac risk often > 5%)■ Emergent major operations,particularly in the elderly■ Aortic and other major vascular surgery■ Peripheral vascular surgery■ Anticipated prolonged surgicalprocedures associated with largefluid shifts and/or blood loss

* Combined incidence of cardi ac death and nonfatal myocardial i nfarction.

†Further preoperative cardiac testi ng is not generally r equired.

Intermediate(Reported cardiac risk generally < 5%)■ Intraperitoneal andintrathoracic surgery■ Carotid endarterectomy surgery■ Head and neck surgery■ Orthopedic surgery■ Prostate surgery

Low†

(Reported cardiac risk generally < 1%):■ Endoscopic procedures■ Superficial procedures■ Cataract surgery■ Breast surgery


7/24

Need for

noncardiacsurgery

Urgent orelectivesurgery

Postoperative risk

stratification and riskfactor m anagement

Coronaryrevascularizationwithin 5 years?

YesRecurrentsymptomsor signs?

Recentcoronaryevaluation

No

Recent coronaryangiogram orstress test?

Favorable result

and no changein symptomsYes

No

Clinicalpredictors

Major clinicalpredictors†

Intermediateclinical

predictor§

Minor or noclinical

predictors**

Go toConsider delay

or cancelnoncardiac surgery

Emergencysurgery

No

Yes

Unfavorableresult or changein symptoms

Operatingroom

Operatingroom

Considercoronary

angiography

Go to

Medicalmanagement and

risk factormodification

Subsequent caredictated byfindings and

treatment results

Step

45

Step

6

Step

7

Step3

Step

2

Step

1

† Major Clinical Predict ors

■ Unstable coronary syndromes■ Decompensated CHF■ Significant arrhythmias (see table 1)■ Severe valvular disease

Step

Clinical predictors

Functional capacity

Surgical risk

Noninvasive testing‡

Invasive testing

Poor(< 4METs)

Intermediate

clinicalpredictors†

High surgicalrisk procedure

Moderate orexcellent

(> 4 METs)

Intermediateor low surgicalrisk procedure

Low surgicalrisk procedure

Noninvasivetesting

Operatingroom

Postoperativerisk stratificationand risk factor

reduction

Considercoronary

angiography

Subsequent care* dictatedby findings and

treatment results

Low risk

§ Intermediate

Clinical Predictors■ Mild angina pectoris■ Prior MI■ Compensated or prior CHF■ Diabetes mellitus■ Renal insufficiency

Highrisk

Step

8

Step

6

1110

E v al u a t i on E

v a l u a t i o n

Stepwise Approach to Preoperat ive Cardiac AssessmentSteps are discussed in text.

continued on next page

‡ Myocardi al perfusion imaging or stress echocardi ography.


8/24

1312

E v al u a t i on E

v a l u a t i o n

The following steps correspond to t he

algorithm presented in the Figure 1.

What is the urgency of noncardiac surgery?In manyinstances, patient or specific surgical factors dictate an

obvious strategy (ie, immediate surgery) which may not allowfurther cardiac evaluation. In such cases, the consultant mayfunction best by making recommendations for perioperativemedical management and surveillance. Postoperative riskstratification may be appropriate for some patients who havenot had such an assessment.

Has the patient undergone coronary revascularization inthe past 5 years?If so, and if clinical status has remained

stable without recurrent symptoms/signs of ischemia, furthercardiac testing is generally not necessary.

Has the patient had a coronary evaluation in the past 2years?If coronary risk was adequately assessed and the

findings were favorable, it is usually not necessary to repeattesting unless the patient has experienced a change or newsymptoms of coronary ischemia since the previous evaluation.

Does the patient have an unstable coronary syndrome ora major clinical predictor of risk (Table1) ?When elec-

tive noncardiac surgery is being considered, the presence of unstable coronary disease, decompensated HF, symptomaticarrhythmias, and/or severe valvular heart disease usually leads

Clinical predictors

Functional capacity

Surgical risk

Noninvasive testing‡

Invasive testing

Poor(< 4METs)

Minor or noclinical

predictors**

High surgicalrisk procedure

Moderate orexcellent

(> 4 METs)

Intermediatesurgical risk

procedure

Noninvasivetesting

OperatingRoom

Postoperativerisk stratificationand risk factor

reduction

Considercoronary

angiography

Subsequent care§§ dictatedby findings and

treatment results

Low riskStep

8

Highrisk

Step

7

** Minor Clinical Predictors

■ Advanced age

■ Abnormal ECG■ Rhythm other than sinus■ Low functional capacity■ History of stroke■ Uncontrolled systemic hypertension

§§ Subsequent care may include cancell ati on or delay of surgery, coronar yrevasculari zati on foll owed by noncardiac surgery, or intensifi ed care.

Step

1

Step

2

Step

3

Step

4

E v a l u a t i o n


9/24

1514

E v al u a t i on E

v a l u a t i o n

to cancellation or delay of surgery until the problem hasbeen identified and treated. Examples of unstable coronarysyndromes include recent MI with evidence of ischemic riskby clinical symptoms or noninvasive study, unstable or severeangina, and new or poorly controlled ischemia-mediated HF.Many patients in these circumstances are referred for coronaryangiography to further assess therapeutic options.

Does the patient have intermediate clini cal predictors ofri sk (Table1) ?The presence or absence of prior M I by

history or electrocardiogram, angina pectoris, compensatedor prior HF, renal insufficiency, and/or diabetes melli tus helpsfurther stratify clinical risk for perioperative coronary events.Consideration of functional capacity and level of surgeryspecific ri sk allows a rational approach to identifying patientsmost likely to benefit from further noninvasive testing.

Functional capacity can be expressed in metabolic equivalent(MET) levels; the oxygen consumption (VO 2) of a 70-kg, 40year-old man in a resting state is 3.5 mL/kg per minute or 1MET. Multiples of the baseline MET value can be used toexpress aerobic demands for specific activities. Perioperativecardiac and long-term risk is increased in patients who areunable to meet a 4-MET demand during most normal dailyactivities. The Duke Activity Status Index (Table 2) and otheractivity scales provide the clinician with a relatively easy set of questions to determine a patient’s functional capacity as lessthan or greater than 4 METs.

Surgery-specific cardi ac ri sk (Table 3) of noncardiac surgeryis related to two important factors. First, the type of surgeryitself may identify a patient with a greater likelihood ofunderlying heart disease, such as in vascular surgery, whereunderlying CAD is present in a substantial portion of patients. A second aspect is the degree of hemodynamic stressassociated with surgery-specific procedures. Certain operationsmore predictably result in intraoperative or postoperativealterations in heart rate and blood pressure, fluid shifts, pain,bleeding, clotting tendencies, oxygenation, neurohumoralactivation, and other perturbations. The duration and inten-sity of these coronary and myocardial stressors help estimate

the likelihood of perioperative cardiac events. This likelihoodis particularly evident for emergency surgery, in which therisk of cardiac complications is substantially elevated.Examples of noncardiac surgery and their surgery-specific risksare provided in Table 3. Higher-risk surgery includes aorticsurgery, peripheral vascular surgery, and anticipated prolongedprocedures associated with major fluid shifts and/or blood lossinvolving the abdomen, thorax, head, and neck.

Patients without major but with intermediate predictorsof clinical risk (Table 1) and with moderate or excellent

functional capacity can generally undergo intermediate-risksurgery with little likelihood of perioperative death or MI.Conversely, further noninvasive testing is often considered forpatients with poor functional capacity or moderate functional

Step

5

Step6


10/24

1716

E v al u a t i on E

v a l u a t i o n

capacity but higher-risk surgery and especially for patientswith two or more intermediate predictors (ie, prior MI,prior or compensated HF, angina, or diabetes mellitus).

Noncardiac surgery is generally safe for patients withneither major nor intermediate predictors of clinical

risk (Table 1) and moderate or excellent functional capacity(4 M ETs or greater). Further testing may be considered onan individual basis for patients without clinical markersbut poor functional capacity who are facing higher-riskoperations, particularly those with several minor clinicalpredictors of risk who are to undergo vascular surgery.

The results of noninvasive testing can be used todetermine further preoperative management. Such

management may include intensified medical therapy; cardiaccatheterization, which may lead to coronary revascularization;or cancellation or delay of the elective noncardiac operation.Alternatively, the results may lead to a recommendation toproceed with surgery. In some patients the risk of interventionor corrective cardiac surgery may approach or even exceedthe risk of the proposed noncardiac surgery. This approachmay be appropriate, however, if it also significantly improvesthe patient’s long-term prognosis. For some patients, a carefulconsideration of clinical, surgery-specific, and functionalstatus attributes leads to a decision to proceed to coronaryangiography.

Shortcut t o the Decision Test

The majority of patients have either intermediate or minorclinical predictors of increased perioperative cardiovascular

risk. Table 4 presents a shortcut approach to a large numberof patients in whom the decision to recommend testingbefore surgery can be difficult. Basically, if 2 of the 3 li stedfactors are true, the guidelines suggest the use of noninvasivecardiac testing as part of the preoperative evaluation.

Table 4. Short cut t o Noninvasive Test ing inPreoperative Patient s if Any Two Factors Are Present

1. Intermediate clinical predictors are present (Canadian class 1 or 2 angina,prior MI based on history or pathologic Q-waves, compensated or prior heartfailure, diabetes, or renal insufficiency)

2. Poor funct ional capacity (l ess than 4 METs)

3. High surgical risk procedure (emergency major operations *; aortic repairor peripheral vascular surgery; prolonged surgical procedures with large fluidshifts or blood loss)

M I indicates myocardial inf arction; M ETs, metabolic equivalents.

Modifi ed wi th permission from: L eppo JA, Dahlberg ST. The questi on: to test or notto test in preoperati ve cardiac ri sk evaluati on. J Nucl Cardiol. 1998;5:332-42.

Copyri ght © 1998 by the Ameri can Society of Nuclear Cardiology. Thi s material may not be reproduced, stored in a retr ieval system, or t ransmitt ed in any form or by any means wi thout the prior permission of the publi sher.

*Emergency major operati ons may require immediately proceeding to surgery wi thoutsuff icient ti me for noni nvasive testi ng or preoperative interventi ons.

Step

7

Step

8


11/24

1918

A s s e s s m en t A

s s e s s m e n t

Methods of Assessing Cardiac Risk

Resti ng Left Ventri cular Function

Several studies have shown that a left ventricular (LV) ejectionfraction below 35% increases risk of noncardiac surgery.Patients with severe diastolic dysfunction are also at increasedrisk. The presence of current or poorly controlled HF is anindication for evaluation of LV function. Possible indicationsinclude prior HF or dyspnea of unknown etiology.

Recommendations forPreoperative Noninvasive Evaluation

of Left Ventricular Function

Class I Patients with current or poorly controlled HF.(I f previous evaluation has documented severe leftventricular dysfunction, repeat preoperative testingmay not be necessary).

Class IIa Patients with prior HF and patients with dyspnea

of unknown origin.

Class III As a routine test of left ventricular function inpatients without prior HF.

12-Lead ECG

The resting 12-lead ECG does not identify increased peri-operative risk in patients undergoing low-risk surgery, but

certain ECG abnormalities are clinical predictors of increasedperioperative and long-term cardiovascular risk in clinicallyintermediate- and high-risk patients.

Recommendations forPreoperative 12-Lead Rest ECG

Class I Recent episode of chest pain or ischemicequivalent in clinically intermediate- or high-riskpatients scheduled for an intermediate- or high-risk operative procedure.

Class IIa Asymptomatic persons with diabetes mellitus.

Class IIb 1. Patients with prior coronary revascularization.

2. Asymptomatic male more than 45 years oldor female more than 55 years old with 2 or more

atherosclerotic risk factors.3. Prior hospital admission for cardiac causes.

Class III As a routine test in asymptomatic subjectsundergoing low-risk operative procedures.


12/24

2120


s s e s s m e n t

Exerci se Stre ss Test ing (see Tabl e 5 )

Preoperative exercise testing using treadmill or bicyclestress and ECG analysis with or without nuclear myocardial

perfusion imaging or echocardiography to identify ischemiaprovides substantial information about risk of perioperativeMI and cardiac death. Poor functional capacity, particularlythat associated with myocardial ischemia, identifies patientswith a severalfold increased risk of untoward outcomes. Agradient of increasing ischemic risk is seen in associationwith degree of functional incapacity, symptoms of ischemia,severity of ischemia (eg, depth, time of onset, and durationof ST-segment depression), and evidence of hemodynamic orelectrical instability during or after stress. This gradient alsocorrelates with increasing likelihood of severe and multivesselcoronary disease.

Table 5. Prognostic Gradient of Ischemic ResponsesDuring an ECG-Monit ored Exerci se Test

Patients with suspected or proven CAD

High risk

Ischemia induced by l ow-level exercise * (less than 4 METs or heart rateless than 100 bpm or less than 70% age predicted) manifested by oneor more of the following:

■ Horizontal or downsloping ST-depression greater than 0 .1mV

■ ST-segment elevation greater than 0.1mV in noninfarct lead

■ Five or more abnormal leads

■ Persistent ischemic response greater than 3 min. after exertion

■ Typical angina

Intermediate risk

Ischemia induced by moderate-level exercise (4 to 6 METs or heart rate 1 00 t o 130bpm [70 to 85% age predicted) manifested by one or more of the following:


■ Typical angina

■ Persistent ischemic response greater than 1 to 3 min. after exertion

■ Three to four abnormal leads

Low risk

No ischemia or ischemia induced at high-level exercise (greater than 7 METs or heartrate greater than 130 bpm [greater than 85% age predicted) manifested by:


■ Typical angina

■ One or two abnormal leads

Inadequate test

Inability to reach adequate target workload or heart rate response for age withoutan ischemic response. For patients undergoing noncardiac surgery, the inabilityto exercise to at least the intermediate-risk level without ischemia should beconsidered an inadequate test.

ECG i ndicates electrocardiographically; M ETs, metabolic equivalents;bpm, beats per minute.

*Workload and heart rate esti mates for r isk severi ty require adjustment for pat ient age.Maximum target heart rates for 40- and 80-year-old subjects on no cardioacti vemedication are 180 and 140 bpm, respectively.


13/24


14/24

2524


s s e s s m e n t

Class III 1. For exercise stress testing, diagnosis of patientswith resting ECG abnormalities that precludeadequate assessment, eg, pre-excitation syndrome,

electronically paced ventricular rhythm, rest STdepression greater than 1 mm, or left bundle-branch block.

2. Severe comorbidity likely to limit life expectancyor candidacy for revascularization.

3. Routine screening of asymptomatic menor women.

4. Investigation of isolated ectopic beats inyoung patients.

Supplemental Preoperative Evaluation:When and Which Test ?

Figure 2 illustrates an algorithm to help the clinician choosethe most appropriate stress test in various situations. Testing is

only indicated if the results will impact care.

Figure 2. Supplemental Preoperative Evaluation:

When and Whic h Test *

Indications for angiography(eg, unstable angina)?

No further preoperativetesting recommended

Preoperativeangiography

Patient ambulatory andable to exercise?‡

ECGETT

Pharmacologic stressimaging(nuclearor echo)

Dipyridamole oradenosine perfusion

Dobutamine stress echoor nuclear imaging

Other (eg, Holter monitor,angiography)

Exercise echo orperfusion imaging* *

Bronchospasm?II°AV Block?

Theophyline dependent?Valvular dysfunction?

Prior symptomaticarrhythmia (par ticularlyventricular tachycardia)?Marked hypertension?

Prior symptomatic

arrhythmia (particularlyventricular tachycardia)?Borderline or lowblood pressure?

Marked hypertension?Poor echo window?

▼

▼

▼

▼

▼

*Testi ng is only indi cated i f the result s wi ll impact care.†See Table 1 for the li st of intermediate cli ni cal predictors, Table 2 for t he metaboli c

equivalents, and Table 3 for the defi ni ti on of high-ri sk surgical procedure.‡ Able to achieve more than or equal t o 85% MPHR.**In t he presence of LBBB, vasodilator perfusion imaging is preferred.

2 or more of the following?†

1. Intermediate clinical predictors2. Poor functional capacity

(less than 4 METS)3. High surgical risk

Yes

No

No

Yes

Yes

▼No

▼No

▼Yes

▼Yes

▼Yes

▼No

▼No

▼Yes

▼No

Resting ECG normal?


15/24

27

Class IIa 1. Multiple markers of intermediate clinical risk †and planned vascular surgery (noninvasive testingshould be considered first).

2. Moderate to large ischemia on noninvasivetesting but without high-risk features and lowerleft ventricular ejection fraction.

3. Nondiagnostic noninvasive test results inpatients at intermediate clinical risk † undergoinghigh-risk* noncardiac surgery.

4. Urgent noncardiac surgery while convalescingfrom acute MI.

Class IIb 1. Perioperative MI.

2. Medically stabilized class III or IV angina andplanned low-risk or minor *surgery.

Class III 1. Low-risk *noncardiac surgery with known CADand no high-risk results on noninvasive testing.

2. Asymptomatic after coronary revascularizationwith excellent exercise capacity (greater than orequal to 7 METs).

3. Mild stable angina with good left ventricularfunction and no high-risk noninvasive test results.

Coronary Angiography

As indicated previously, it may be appropriate to proceeddirectly to coronary angiography in certain patients at high

risk. Indications for coronary angiography in the preopera-tive setting generally are similar to those in the nonoperativesetting. First, it is essential to ensure that management withpercutaneous coronary intervention (PCI) or coronary arterybypass graft (CABG) surgery is a viable option. Otherwise,coronary angiography may add to cost and risk withoutmeasurably benefiting outcome. Second, angiography shouldbe reserved for patients at very high risk, including those withevidence of advanced ischemic risk or symptoms, and particu-

larly those suspected of having left main or three-vessel CAD.

Recommendations f or Coronary Angiographyin Perioperative Evaluation Before (or After)Noncardiac Surgery

Class I Patients With Suspected or Known CAD

1. Evidence for high risk of adverse outcome based

on noninvasive test results.2. Angina unresponsive to adequate medicaltherapy.

3. Unstable angina, particularly when facing inter-mediate-risk* or high-risk* noncardiac surgery.

4. Equivocal noninvasive test results in patients athigh clinical risk † undergoing high-risk *surgery.

26


s s e s s m e n t

cont inued on next page


16/24

2928

M an a g em en t M

a n a g e m e n t

Management of Specific

Preoperative Cardiovascular Conditions

Hypertension

Severe hypertension (eg, diastolic blood pressure110 mm Hg or greater) should be controlledbefore surgery when possible. The decision todelay surgery because of elevated blood pressureshould take into account the urgency of surgeryand the potential benefit of more intensive medicaltherapy. Continuation of preoperative antihyper-tensive treatment through the perioperativeperiod is critical, particularly for agents such asbeta blockers or clonidine, to avoid severe post-operative hypertension.

Valvular Heart Disease

Indications for evaluation and treatment of val-vular heart disease are identical to those in thenonoperative setting. Symptomatic stenotic lesions

such as mitral and aortic stenosis are associatedwith risk of perioperative severe HF or shock andoften require percutaneous valvotomy or valvereplacement before noncardiac surgery to lowercardiac risk. Conversely, symptomatic regurgitantvalve disease (eg, aortic regurgitation and/or mitralregurgitation) is usually better tolerated periopera-tively and may be stabilized before surgery with

4. Noncandidate for coronary revascularizationowing to concomitant medical illness, severeleft ventricular dysfunction (eg, left ventricularejection fraction less than 0.20), or refusal toconsider revascularization.

5. Candidate for liver, lung, or renal transplant40 years old or more, as part of evaluation fortransplantation, unless noninvasive testing revealshigh risk for adverse outcome.

*Cardiac risk accordi ng to type of noncardiac surgery. H igh ri sk: emergent major operati ons, aort ic and major vascular surgery, peripheral vascular

surgery, or ant icipated prolonged surgical procedure associated wi th l arge fluid shifts and blood loss; i ntermediate ri sk: caroti d endart erectomy,major head and neck surgery, i ntraperi toneal and intr athoracic surgery,orthopedic surgery, or prostate surgery; and low r isk: endoscopic procedures, superfi cial procedures, cataract surgery, or breast surgery.

†Cardiac ri sk according to cli ni cal predictors of peri operative death, M I,or HF. H igh clini cal r isk: unstable angina, acute or r ecent M I withevidence of important r esidual ischemic risk, decompensated HF, high degree of atri oventri cular block, symptomatic ventri cular arrhythmias with known structural heart disease, severe symptomatic valvul ar heart disease, or patient with mult iple int ermediate-ri sk markers such as prior MI, HF, and diabetes; intermediate cli nical ri sk: Canadian Cardiovascular Society class I or I I angina, pr ior M I by history or ECG, compensated or prior HF, di abetes mell itus, or renal insuff iciency.


17/24

3130

M an a g em en t M

a n a g e m e n t

should be initiated for symptomatic or hemodynamically sig-nificant arrhythmias, first to reverse any underlying cause andsecond to treat the arrhythmia. Indications for antiarrhythmictherapy and cardiac pacing are identical to those in thenonoperative setting.

Implantable Pacemakers or ICDs

The type and extent of evaluation of a pacemaker or ICDdepend on the urgency of the surgery, whether a pacemakerhas unipolar or bipolar leads, whether electrocautery is bipolaror unipolar, the distance between electrocautery and pace-maker, and pacemaker dependency. ICD devices should be

programmed off immediately before surgery and then onagain postoperatively.

Venothromboembolism/Peripheral Arterial Disease

Prophylactic measures need to be planned and in some casesstarted preoperatively for persons with clinical circumstancesassociated with postoperative venous thromboembolism.Table 6 provides published recommendations for various types

of surgical procedures. Patients with chronic occlusive periph-eral arterial disease may be at increased risk of perioperativecardiac complications, warranting particular attention to thepreoperative evaluation and intraoperative therapy. Protectionof the limbs from trauma during and after surgery is as impor-tant for those with asymptomatic arterial disease as for thosewith claudication.

intensive medical therapy and monitoring. It is thentreated definitively with valve repair or replacementafter noncardiac surgery. This is appropriate whena wait of several weeks or months before noncardiacsurgery may have severe consequences, for example,in patients with surgically curable malignantneoplasms. Exceptions may include patients withboth severe valvular regurgitation and reduced LVfunction in whom overall hemodynamic reserve isso limited that destabilization during perioperativestresses is very likely.

Myocardial Heart Disease

Dilated and hypertrophic cardiomyopathy are asso-ciated with an increased incidence of perioperativeHF. Management is directed toward maximizingpreoperative hemodynamic status and providingintensive postoperative medical therapy and surveil-lance. An estimate of hemodynamic reserve is usefulfor anticipating potential complications arising fromintraoperative and/or postoperative stress.

Arrhythmias and Conduction Abnormaliti es

The presence of an arrhythmia or cardiac con-duction disturbance should provoke a carefulevaluation for underlying cardiopulmonary disease,drug toxicity, or metabolic abnormality. Therapy


18/24

3332

M an a g em en t M

a n a g e m e n t

Table 6. Genera l Guideli nes for Perio perat ive Prophylaxisfor Venous Thromboembolism*

Typ e o f Pa t ie nt /Surge ry Re co mme nd at i on

Minor surgery in a patient Early ambulationless than 40 years old with

no correlates of venous

thromboembolism risk †

Moderate-risk surgery ES; LDH (2h preoperativelyin a patient more than and every 12h after) or IPC40 to 60 years old (intraoperatively and postoperatively)with no correlates of

thromboembolism risk

Major surgery in a patient LDH (every 8h) or LMWH,less than 40 to 60 years old IPC if prone to wound bleedingwith clinical conditions

associated with venous

thromboembolism risk, or

older than 60 years old

without risk factors

Very-high-risk surgery in LDH, LMWH, or dextrana patient with multiple combined with IPC. In selectedclinical conditions associated patients, perioperative warfarinwith thromboembolism risk (INR 2 to 3) may be used.

Total hi p replacement LM WH (postoperative, subcutaneous,twice daily, fixed dose unmonitored)or warfarin (INR 2 to 3, startedpreoperatively or immediately aftersurgery) or adjusted-dose unfractionatedheparin (started preoperatively). ES orIPC may provide additional efficacy.

Total knee replacement LM WH (postoperative, subcutaneous,twice daily, fixed dose unmonitored)or IPC

Hip fracture surgery LM WH (preoperative, subcutaneous,fixed dose unmonitored) or warfarin(INR 2 to 3). IPC may provideadditional benefit.

Intracranial neurosurgery IPC with or without ES. Consideraddition of LDH or LMWH inhigh-ri sk patients.

Acute spinal cord injury LMWH for prophylaxis. Warfarin maywith lower-extremity paralysis also be effective. ES and IPC may have

benefit when used with LMWH.

Patients with multiple trauma LMWH when feasible; serial surveil-lance with duplex ultrasonography maybe useful. In selected very-high-riskpatients, consider prophylactic cavalfilter. If LMWH not feasible, IPC maybe useful.

ES indicates graded-compression elasti c stocki ngs; LDH, low-dose subcutaneous hepari n; IPC, i ntermit tent pneumatic compression; L MWH , low-molecular-weight heparin; I NR,international normalized rati o.

Developed from Clagett GP, Anderson FA Jr, Geerts W, et al. Prevent ion of venous thromboembolism. Chest. 1998;114:531S-60S.

†Cli nical condit ions associated wi th increased r isk of venous thromboembolism: advanced age; prolonged i mmobil ity or paralysis; previous venous thromboembolism; mali gnancy; major surgery of abdomen, pelvi s, or lower extremity; obesit y; varicose veins; heart fai l- ure; myocardi al i nfarction; stroke; fracture(s) of the pelvi s, hi p, or leg; hypercoagulable states; and possibly high-dose estrogen use.


19/24

3534

R ev a s c ul ar i z a t i on R

e v a s c u l a r i z a t i o n

patients who have undergone PCI before noncardiac surgery.Several studies have also demonstrated a number of compli-cations from angioplasty, including emergency CABG insome patients. Until further data are available, indicationsfor PCI in the perioperative setting are similar to those inthe ACC/AHA guidelines for use of PCI in general. There isuncertainty regarding how much time should pass betweenPCI and noncardiac procedures. Delaying surgery for at least1 week after balloon angioplasty to allow for healing of thevessel injury has theoretical benefits. If a coronary stent isused, a delay of at least 2 weeks and ideally 4 to 6 weeksshould occur before noncardiac surgery to allow 4 full weeksof dual antiplatelet therapy and re-endothelialization of thestent to be completed, or nearly so.

Medical Therapy for Coronary Arter y Disease

There are still very few randomized trials of medical therapybefore noncardiac surgery to prevent perioperative cardiaccomplications, and they do not provide enough data fromwhich to draw firm conclusions or recommendations. Mostare insufficiently powered to address the effect on outcome of MI or cardiac death, and they rely on the surrogate end pointof ECG ischemia to show effect. Current studies, however,suggest that appropriately administered beta-blockers reduceperioperative ischemia and may reduce the risk of MI anddeath in high-risk patients. When possible, beta blockersshould be started days or weeks before elective surgery, withthe dose titrated to achieve a resting heart rate between 50

Preoperative Coronary Revascularization

Coronary Arter y Bypass Graft Surgery

Indications for coronary artery bypass grafting(CABG) before noncardiac surgery are identicalto those reviewed in the ACC/AHA guidelinesfor CABG. CABG is rarely indicated simply to“get a patient through” noncardiac surgery. Inpatients enrolled in the Coronary Artery SurgeryStudy (CASS) database, the cardiac risk associatedwith noncardiac operations involving the thorax,abdomen, arterial vasculature, and head and neck

was reduced significantly in those patients whohad undergone prior CABG. Patients undergoingelective noncardiac procedures who are found tohave prognostic high-risk coronary anatomy andin whom long-term outcome would likely beimproved by CABG should generally undergo re-vascularization before a noncardiac elective surgicalprocedure of high or intermediate risk (Table 3) .

Percutaneous Coronary Intervention

There are no controlled trials comparing peri-operative cardiac outcome after noncardiac surgeryfor patients treated with preoperative PCI versusmedical therapy. Several small observational serieshave suggested that cardiac death is infrequent in


20/24

3736

A n e s t h e t i c

R e v a s c u l a r i z a t i o n

and 60 beats per minute. Perioperative treatment with alpha-2agonists may have similar effects on myocardial ischemia,infarction, and cardiac death. Clearly, this is an area in whichfurther research would be valuable.

Recommendations forPerioperat ive Medical Therapy

Class I 1. Beta blockers required in the recent past tocontrol symptoms of angina or patients withsymptomatic arrhythmias or hypertension.

2. Beta blockers: patients at high cardiac risk

owing to the finding of ischemia on preoperativetesting who are undergoing vascular surgery.

Class IIa 1. Beta blockers: preoperative assessment identifiesuntreated hypertension, known coronary disease,or major risk factors for coronary disease.

Class IIb 1. Alpha-2 agonists: perioperative control ofhypertension, or known CAD or major riskfactors for CAD.

Class III 1. Beta blockers: contraindication to beta blockade.

2. Alpha-2 agonists: contraindication to alpha-2agonists.

Anesthet ic Considerations

and Intraoperat ive Management

Anesthet ic Agent

All anesthetic techniques and drugs have knowncardiac effects that should be considered in theperioperative plan. There appears to be no onebest myocardium-protective anesthetic technique.Therefore, the choice of anesthesia and intraopera-tive monitors is best left to the discretion of theanesthesia care team, which will consider the needfor postoperative ventilation, cardiovascular effects

(including myocardial depression), sympatheticblockade, and dermatomal level of the procedure.Advocates of monitored anesthesia, in whichlocal anesthesia is supplemented by intravenoussedation/analgesia, have argued that use of thistechnique avoids the undesirable effects of generalor neuraxial techniques, but no studies haveestablished this. Failure to produce complete localanesthesia/analgesia can lead to increased stress

response and/or myocardial ischemia.

Perioperat ive Pain Management

Patient-controlled intravenous and/or epiduralanalgesia is a popular method for reducing postop-erative pain. Several studies suggest that effectivepain management leads to a reduction in postoper-ative catecholamine surges and hypercoagulability.


21/24

3938

A n e s t h e t i c A

n e s t h e t i c

Transesophageal Echocardiography

There are few data on the value of transesophagealechocardiography to detect transient wall motion

abnormalities in predicting cardiac morbidity innoncardiac surgical patients. Experience to datesuggests that the incremental value of this techniquefor risk prediction is small. Guidelines for appro-priate use of transesophageal echocardiographyhave been published by the American Society of Anesthesiologists and the Society of CardiovascularAnesthesiologists.

Perioperat ive Maintenance of Body Temperature

One randomized trial demonstrated a reducedincidence of perioperative cardiac events in patientswho were maintained in a state of normothermiavia forced-air warming compared with routine care.

Intraoperative Nitroglycerin

There are insufficient data about the effects of pro-phylactic intraoperative intravenous nitroglycerin inpatients at high risk. Nitroglycerin should be usedonly when the hemodynamic effects of other agentsin use have been considered.

Recommendations forIntraoperative Nitroglycerin

Class I High-risk patients previously taking nitroglycerinwho have active signs of myocardial ischemiawithout hypotension.

Class IIb As a prophylactic agent for high-risk patientsto prevent myocardial ischemia and cardiacmorbidity, particularly in those who have requirednitrate therapy to control angina. The recommen-dation for prophylactic use of nitroglycerin musttake into account the anesthetic plan and patienthemodynamics and must recognize that vasodila-tion and hypovolemia can readily occur duringanesthesia and surgery.

Class III Patients with signs of hypovolemia or hypotension.

39


22/24

4140

S ur v ei l l an c e S

u r v e i l l a n c e

Perioperat ive Surveillance

Pulmonary Artery Catheters

Although a great deal of literature has evaluatedthe usefulness of pulmonary artery catheters intreating perioperative patients, very few studieshave compared outcomes in patients treated withor without such monitoring. The AmericanSociety of Anesthesiologists recommends that thefollowing three variables are particularly importantin assessing benefit versus risk of pulmonary arterycatheter use: disease severity, magnitude of anti-

cipated surgical procedure, and practice setting.The extent of expected fluid shifts is a primaryconcern with regard to surgery. Current evidenceindicates that patients most likely to benefit fromuse of pulmonary artery catheters in the periopera-tive period are those with a recent MI complicatedby CHF, those with significant CAD who areundergoing procedures associated with significanthemodynamic stress, and those with systolic ordiastolic LV dysfunction, cardiomyopathy, andvalvular disease undergoing high-risk operations.

Recommendations for Intraoperative Useof Pulmonary Artery Catheters

Class IIa Patients at risk for major hemodynamicdisturbances that are most easily detected by apulmonary artery catheter who are undergoing aprocedure that is likely to cause these hemody-namic changes in a setting with experience ininterpreting the results (eg, suprarenal aorticaneurysm repair in a patient with angina).

Class IIb Either the patient’s condition or the surgicalprocedure (but not both) places the patient at riskfor hemodynamic disturbances (eg, supraceliacaortic aneurysm repair in a patient with a negativestress test).

Class III No risk of hemodynamic disturbances.

Intraoper ative and Postoperat ive ST-Segment Monit oring

Intraoperative and postoperative ST changes indicatingmyocardial ischemia are strong predictors of perioperativeMI in patients at high risk who undergo noncardiac surgery.Similarly, postoperative ischemia is a significant predictor of long-term risk of MI and cardiac death. Conversely, in

41


23/24

4342

S ur v ei l l an c e S

u r v e i l l a n c e

patients at low risk who undergo noncardiac surgery, STdepression may occur and often is not associated withregional wall-motion abnormalities. Accumulating evidencesuggests that proper use of computerized ST-segment analysisin appropriately selected patients at high risk may improvesensitivity for myocardial ischemia detection.

Recommendations forPerioperat ive ST-Segment Monitoring

Class IIa When available, proper use of computerizedST-segment analysis in patients with known

CAD or undergoing vascular surgery mayprovide increased sensitivity to detect myocardialischemia during the perioperative period and mayidentify patients who would benefit from furtherpostoperative and long-term interventions.

Class IIb Patients with single or multiple risk factorsfor CAD.

Class III Patients at low risk for CAD.

Surveillance for PerioperativeMyocardial Infarction

Few studies have examined the optimal methodfor diagnosing a perioperative MI. Clinical symp-toms, postoperative ECG changes, and elevationof the MB fraction of creatine kinase (CK-MB)have been studied most extensively. Recently,elevations of myocardium-specific enzymes suchas troponin-I, troponin-T, or CK-MB isoformshave also been shown to be of value. In patientswith known or suspected CAD who are under-going high-risk procedures, ECGs obtained at

baseline, immediately after surgery, and on thefirst 2 days after surgery appear to be cost-effective.A risk gradient can be based on the magnitude of biomarker elevation, the presence or absence of concomitant new ECG abnormalities, hemody-namic instability, and quality and intensity ofchest pain syndrome, if present. Use of cardiacbiomarkers is best reserved for patients at highrisk and those with clinical, ECG, or hemody-namic evidence of cardiovascular dysfunction.

43


24/24

44 P o s t o p e r a t i v e

Postoperative Therapy

and Long-Term Management

When possible, postoperative management

should include assessment and management of modifiable risk factors for CAD, heart failure,hypertension, stroke, and other cardiovasculardiseases. For many patients, the need for non-cardiac surgery may be their first opportunity fora systematic cardiovascular evaluation. Assessmentfor hypercholesterolemia, smoking, hypertension,diabetes, physical inactivity, peripheral vasculardisease, cardiac murmur(s), arrhythmias, conduc-

tion abnormalities, perioperative ischemia, andpostoperative MI may lead to evaluation andtreatments that reduce future cardiovascular risk.In particular, patients who experience repetitivepostoperative myocardial ischemia and/or sustaina perioperative MI are at substantially elevatedrisk for MI or cardiac death during long-termfollow-up. These patients should be a particularfocus for risk factor interventions and future riskstratification and therapy.

periop guideline hand book

Documents