Preoperative cardiac risk assessment

Pre-operative cardiac risk assessment Microchapters
Stepwise approach to preoperative cardiac assessment
Estimated energy requirements for various activities
Cardiac risk stratification for noncardiac surgical procedures
ACC / AHA recommendations for perioperative cardiac assessment
Preoperative cardiac risk assessment On the Web

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Kashish Goel,M.D. Prince Tano Djan, BSc, MBChB [3]

For a printable checklist for pre-operative cardiac work up click here
To view the full Pre-operative clearance page click here

Stepwise Approach to Pre-operative Cardiac Assessment

Adapted from Fleisher et al. Circulation. 2009 Nov 24;120(21):e169-276; HR, Heart rate

^§,∧ Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk or low-risk noncardiac surgery (AHA guidelines Class III, Level of Evidence: C).

^¶ Clinical risk factors: Ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease.

Cardiac Risk Index

Original / Goldman Index

Goldman et.al devised a cardiac index for preoperative evaluation in 1977.

Risk Factors	Points
History
Age > 70 years	5
Recent MI (6 months)	10
Aortic Stenosis	3
Physical Examination
Signs of Chronic Heart Failure	11
Electrocardiogram
Rhythm other than Sinus Rhythm	7
PVC's > 5/ min	7
Poor General Medical Condition
PO2 < 60mmHg; PCO2 > 50mmHg; K < 3mmol/l; HCO3 < 20mmol/l; urea >18mmol/l (BUN > 50mg/dl); Creatinine > 260umol/l (3mg/dl); bedridden from non-cardiac cause	3
Surgery
Emergency	4
Intrathoracic	3
Total Points	53

Goldman Classification	Total Points
1	0 - 5
2	6 - 12
3	13 - 25
4	> 25

Revised Cardiac Risk Index

• Identification of patients at high rate of complications who are undergoing elective cardiac surgery.
• Risk stratification with non invasive techniques.

Revised Cardiac Risk Index
1. History of ischemic heart disease Includes "history of myocardial infarction, history of a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves" Excludes: "patients with prior coronary revascularization procedures were categorized as having ischemic heart disease only if they had any of the other criteria"
2. History of congestive heart failure
3. History of cerebrovascular disease
4. Insulin therapy for diabetes
5. Renal insufficiency
6. High risk type surgery (intraperitoneal, intrathoracic, or vascular surgery above the inguinal ligaments)

• Rates of major cardiac complications increased with 2 or more risk factors of revised cardiac risk index.

Surgery Specific Risk - 2007 ACC/AHA Guidelines

• Vascular surgery has a risk more than 5%
  • Aortic surgeries
  • Peripheral vascular surgery
• Intermediate risk surgeries are as follows:(1- 5% risk)
  • Intraperitoneal
  • Intrathoracic
  • Carotid endarterectomy
  • Head and neck surgery
  • Orthopedic surgery
  • Prostate surgery
• Low risk:(< 1%)
  • Endoscopic procedures
  • Superficial procedures
  • Cataract surgery
  • Breast surgery
  • Ambulatory surgery

Cardiac Conditions with Increased Pre-operative Risk

1. Unstable Coronary Syndromes

• Unstable or severe angina (Canadian Cardiovascular Society class III or IV): May include “stable” angina in patients who are unusually sedentary.
• Recent MI: Greater than 7 days, but less than or equal to 1 month (within 30 days).

2. Decompensated HF

• NYHA functional class IV
• Worsening or new-onset heart failure

3. Significant Arrhythmias

• Mobitz II atrioventricular block
• Third degree AV block
• Symptomatic ventricular arrhythmias
• Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR greater than 100 bpm at rest)
• Symptomatic bradycardia
• Newly recognized ventricular tachycardia

4. Severe Valvular Disease

• Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm2, or symptomatic)
• Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or heart failure)

Estimated Energy Requirements for Various Activities

The metabolic equivalent of task (MET), or simply metabolic equivalent, is a physiological concept expressing the energy cost of physical activities as multiples of resting metabolic rate (RMR) and is defined as the ratio of metabolic rate (and therefore the rate of energy consumption) during a specific physical activity to a reference rate of metabolic rate at rest, set by convention to 3.5 ml O2·kg-1·min-1 or equivalently 1 kcal·kg-1· h-1 or 4.184 kJ·kg-1· h-1. By convention 1 MET is considered as the resting metabolic rate obtained during quiet sitting . MET values of physical activities range from 0.9 (sleeping) to 18 (running at 17.5 km/h or a 5:31 mile pace).

Calculating the Weekly Energy Expended in Recreational-time Physical Activity using METs (Metabolic equivalent task)

Physical Activity	MET
Light Intensity Activities	< 3
Sleeping	0.9
Watching television	1.0
Writing, desk work, typing	1.8
Walking, 1.7 mph (2.7 km/h), level ground, strolling, very slow	2.3
Walking, 2.5 mph (4 km/h)	2.9
Moderate Intensity Activities	3 to 6
Bicycling, stationary, 50 watts, very light effort	3.0
Walking 3.0 mph (4.8 km/h)	3.3
Calisthenics, home exercise, light or moderate effort, general	3.5
Walking 3.4 mph (5.5 km/h)	3.6
Bicycling, <10 mph (16 km/h), leisure, to work or for pleasure	4.0
Bicycling, stationary, 100 watts, light effort	5.5
Vigorous Intensity Activities	> 6
Jogging, general	7.0
Calisthenics (e.g. pushups, situps, pullups,jumping jacks), heavy, vigorous effort	8.0
Running jogging, in place	8.0
Rope jumping	10.0

Cardiac Risk Stratification for Non-cardiac Surgical Procedures

High (Reported cardiac risk often greater than 5%)

• Aortic and other major vascular surgery.
• Peripheral vascular surgery.
• Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss.

Intermediate (Reported cardiac risk generally 1% to 5%)

• Carotid endarterectomy.
• Head and neck surgery.
• Intraperitoneal and intrathoracic surgery.
• Orthopedic surgery.
• Prostate surgery.

Low (Reported cardiac risk generally less than 1%)

• Endoscopic procedures.
• Superficial procedure.
• Cataract surgery.
• Breast surgery.
• Ambulatory surgery.

Key points about NST

• No Class I recommendation
• Class IIa recommendation in patients with
  • >= 3 risk factors
  • Functional capacity of < 4 METs
  • High risk surgery (Vascular surgery)

Pre-operative Stress Testing

• For patients who are able to exercise : Treadmill Exercise ECG.
• For patients who are unable to exercise : Pharmacological Stress Imaging.

Electrocardiogram - Treadmill Exercise ECG

Risk Assessment

Risk	METs	Heart rate
High Risk - Ischemia induced by low level of exercise	< 4	< 100 or 70% age pred. max
Intermediate Risk - Ischemia induced by moderate exercise	4 - 6	> 100 - 130 or 70 - 85% of age pred. max
Low Risk - No ischemia or ischemia induced at higher level of exercise	> 7	> 130 or > 85% of age pred. max

Inadequate test : In patients undergoing non cardiac surgery ,the inabilty to exercise to a level of 4 - 6 METs without out ischemia should be considered as inadequate test. (Stage II Bruce protocol)

Pre-operative 12 Lead ECG

• The time frame for ECG testing is fixed, it can be done within 30 days of planned surgery when indicated.
• The resting 12-lead ECG did not identify increased perioperative risk in patients undergoing low-risk surgery.
• In patients with coronary disease, the resting 12-lead ECG may have contains important prognostic information relating to long-term morbidity and mortality.

Non invasive Stress Testing (NST)

These are used for preoperative evaluation of patients undergoing non cardiac surgery. These are used in patients who cannot exercise.

Techniques

• Increasing oxygen demand of the heart either by pacing or inotropes
• Increasing blood supply (hyperemic response) by vasodilators

Dobutamine Stress Echocardiography

• Increasing doses of supratherapeutic doses of dobutamine are infused , which increases myocardial contractility and heart rate. This leads to significant coronary artery stenosis which can be identified by regional wall-motion abnormalities within the distribution of the affected vessels.
• It has high negative predictive value (93-100%)
• It has low positive predicitive value (5 - 33%)
• Extent of regional wall motion abnormality and low threshold of ischemia is an important predictor of post operative events.

Radionuclide Myocardial Perfusion Imaging

• Stress nuclear myocardial perfusion imaging has a high sensitivity for detecting patients at risk for perioperative cardiac events.
• It has high negative predictive value (95-100%)
• It has low positive predictive value (5- 20%)
• Perioperative cardiac risk is directly proportional to the myocardium at risk detected by the extent of reversible defects found on imaging.
• It is of high clinical value when used for selective population of high clinical risk.

In Left Bundle-Branch Block

• Exercise may at times induce reversible septal defects in the absence of LAD disease. Specificity of exercise myocardial perfusion imaging in presence of LBBB is low.
• Pharmacologic strss testing with perfusion scintigraphy or DSE is preferred over exercise stress testing.

Perioperative Revascularization Therapy

• Extensive ischemia is a risk factor for increased peri-operative events
• Pre-op coronary revascularization does not prevent death or MI.

Pre-operative CABG

• Patients who have high-risk coronary anatomy and in whom long-term outcome would likely be improved by CABG should generally undergo coronary revascularization before a noncardiac elective vascular surgical procedure or noncardiac operative procedures of intermediate or high risk.
• The cumulative mortality and morbidity of both the coronary revascularization procedure and the noncardiac surgery should be weighed carefully. The individual patient’s overall health,functional status, and prognosis have to be taken into consideration.

Pre-operative PCI

• Prophylactic preoperative PCI in non cardiac surgical procedures is of no value in preventing perioperative cardiac events.
• Unscheduled noncardiac surgery in a patient who has undergone a prior PCI presents special challenges, particularly with regard to management of the dual-antiplatelet agents required in those who have received coronary stents.
• Following flowchart depicts the approach based on expert opinion in patients who have undergone successful coronary intervention with or without stent placement before planned or unplanned noncardiac surgery.

Prior PCI

Balloon Angioplasty

Bare Metal Stent

Drug

Time since PCI < 14 days

Time since PCI > 14 days

Time since PCI > 30-45 days

Time since PCI < 30-45 days

Time since PCI < 365 days

Time since PCI > 365 days

Delay for elective surgery

Proceed to operating room with aspirin

Delay for elective surgery

Proceed to operating room with aspirin

Perioperative Medical Therapy

Beta Blockers

Key points about perioperative beta blocker therapy

• Start well before surgery. ( minimum of 1 week - don't start on the day of surgery)
• Use is in high or intermediate risk population only.
• Titrate dose to heart rate and blood pressure starting with a low dose. (Fixed doses shouldn't be used)
• Long acting betablockers are better to use.
• If intra-operative heat rate goes above 80 start IV administration.(Look for alternative causes of tachycardia)

For more information on perioperative betablocker therapy click here.

Statins

• Statins have protective effective on cardiac complications in non cardiac surgery, but the dosage and the target levels are unclear.
• Utilizing the perioperative period as an opportunity to impact long-term health, consideration should be given to starting statin therapy in patients who meet National Cholesterol Education Program criteria.

Alpha 2 Agonists

• Strong evidence is lacking for the recommendation of clonidine for blood pressure control.
• Administration of clonidine had minimal effects on hemodynamics and post operative mortality.

2009 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Preoperative Cardiac Assessment (DO NOT EDIT)

Risk Factors	Functional Capacity	Vascular Surgery (High Risk)	Intermediate Risk Surgery	Low Risk Surgery
0	< 4	Proceed with surgery	Proceed with surgery	Proceed with surgery
0	>= 4	Proceed with surgery	Proceed with surgery	Proceed with surgery
1 or 2	< 4	Proceed with surgery and heart rate control	Proceed with surgery and heart rate control	Proceed with surgery
1 or 2	>= 4	Proceed with surgery and heart rate control	Proceed with surgery and heart rate control	Proceed with surgery
>= 3	< 4	Non-invasive Stress Test (NST)	Proceed with surgery and heart rate control	Proceed with surgery
>= 3	>= 4	Proceed with surgery and heart rate control	Proceed with surgery and heart rate control	Proceed with surgery

Adapted from lecture of Robert B.McCully,M.D.;

Class I recommendation

Class IIa recommendation

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Clinical Risk Factors

Valvular Heart Disease

Class I

"1. It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation (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(Level of Evidence: C)"

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 (Level of Evidence: B)"

"2. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe MR (Level of Evidence: C)"

"3. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe aortic regurgitation and a normal left ventricular ejection fraction (Level of Evidence: C)"

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)"

Other clinical risk factors

Class I

"1. Before elective surgery in a patient with a CIED, the surgical/procedure team and clinician following the CIED should communicate in advance to plan perioperative management of the CIED. (Level of Evidence: C)"

"2. Chronic pulmonary vascular targeted therapy (i.e., phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, and prostanoids) 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 benefits, preoperative evaluation by a pulmonary hypertension specialist before noncardiac surgery can be beneficial for patients with pulmonary hypertension, particularly for those with features of increased perioperative risk (Level of Evidence: C)"

Approach to perioperative cardiac testing

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 (Level of Evidence: B)"

Class III (No Benefit)

"1.For patients with a low risk of perioperative MACE, further testing is not recommended before the planned operation (Level of Evidence: B)"

Supplemental preoperative evaluation

The 12-Lead Electrocardiogram

Class IIa

"1. Preoperative resting 12-lead electrocardiogram (ECG) is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery (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 (Level of Evidence: B)"

Class III (No Benefit)

"1. Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures (Level of Evidence: B)"

Assessment of Left Ventricular Function

Class IIa

"1. It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of left ventricular (LV) function (Level of Evidence: C)"

"2. It is reasonable for patients with heart failure (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 LV dysfunction may be considered if there has been no assessment within a year (Level of Evidence: C)"

Class III (No Benefit)

"1. Routine preoperative evaluation of LV function is not recommended (Level of Evidence: B)"

Exercise Testing

Class IIa

"1. For patients with elevated risk and excellent (>10 metabolic equivalents [METs]) functional capacity, it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery (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 (Level of Evidence: B)"

"2. Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown (Level of Evidence: B)"

"3. 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 (Level of Evidence: B)"

"4. For patients with elevated risk and poor (<4 METs) or unknown functional capacity, it may be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia if it will change management (Level of Evidence: C)"

Class III (No Benefit)

"1. Routine screening with noninvasive stress testing is not useful for patients at low risk for noncardiac surgery (Level of Evidence: C)"

Noninvasive Pharmacological Stress Testing Before Noncardiac Surgery

Class IIa

"1. It is reasonable for patients who are at an elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo noninvasive pharmacological stress testing (either dobutamine stress echocardiogram or pharmacological stress myocardial perfusion imaging) if it will change management (Level of Evidence: B)"

Class III (No Benefit)

"1. Routine screening with noninvasive stress testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence: B)"

Preoperative Coronary Angiography

Class III (No Benefit)

"1. Routine preoperative coronary angiography is not recommended. (Level of Evidence: C)"

Perioperative therapy

Coronary Revascularization Before Noncardiac Surgery

Class I

"1. Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs(Level of Evidence: C)"

Class III (No Benefit)

"1. It is not recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events (Level of Evidence: B)"

Timing of Elective Noncardiac Surgery in Patients With Previous PCI

Class I

"1. Elective noncardiac surgery should be delayed 14 days after balloon angioplasty(Level of Evidence: C) and 30 days after BMS implantation(Level of Evidence: B)"

"2. Elective noncardiac surgery should optimally be delayed 365 days after drug-eluting stent (DES) implantation(Level of Evidence: B)"

Class IIa

"1. In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful (Level of Evidence: C)"

Class IIb

"1. Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis (Level of Evidence: B)"

Class III (Harm)

"1. Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom dual antiplatelet therapy will need to be discontinued perioperatively (Level of Evidence: B)"

"2. Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively. (Level of Evidence: C)"

Perioperative Beta-Blocker Therapy

Class I

"1. Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically(Level of Evidence: B)"

Class IIa

"1. It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started (Level of Evidence: B)"

Class IIb

"1. In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers (Level of Evidence: C)"

"2. In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, coronary artery disease, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery (Level of Evidence: B)"

"3. In patients with a compelling long-term indication for betablocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit (Level of Evidence: B)"

"4. In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery ( (Level of Evidence: B)"

Class III (Harm)

"1. Beta-blocker therapy should not be started on the day of surgery (Level of Evidence: B)"

Perioperative Statin Therapy

Class I

"1. Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery(Level of Evidence: B)"

Class IIa

"1. Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery (Level of Evidence: B)"

Class IIb

"1. Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures (Level of Evidence: C)"

Alpha-2 Agonists

Class III (No Benefit)

"1. Alpha-2 agonists for prevention of cardiac events are not recommended in patients who are undergoing noncardiac surgery (Level of Evidence: B)"

Angiotensin-Converting Enzyme Inhibitors

Class IIa

"1. Continuation of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers perioperatively is reasonable (Level of Evidence: B)"

"2. If angiotensin-converting enzyme inhibitors or angiotensinreceptor blockers are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively (Level of Evidence: C)"

Antiplatelet Agents

Class I

"1. In patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES implantation, dual antiplatelet therapy should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis (Level of Evidence: C)"

"2. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor–inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor–inhibitor be restarted as soon as possible after surgery. (Level of Evidence: C)"

"3. Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis. (Level of Evidence: C)"

Class IIb

"1. In patients undergoing nonemergency/nonurgent noncardiac surgery who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of potential increased cardiac events outweighs the risk of increased bleeding (Level of Evidence: B)"

Class III (No Benefit)

"1. Initiation or continuation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting (Level of Evidence: B), unless the risk of ischemic events outweighs the risk of surgical bleeding (Level of Evidence: C)"

Perioperative Management of Patients With CIEDs

Class I

"1. Patients with implantable cardioverter-defibrillators who have preoperative reprogramming to inactivate tachytherapy should be on cardiac monitoring continuously during the entire period of inactivation, and external defibrillation equipment should be readily available. Systems should be in place to ensure that implantable cardioverter-defibrillators are reprogrammed to active therapy before discontinuation of cardiac monitoring and discharge from the facility (Level of Evidence: C)"

Anesthetic consideration and intraoperative management

Choice of Anesthetic Technique and Agent

Class IIa

"1. Use of either a volatile anesthetic agent or total intravenousanesthesia is reasonable for patients undergoing noncardiac surgery, and the choice is determined by factors other than the prevention of myocardial ischemia and MI ( (Level of Evidence: A)"

"2. Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI (Level of Evidence: B)"

Class IIb

"1. Perioperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with a hip fracture (Level of Evidence: B)"

Intraoperative Management

Class IIa

"1. The emergency use of perioperative transesophageal echocardiogram is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy, if expertise is readily available. (Level of Evidence: C)"

Class IIb

"1. . Maintenance of normothermia may be reasonable to reduce perioperative cardiac events in patients undergoing noncardiac surgery (Level of Evidence: B)"

"2. Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the setting of acute severe cardiac dysfunction (i.e., acute MI,cardiogenic shock) that cannot be corrected before surgery. (Level of Evidence: C)"

"3. The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics (i.e., HF, severe valvular disease, combined shock states) cannot be corrected before surgery (Level of Evidence: C)"

Class III (No Benefit)

"1. Routine use of pulmonary artery catheterization in patients, even those with elevated risk, is not recommended (Level of Evidence: A)"

"2. Prophylactic intravenous nitroglycerin is not effective in reducing myocardial ischemia in patients undergoing noncardiac surgery (Level of Evidence: B)"

"3. The routine use of intraoperative transesophageal echocardiogram during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is not recommended in patients without risk factors or procedural risks for significant hemodynamic, pulmonary, or neurologic compromise (Level of Evidence: C)"

Surveillance and management for perioperative MI

Class I

"1. Measurement of troponin levels is recommended in the setting of signs or symptoms suggestive of myocardial ischemia or MI (Level of Evidence: A)"

"2. Obtaining an ECG is recommended in the setting of signs or symptoms suggestive of myocardial ischemia, MI, or arrhythmia(Level of Evidence: B)"

Class IIb

"1.The usefulness of postoperative screening with troponin levels in patients at high risk for perioperative MI but without signs or symptoms suggestive of myocardial ischemia or MI, is uncertain in the absence of established risks and benefits of a defined management strategy (Level of Evidence: B)"

"2.The usefulness of postoperative screening with ECGs in patients at high risk for perioperative MI, but without signs or symptoms suggestive of myocardial ischemia, MI, or arrhythmia, is uncertain in the absence of established risks and benefits of a defined management strategy(Level of Evidence: B)"

Class III (No Benefit)

"1. Routine postoperative screening with troponin levels in unselected patients without signs or symptoms suggestive of myocardial ischemia or MI is not useful for guiding perioperative management (Level of Evidence: B)"

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)

Revascularization Before Noncardiac Surgery (DO NOT EDIT)

Class III (No Benefit)

"1. Routine prophylactic coronary revascularizationshould not be performed in patients with stable CAD before noncardiac surgery. (Level of Evidence: B)"

"2. Elective non-cardiac surgery should not be performed in the 4 to 6 weeks after balloon angioplasty or BMS implantationor the 12 months after DES implantation in patients in whom theP2Y12 inhibitor will need to be discontinued peri-operatively. (Level of Evidence: B)"

Class IIa

"1. For patients who require PCI and are scheduled for elective non-cardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty, orBMS implantation followed by 4 to 6 weeks of dual antiplatelet therapy (DAPT), is reasonable. (Level of Evidence: B)"

"2. For patients with drug eluting stent (DES) who must undergo urgent surgical procedures that mandate the discontinuation of dual antiplatelet therapy (DAPT), it is reasonable to continue aspirin if possible and restart the P2Y12 inhibitor as soon as possible in the immediate postoperative period.(Level of Evidence: C)"

Sources

• 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (DO NOT EDIT)

• 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (DO NOT EDIT)

• 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)