2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and.

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Presentation transcript:

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 by , Lee A. Fleisher, Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliot L. Chaikof, Kirsten E. Fleischmann, William K. Freeman, James B. Froehlich, Edward K. Kasper, Judy R. Kersten, Barbara Riegel, and John F. Robb Circulation Volume 120(21):e169-e276 November 24, 2009 Copyright © American Heart Association, Inc. All rights reserved.

Table 1. Applying Classification of Recommendations and Level of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. Table 1. Applying Classification of Recommendations and Level of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

Table 3. Estimated Energy Requirements for Various Activitieskph indicates kilometers per hour; MET, metabolic equivalent; and mph, miles per hour.Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.14. Table 3. Estimated Energy Requirements for Various Activitieskph indicates kilometers per hour; MET, metabolic equivalent; and mph, miles per hour.Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.14 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk for patients 50 years of age or greater. *See Table 2 for active cardiac conditions. †See Class III recommendations in Section 5.2.3. Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk for patients 50 years of age or greater. *See Table 2 for active cardiac conditions. †See Class III recommendations in Section 5.2.3. Noninvasive Stress Testing. ‡See Table 3 for estimated MET level equivalent. §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 blockade (see Table 11 for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

Figure 2. Proposed approach to the management of patients with previous PCI requiring noncardiac surgery (based upon expert opinion). Figure 2. Proposed approach to the management of patients with previous PCI requiring noncardiac surgery (based upon expert opinion). PCI indicates percutaneous coronary intervention. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery. Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI) who need subsequent surgery. ACS indicates acute coronary syndrome; and MI, myocardial infarction. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

. 2007 WRITING COMMITTEE MEMBERS et al. Circulation. 2009;120:e169-e276 Copyright © American Heart Association, Inc. All rights reserved.

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