Preoperative cardiac risk assessment

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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.

Stepwise Approach to Pre-operative Cardiac Assessment


Adapted from Fleisher et al. Circulation. 2009 Nov 24;120(21):e169-276[1]; 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. [2]

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.[3]
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.[3]

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

4. Severe Valvular Disease

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[4] 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[5][6] . 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)[7]

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

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. [8]

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. [9]
  • 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. [10]

Pre-operative PCI

  • Prophylactic preoperative PCI in non cardiac surgical procedures is of no value in preventing perioperative cardiac events. [11]
  • 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[12] 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)[13]

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. 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 (143) (Level of Evidence: B), unless the risk of ischemic events outweighs the risk of surgical bleeding (Level of Evidence: C)"

2009 ACC/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)[1]

Perioperative Cardiac Assessment (DO NOT EDIT)[1]

Class I
"1. Patients who have a need for emergency noncardiac surgery should proceed to the operating room and continue perioperative surveillance and postoperative risk stratification and risk factor management. (Level of Evidence: C)"
"2. Patients with active cardiac conditions should be evaluated and treated per ACC/AHA guidelines and, if appropriate, consider proceeding to the operating room. (Level of Evidence: B)"
"3. Patients undergoing low risk surgery are recommended to proceed to planned surgery. (Level of Evidence: B)"
"4. Patients with poor (less than 4 METs) or unknown functional capacity and no clinical risk factors should proceed with planned surgery. (Level of Evidence: B)"
Class IIa
"1. It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms proceed to planned surgery.§ (Level of Evidence: B)"
"2. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for vascular surgery consider testing if it will change management. (Level of Evidence: B)"
"3. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control. (Level of Evidence: B)"
"4. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control. (Level of Evidence: B)"
Class IIb
"1. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery. (Level of Evidence: B)"
"2. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery. (Level of Evidence: B)"
“

§ Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management. Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease.

”
“

¶ Consider perioperative beta blockers for populations in which this has been shown to reduce cardiac morbidity/mortality.

”

Preoperative Noninvasive Evaluation of LV Function (DO NOT EDIT)[1]

Class III (No Benefit)
"1. Routine perioperative evaluation of LV function in patients is not recommended. (Level of Evidence: B)"
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 current or prior heart failure with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months. (Level of Evidence: C)"
Class IIb
" 1. Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (Level of Evidence: C)"

Preoperative Resting 12-Lead ECG (DO NOT EDIT)[1]

Class I
"1. Preoperative resting 12-lead ECG is recommended for patients with at least 1 clinical risk factor who are undergoing vascular surgical procedures. (Level of Evidence: B)"
"2. Preoperative resting 12-lead ECG is recommended for patients with known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (Level of Evidence: C)"
Class III (No Benefit)
"1. Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (Level of Evidence: B)"
Class IIa
"1. Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (Level of Evidence: B)"
Class IIb
"1. Preoperative resting 12-lead ECG may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (Level of Evidence: B)"

Noninvasive Stress Testing (DO NOT EDIT)[1]

Class I
"1. Patients with active cardiac conditions in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines before noncardiac surgery. (Level of Evidence: B)"
Class III (No Benefit)
"1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery. (Level of Evidence: C)"
"2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence: C)"
Class IIa
"1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery is reasonable if it will change management. (Level of Evidence: B)"
Class IIb
"1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B)"
"2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (Level of Evidence: B)"

Preoperative Coronary Revascularization With CABG or Percutaneous Coronary Intervention (DO NOT EDIT)[1]

Class I
"1. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have significant left main coronary artery stenosis. (Level of Evidence: A)"
"2. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 3-vessel disease (Survival benefit is greater when left ventricular ejection fraction is less than 0.50). (Level of Evidence: A)"
"3. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 2-vessel disease with significant proximal left anterior descending stenosis and either ejection fraction less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of Evidence: A)"
"4. Coronary revascularization before noncardiac surgery is recommended for patients with high-risk unstable angina or non ST-segment elevation myocardial infarction (MI). (Level of Evidence: A)"
"5. Coronary revascularization before noncardiac surgery is recommended in patients with acute ST elevation MI. (Level of Evidence: A)"
Class III (No Benefit)
"1. It is not recommended that routine prophylactic coronary revascularization be performed in patients with stable CAD before noncardiac surgery. (Level of Evidence: B)"
"2. Elective noncardiac surgery is not recommended within 4 to 6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued perioperatively. (Level of Evidence: B)"
"3. Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. (Level of Evidence: B)"
Class IIa
"1. In patients in whom coronary revascularization with PCI is appropriate for mitigation of cardiac symptoms and who need elective noncardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is probably indicated. (Level of Evidence: B)"
"2. In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Level of Evidence: C)"
Class IIb
"1. The usefulness of preoperative coronary revascularization is not well established in high-risk ischemic patients (e.g., abnormal dobutamine stress echocardiograph with at least 5 segments of wall-motion abnormalities). (Level of Evidence: C)"
"2. The usefulness of preoperative coronary revascularization is not well established for low-risk ischemic patients with an abnormal dobutamine stress echocardiograph (segments 1 to 4). (Level of Evidence: B)"

Statin Therapy (DO NOT EDIT)[1]

Class I
"1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued.Level of Evidence: B)"
Class IIa
"1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B)"
Class IIb
"1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (Level of Evidence: C)"

Alpha- 2 agonists (DO NOT EDIT)[1]

Class III (No Benefit)
"1. Alpha-2 agonists should not be given to patients undergoing surgery who have contraindications to this medication. (Level of Evidence: C)"
Class IIb
"1. Alpha-2 agonists for perioperative control of hypertension may be considered for patients with known CAD or at least 1 clinical risk factor who are undergoing surgery. (Level of Evidence: B)"

Intensive Care (DO NOT EDIT)[1]

Class IIb
"1. Preoperative intensive care monitoring with a pulmonary artery catheter for optimization of hemodynamic status might be considered; however, it is rarely required and should be restricted to a very small number of highly selected patients whose presentation is unstable and who have multiple comorbid conditions. (Level of Evidence: B)"

Volatile Anesthetic Agents (DO NOT EDIT)[1]

Class IIa
"1. It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. (Level of Evidence: B)"

Prophylactic Intraoperative Nitroglycerine (DO NOT EDIT)[1]

Class IIa
"1. The usefulness of intraoperative nitroglycerin as a prophylactic agent to prevent myocardial ischemia and cardiac morbidity is unclear for high-risk patients undergoing noncardiac surgery, particularly those who have required nitrate therapy to control angina. The recommendation for prophylactic use of nitroglycerin must take into account the anesthetic plan and patient hemodynamics and must recognize that vasodilation and hypovolemia can readily occur during anesthesia and surgery. (Level of Evidence: C) "

Transesophageal Echocardiography (DO NOT EDIT)[1]

Class IIa
"1. The emergency use of intraoperative or perioperative transesophageal echocardiography is reasonable to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality. (Level of Evidence: C)"

Body Temperature Maintenace (DO NOT EDIT)[1]

Class I
"1. Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (eg, during high aortic cross-clamping). (Level of Evidence: B)"

Blood Glucose Concentration Control (DO NOT EDIT)[1]

Class IIa
"1. It is reasonable that blood glucose concentration be controlled during the perioperative period in patients with diabetes mellitus or acute hyperglycemia who are at high risk for myocardial ischemia or who are undergoing vascular and major noncardiac surgical procedures with planned intensive care unit admission. (Level of Evidence: B) "
Class IIb
"1. The usefulness of strict control of blood glucose concentration during the perioperative period is uncertain in patients with diabetes mellitus or acute hyperglycemia who are undergoing noncardiac surgical procedures without planned intensive care unit admission. (Level of Evidence: C)"

Pulmonary Artery Catheters (DO NOT EDIT)[1]

Class III (No Benefit)
"1. Routine use of a pulmonary artery catheter perioperatively, especially in patients at low risk of developing hemodynamic disturbances, is not recommended. (Level of Evidence: A)"
Class IIb
"1. Use of a pulmonary artery catheter may be reasonable in patients at risk for major hemodynamic disturbances that are easily detected by a pulmonary artery catheter; however, the decision must be based on 3 parameters: patient disease, surgical procedure (ie, intraoperative and postoperative fluid shifts), and practice setting (experience in pulmonary artery catheter use and interpretation of results), because incorrect interpretation of the data from a pulmonary artery catheter may cause harm. (Level of Evidence: B)"

Intraoperative and Postoperative ST Segment Monitoring (DO NOT EDIT)[1]

Class IIa
"1.Intraoperative and postoperative ST segment monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, with computerized ST segment analysis, when available, used to detect myocardial ischemia during the perioperative period. (Level of Evidence: B)"
Class IIb
"1. Intraoperative and postoperative ST segment monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery. (Level of Evidence: B)"

Surveillance for Perioperative MI (DO NOT EDIT)[1]

Class I
"1. Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome. (Level of Evidence: C)"
Class III (No Benefit)
"1. Postoperative troponin measurement is not recommended in asymptomatic stable patients who have undergone low-risk surgery. (Level of Evidence: C)"
Class IIb
"1. The use of postoperative troponin measurement is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery. (Level of Evidence: C)"

Perioperative Beta-Blocker Therapy (DO NOT EDIT)[1]

Class I
"1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs. (Level of Evidence: C)"
Class III
"1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)"
"2. Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery.[14] (Level of Evidence: B)"
Class IIa
"1. Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing.[15] [16] (Level of Evidence: B)"
"2. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (Level of Evidence: C)"
"3. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk surgery.[17] (Level of Evidence: B)"
Class IIb
"1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease.* (Level of Evidence: C)"
"2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors* who are not currently taking beta blockers.[18] (Level of Evidence: B)"
“

* Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency (defined in the Revised Cardiac Risk Index as a preoperative serum creatinine of >2 mg/dL).[3]

”

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[19]

Revascularization Before Noncardiac Surgery (DO NOT EDIT)[19]

Class III (No Benefit)
"1. Routine prophylactic coronary revascularizationshould not be performed in patients with stable CAD before noncardiac surgery.[20][21] (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.[22][23][24][25] (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.[26][27][28][24][29][23][30] (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.[28][12](Level of Evidence: C)"

Sources

  • 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (DO NOT EDIT)[31]
  • 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)[1]
  • 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[19]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 Fleisher LA, Beckman JA, Brown KA; et al. (2009). "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: a report of the American college of cardiology foundation/American heart association task force on practice guidelines". Circulation. 120 (21): e169–276. doi:10.1161/CIRCULATIONAHA.109.192690. PMID 19884473. Unknown parameter |month= ignored (help)
  2. ↑ Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE (1977). "Multifactorial index of cardiac risk in noncardiac surgical procedures". The New England Journal of Medicine. 297 (16): 845–50. doi:10.1056/NEJM197710202971601. PMID 904659. Retrieved 2012-10-11. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L (1999). "Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery". Circulation. 100 (10): 1043–9. PMID 10477528. Retrieved 2012-10-11. Unknown parameter |month= ignored (help)
  4. ↑ Physical activity can be defined as “bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above the basal level”
  5. ↑ Ainsworth et al., 1993
  6. ↑ Ainsworth et al., 2000.
  7. ↑ Adapted from Compendium of Physical Activities. Ainsworth, BE et al. Medicine and Science in Sports and Exercise. Vol 25, Pg 713 (1993) and Vol 32, S498 (2000).
  8. ↑ Garcia S, Rider JE, Moritz TE, Pierpont G, Goldman S, Larsen GC, Shunk K, Littooy F, Santilli S, Rapp J, Reda DJ, Ward HB, McFalls EO (2011). "Preoperative coronary artery revascularization and long-term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: a subgroup analysis of the coronary artery revascularization prophylaxis trial". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 77 (1): 134–41. doi:10.1002/ccd.22699. PMID 20602474. Retrieved 2012-10-12. Unknown parameter |month= ignored (help)
  9. ↑ "Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery)". Journal of the American College of Cardiology. 17 (3): 543–89. 1991. PMID 1993774. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  10. ↑ Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM, Lytle BW, Marlow RA, Nugent WC, Orszulak TA, Antman EM, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Ornato JP (2004). "ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery)". Journal of the American College of Cardiology. 44 (5): e213–310. doi:10.1016/j.jacc.2004.07.021. PMID 15337239. Retrieved 2012-10-12. Unknown parameter |month= ignored (help)
  11. ↑ Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)". Journal of the American College of Cardiology. 47 (1): e1–121. doi:10.1016/j.jacc.2005.12.001. PMID 16386656. Retrieved 2012-10-12. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW (2007). "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery". Journal of the American College of Cardiology. 50 (17): 1707–32. doi:10.1016/j.jacc.2007.09.001. PMID 17950159. Retrieved 2012-10-12. Unknown parameter |month= ignored (help)
  13. ↑ Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK; et al. (2009). "2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines". Circulation. 120 (21): 2123–51. doi:10.1161/CIRCULATIONAHA.109.192689. PMID 19884474.
  14. ↑ Devereaux PJ, Yang H, Yusuf S; et al. (2008). "Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial". Lancet. 371 (9627): 1839–47. doi:10.1016/S0140-6736(08)60601-7. PMID 18479744. Unknown parameter |month= ignored (help)
  15. ↑ Poldermans D, Boersma E, Bax JJ; et al. (1999). "The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group". N. Engl. J. Med. 341 (24): 1789–94. doi:10.1056/NEJM199912093412402. PMID 10588963. Unknown parameter |month= ignored (help)
  16. ↑ Boersma E, Poldermans D, Bax JJ; et al. (2001). "Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy". JAMA. 285 (14): 1865–73. PMID 11308400. Unknown parameter |month= ignored (help)
  17. ↑ Dunkelgrun M, Boersma E, Schouten O; et al. (2009). "Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV)". Ann. Surg. 249 (6): 921–6. doi:10.1097/SLA.0b013e3181a77d00. PMID 19474688. Unknown parameter |month= ignored (help)
  18. ↑ Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM (2005). "Perioperative beta-blocker therapy and mortality after major noncardiac surgery". N. Engl. J. Med. 353 (4): 349–61. doi:10.1056/NEJMoa041895. PMID 16049209. Unknown parameter |month= ignored (help)
  19. ↑ 19.0 19.1 19.2 Levine GN, Bates ER, Blankenship JC; et al. (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions". Circulation. 124 (23): 2574–609. doi:10.1161/CIR.0b013e31823a5596. PMID 22064598. Unknown parameter |month= ignored (help)
  20. ↑ Cinà CS, Devereaux PJ (2006). "Coronary-artery revascularization before elective major vascular surgery. McFalls EO, ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. N Engl J Med. 2004; 351: 2795-804". Vascular Medicine (London, England). 11 (1): 61–3. PMID 16669417. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  21. ↑ Schouten O, van Kuijk JP, Flu WJ, Winkel TA, Welten GM, Boersma E, Verhagen HJ, Bax JJ, Poldermans D (2009). "Long-term outcome of prophylactic coronary revascularization in cardiac high-risk patients undergoing major vascular surgery (from the randomized DECREASE-V Pilot Study)". The American Journal of Cardiology. 103 (7): 897–901. doi:10.1016/j.amjcard.2008.12.018. PMID 19327412. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  22. ↑ Grines CL, Bonow RO, Casey DE, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P (2007). "Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians". Journal of the American College of Cardiology. 49 (6): 734–9. doi:10.1016/j.jacc.2007.01.003. PMID 17291948. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  23. ↑ 23.0 23.1 Sharma AK, Ajani AE, Hamwi SM, Maniar P, Lakhani SV, Waksman R, Lindsay J (2004). "Major noncardiac surgery following coronary stenting: when is it safe to operate?". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 63 (2): 141–5. doi:10.1002/ccd.20124. PMID 15390248. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  24. ↑ 24.0 24.1 Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000). "Catastrophic outcomes of noncardiac surgery soon after coronary stenting". Journal of the American College of Cardiology. 35 (5): 1288–94. PMID 10758971. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  25. ↑ Win HK, Caldera AE, Maresh K, Lopez J, Rihal CS, Parikh MA, Granada JF, Marulkar S, Nassif D, Cohen DJ, Kleiman NS (2007). "Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents". JAMA : the Journal of the American Medical Association. 297 (18): 2001–9. doi:10.1001/jama.297.18.2001. PMID 17488965. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  26. ↑ Berger PB, Bell MR, Hasdai D, Grill DE, Melby S, Holmes DR (1999). "Safety and efficacy of ticlopidine for only 2 weeks after successful intracoronary stent placement". Circulation. 99 (2): 248–53. PMID 9892591. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  27. ↑ Cruden NL, Harding SA, Flapan AD, Graham C, Wild SH, Slack R, Pell JP, Newby DE (2010). "Previous coronary stent implantation and cardiac events in patients undergoing noncardiac surgery". Circulation. Cardiovascular Interventions. 3 (3): 236–42. doi:10.1161/CIRCINTERVENTIONS.109.934703. PMID 20442357. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  28. ↑ 28.0 28.1 Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF (2009). "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". Journal of the American College of Cardiology. 54 (22): e13–e118. doi:10.1016/j.jacc.2009.07.010. PMID 19926002. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  29. ↑ Reddy PR, Vaitkus PT (2005). "Risks of noncardiac surgery after coronary stenting". The American Journal of Cardiology. 95 (6): 755–7. doi:10.1016/j.amjcard.2004.11.029. PMID 15757604. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  30. ↑ Wilson SH, Fasseas P, Orford JL, Lennon RJ, Horlocker T, Charnoff NE, Melby S, Berger PB (2003). "Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting". Journal of the American College of Cardiology. 42 (2): 234–40. PMID 12875757. Retrieved 2011-12-08. Unknown parameter |month= ignored (help)
  31. ↑ Fleisher LA, Beckman JA, Brown KA; et al. (2007). "ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery". Circulation. 116 (17): e418–99. doi:10.1161/CIRCULATIONAHA.107.185699. PMID 17901357. Unknown parameter |month= ignored (help)

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