Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery* A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline *Circulation 2002;105:1257-68 and J Am Coll Cardiol 2002;39:542-53

Kim A. Eagle, MD, FACC, Chair Committee to Update the Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery Kim A. Eagle, MD, FACC, Chair Peter B. Berger, MD, FACC Hugh Calkins, MD, FACC Bernard R. Chaitman, MD, FACC Gordon A. Ewy, MD, FACC Kirsten E. Fleischmann, MD, MPH, FACC Lee A. Fleisher, MD, FACC James B. Froehlich, MD, MPH, FACC Richard J. Gusberg, MD, FACS Jeffrey A. Leppo, MD, FACC Thomas Ryan, MD, FACC Robert C. Schlant, MD, FACC William L. Winters, Jr, MD, MACC

Purpose of Preoperative Evaluation Evaluate patient’s current medical status Provide clinical risk profile Recommend management of cardiac risk over entire perioperative period Treatment of modifiable risk factors The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status, make recommendations concerning the risk of cardiac problems over the entire perioperative period, and provide a clinical risk profile that the patient, his or her primary physician, anesthesiologist, and surgeon can use in making treatment decisions. No test should be performed unless it is likely to influence patient treatment.

Role of the Consultant Review available patient data, history and physical examination Determine if further testing is needed to define cardiovascular status Recommend treatment to improve medical condition Preoperative testing recommended only if it will change surgical care or perioperative medical therapy The consultant should review available patient data, obtain a history, and perform a physical examination pertinent to the patient's problem and the proposed surgery. A critical role of the consultant is to communicate the severity and stability of the patient's cardiovascular status and to determine if the patient is in the best reasonable medical condition, given the context of the surgical illness.

General Approach to the Patient History – angina, recent or past MI, HF, symptomatic arrhythmias, presence of pacemaker or ICD Physical Examination – general appearance, rales, elevated JVP, carotid and other arterial pulses, S3 gallop, murmurs Comorbid Diseases Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders Ancillary Studies - ECG almost always indicated, blood chemistries and chest X-ray based on history and physical findings Preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and nature of the surgical illness. A careful history and cardiovascular examination are crucial. In addition, the consultant must evaluate the cardiovascular system within the framework of the patient's overall health. Ancillary studies may be minimal, but should include review of the electrocardiogram

Clinical Predictors of Increased Perioperative Cardiovascular Risk Major Unstable coronary syndromes Decompensated CHF Significant Arrhythmias Intermediate Mild angina pectoris Prior MI Compensated or prior HF Diabetes Mellitus (particularly taking insulin) Renal insufficiency Minor Advanced Age. Abnormal ECG. Rhythm other than sinus. Low functional capacity. History of stroke. Uncontrolled systemic hypertension

Disease Specific Approaches Coronary Artery Disease (CAD) Patients with known CAD Patients with major risk factors for CAD Hypertension Heart Failure Valvular Heart Disease Arrhythmias and Conduction Defects Implanted Pacemakers and ICD’S Pulmonary Vascular Disease In patients with known CAD, as well as those with newly discovered coronary disease, the following questions should be answered: 1. What is the amount of myocardium in jeopardy? 2. What is the ischemic threshold? 3. What is the patient’s ventricular function?

Type of Surgery Urgency High surgical risk: Emergent major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss. Cardiac complications are two to five times more likely to occur with emergency surgical procedures than with elective operations. In addition, the magnitude of the surgical procedure influences the cardiac risk. Major vascular procedures represent the highest risk, as well as those with prolonged duration and large fluid shifts.

Type of Surgery Intermediate surgical risk: Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic Orthopedic surgery Prostate surgery

Type of Surgery Low surgical risk: Endoscopic procedures Superficial procedures Cataract surgery Breast surgery

Supplemental Preoperative Evaluation Noninvasive testing in preoperative patients indicated if 2 or more of following present: Intermediate clinical predictors (Canadian Class I or II angina, prior MI based on history or pathological Q waves, compensated or prior HF, or diabetes) Poor functional capacity (<4 METs) High surgical risk procedure (emergency major surgery*, aortic repair or peripheral vascular, prolonged surgical procedures with large fluid shifts or blood loss) * Emergency major operations may require immediately proceeding to surgery without sufficient time for noninvasive testing or preoperative interventions. Class I: Conditions for which or patients for whom there is general agreement that this procedure is useful. Class II: Procedure frequently used but there is divergence of opinion with respect to its usefulness. Class III: General agreement that procedure is of little or no usefulness. The greatest risk of complications is seen in patients with left ventricular function less than 35%. Preoperative noninvasive evaluation of left ventricular function is indicated in patients with current or poorly controlled CHF. It is probably indicated in patients with prior CHF and patients with dyspnea of unknown etiology.

Supplemental Preoperative Evaluation: When and Which Test* 2 or more of the following?†* 1. Intermediate clinical predictors 2. Poor functional capacity (less than 4 METS) 3. High surgical risk No No further preoperative testing recommended Yes Indications for angiography? (eg, unstable angina?) Yes Preoperative angiography *Testing is only indicated if the results will impact care. †See Table 1 for the list of intermediate clinical predictors, Table 2 for thermetabolic equivalents, and Table 3 for the definition of high-risk surgical procedure. ‡Able to achieve more than or equal to 85% MPHR ** In the presence of LBBB, vasodilator perfusion imaging is preferred. No Patient ambulatory and able to exercise?‡ Yes Resting ECG normal? Yes ECG ETT No Exercise echo or perfusion imaging‡** Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Marked hypertension? Bronchospasm? II AV Block? Theophylline dependent? Valvular dysfunction? Pharmacologic stress imaging (nuclear or echo) No No Yes Yes Dipyridamole or adenosine perfusion Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Borderline or low blood pressure? Marked hypertension? Poor echo window? No Dobutamine stress echo or nuclear imaging Yes Other (eg, Holter monitor, angiography)

Supplemental Preoperative Evaluation Noninvasive resting left ventricular function: Risk of complications greatest with EF<35%. *If previous evaluation has documented severe left ventricular dysfunction, repeat preoperative testing may not be necessary. Recommendations Class I: Poorly controlled HF.* Class IIa: Prior HF or dyspnea of unknown etiology. Class III: Routine test without prior HF.

Assessment of Risk for Coronary Artery Disease and Functional Capacity (1) Potential Goal, when indicated: Provide objective measure of functional capacity Identify presence of preoperative myocardial ischemia or cardiac arrhythmias Estimate perioperative cardiac risk and long-term prognosis

Assessment of Risk for Coronary Artery Disease and Functional Capacity (2) Specific Approaches: Exercise stress testing. Nonexercise stress testing: Dobutamine stress echocardiography. Myocardial perfusion imaging Ambulatory electrocardiographic monitoring. In most ambulatory patients, the test of choice is exercise ECG testing, which can provide both an estimate of functional capacity and detect myocardial ischemia through changes in the ECG and hemodynamic response. In patients with abnormalities on their resting ECG, other techniques such as exercise echo or radionuclear imaging should be considered. In patients unable to perform adequate exercise, a nonexercise stress test should be used.

Assessment of Risk for Coronary Artery Disease and Functional Capacity (3) Recommendations: Test of choice is exercise ECG testing Provides estimate of functional capacity Detects myocardial ischemia through ECG changes and hemodynamic response In most settings, the test of choice is exercise ECG testing, which can provide both an estimate of functional capacity and detect myocardial ischemia.

Implications of Risk Assessment Strategies on Costs Potential benefit: Identifying unsuspected CAD Decreasing morbidity/mortality Risk: Morbidity/mortality from test Cost of screening Cost of treatment The decision to recommend further noninvasive or invasive testing for the individual patient is based on the risk/benefit ratio. The benefit to the patient is identifying unsuspected CAD, and possibly decreasing morbidity and mortality postoperatively. The risk from the test, as well as the cost, should also be considered.

Recommendations for Coronary Angiography in Perioperative Evaluation Class I: Patients with suspected or known CAD Evidence for high risk of adverse outcome based on noninvasive test results Angina unresponsive to adequate medical therapy Unstable angina, particularly when facing intermediate-risk or high-risk noncardiac surgery Equivocal noninvasive test results in patients at high-clinical risk undergoing high-risk surgery

Recommendations for Coronary Angiography in Peri-operative evaluation Class IIa Multiple markers of intermediate clinical risk and planned vascular surgery (noninvasive testing should be considered first). Moderate to large region of ischemia on noninvasive testing but without high-risk features and without lower LVEF. Nondiagnostic noninvasive test results in patients of intermediate clinical risk undergoing high-risk noncardiac surgery. Urgent noncardiac surgery while convalescing from acute MI.

Recommendations for Coronary Angiography in Peri-operative evaluation Class IIb 1. Perioperative MI. 2. Medically stabilized class III or IV angina and planned low-risk or minor

Recommendations for Coronary Angiography in Perioperative Evaluation Class III Low-risk noncardiac surgery with known CAD and no high-risk results on noninvasive testing Asymptomatic after coronary revascularization with excellent exercise capacity (> 7 METs). Mild stable angina with good left ventricular function and no high-risk noninvasive test results. Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., LVEF less than 0.20), or refusal. Candidate for liver, lung, or renal transplant more than 40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk.

Preoperative Therapy (1) Recommendation: Preoperative CABG No randomized clinical trials documenting decreased incidence of perioperative cardiac events Patients with prognostic high risk coronary anatomy in whom long-term outcome would likely be improved. (ACC/AHA CABG Guidelines) Noncardiac elective surgical procedure of high or intermediate risk. The decision to perform revascularization on a patient before noncardiac surgery is appropriate only in a small subset of very high-risk patients. Patients undergoing elective noncardiac procedures with high risk coronary anatomy, and in whom long-term outcome would likely be improved by CABG, should undergo revascularization before a noncardiac elective surgical procedure of high or intermediate risk.

Preoperative Therapy (2) Recommendation: Preoperative percutaneous coronary intervention (PCI) No randomized clinical trials documenting decreased incidence of perioperative cardiac events No prospective studies to determine optimal period of delay after PCI before noncardiac surgery Delay of 2-4 weeks after PCI with stent placement supported by observational study There are no randomized clinical trials documenting the benefit of prophylactic percutaneous transluminal coronary angioplasty or other transcatheter revascularization before noncardiac surgery.

Preoperative Therapy (3) Recommendations: Medical Therapy. Few randomized trials Studies suggest B-blockers reduce perioperative ischemia and may reduce risk of MI and death Alpha-agonists may also reduce cardiac events when administered perioperatively Preliminary studies suggest that B-blockers reduce perioperative ischemia and may reduce risk of MI and death.

Preoperative Therapy with B-Blockers Class I. B-blockers required in recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery Class IIa. Preoperative assessment identifies untreated hypertension, known coronary disease, or major risk factors for coronary disease Class III. Contraindications to B-blockade This slide summarizes the Class I, II, and III indications for perioperative B-blocker therapy. Class I: Conditions for which or patients for whom there is general agreement that this medication is useful. Class II: Medication frequently used but there is divergence of opinion with respect to its usefulness. Class III: General agreement that medication is of little or no usefulness

Preoperative Therapy with B-Blockers Start pre-op, titrate to HR<60 bpm Short acting beta-blockers provide more flexible dosing Give orally, if possible, with IV supplementation when patient NPO This slide summarizes the Class I, II, and III indications for perioperative B-blocker therapy. Class I: Conditions for which or patients for whom there is general agreement that this medication is useful. Class II: Medication frequently used but there is divergence of opinion with respect to its usefulness. Class III: General agreement that medication is of little or no usefulness

Preoperative Therapy with Alpha2-Agonists Class I: None Class IIb: Alpha2 agonists: perioperative control of hypertension, or known CAD or major risk factors for CAD Class III: Contraindications to alpha2 agonists.

Preoperative Valve Surgery If valvular heart surgery indicated, then should be performed before elective noncardiac surgery. Catheter balloon valvuloplasty may offer amelioration of severe mitral or aortic stenosis who require urgent noncardiac surgery.

Preoperative Intensive Care (1) Goal Optimize and augment oxygen delivery in patients at high risk Hypothesis Indices derived from pulmonary artery catheter and invasive blood pressure monitoring can be used to maximize oxygen delivery, which leads to reduction in organ dysfunction Preoperative invasive monitoring in an intensive care setting can be used to optimize and even augment oxygen delivery in patients at high risk.

Preoperative Intensive Care (2) Recommendation: Based on scant evidence, preoperative preparation in intensive care unit may benefit certain high risk patients, particularly those with decompensated HF.

General Guidelines for Perioperative Prophylaxis for Venous Thromboembolism* Type of Patient/Surgery Minor surgery in a pt <40 yo w/ no correlates of venous thromboembolism risk Moderate-risk surgery in a pt >40-60 yo w/ No correlates of thromboembolism risk Major surgery in pt <40-60 yo w/ clinical conditions associated w/ venous thromboembolism risk, >60 yo without increased risk Recommendation Early ambulation ES; low dose subq heparin [LDH] (2 h preop & q 12 h after), or IPC (intraop & postop) LDH (q 8 h) or LMWH. IPC if prone to wound bleeding ES indicates graded compression elastic stockings; LDH, low-dose subcutaneous heparin; IPC, intermittent pneumatic compression; LMWH, low molecular weight heparin. †Clinical conditions associated with increased risk of venous thromboembolism: advanced age; prolonged immobility or paralysis; previous venous thromboembolism; malignancy; major surgery of abdomen, pelvis, or lower extremity; obesity; varicose veins; congestive heart failure; myocardial infarction; stroke; fracture(s) of the pelvis, hip or leg; hypercoagulable states; and possibly high-dose estrogen use. ES: Elastic Stockings; LDH: Low Dose Heparin (subQ); LMWH: Low Molecular Weight Heparin; IPC: Intermittent Pneumatic Compression *Developed from Geerts et al. Prevention of venous thromboembolism. Chest. 2001;119:132S-175S

Perioperative Prophylaxis for Venous Thromboembolism (2) Type of Patient/Surgery Very high-risk surgery in a pt w/ multiple clinical conditions associated with thromboembolism risk Total hip replacement Recommendation LDH, LMWH, or dextran combined w/ IPC. In selected pts, periop warfarin (INR 2.0-3.0) may be used. LMWH (postop, subq twice daily, fixed dose unmonitored) or warfarin (INR 2.0-3.0, started preop) or immed after surgery) or adjusted dose unfractionated heparin (started preop). ES or IPC may provide addn’l efficacy. ES: Elastic Stockings; LDH: Low Dose Heparin (subQ); LMWH: Low Molecular Weight Heparin; IPC: Intermittent Pneumatic Compression

Perioperative Prophylaxis for Venous Thromboembolism (3) Type of Patient/Surgery Total knee replacement Hip fracture surgery Intracranial neurosurgery Recommendation LMWH (postop, subq, twice daily, fixed dose unmonitored) or IPC. LMWH (preop, subq, fixed dose unmonitored) or warfarin (INR 2.0-3.0). IPC may provide additional benefit. IPC w/ or w/o ES. Consider additional of LDH or LMWH in high-risk pts. ES: Elastic Stockings; LDH: Low Dose Heparin (subQ); LMWH: Low Molecular Weight Heparin; IPC: Intermittent Pneumatic Compression

Perioperative Prophylaxis for Venous Thromboembolism (4) Type of Patient/Surgery Acute spinal cord injury with lower- extremity paralysis Patients with multiple trauma Recommendation LMWH for prophylaxis. Warfarin may also be effective. ES and IPC may have benefit when used with LMWH. LMWH when feasible, serial surveillance with duplex ultrasonography may be useful. In selected very high-risk pts, consider prophylactic caval filter. If LMWH not feasible, IPC may be useful. ES: Elastic Stockings; LDH: Low Dose Heparin (subQ); LMWH: Low Molecular Weight Heparin; IPC: Intermittent Pneumatic Compression

Anesthetic Considerations and Intraoperative Management (1) No study clearly demonstrated improved outcome from use of: Regional versus general anesthesia Pulmonary artery catheter Intraoperative Nitroglycerin ST-Segment Monitoring Transesophageal echocardiography Prophylactic placement of intra-aortic balloon counterpulsation device

Anesthetic Considerations and Intraoperative Management (2) Recommendations for Intraoperative Nitroglycerin Class I: High-risk patients previously taking nitroglycerin who have active signs of myocardial ischemia without hypotension. Class IIb: Prophylactic agent for high-risk patients, particularly when nitrate therapy required to control angina. (Consider side effects of vasodilation) Class III: Patients with signs of hypovolemia or hypotension.

Anesthetic Considerations and Intraoperative Management (3) Recommendations for Perioperative ST-Segment Monitoring Class IIa When available, proper use of computerized ST-segment analysis in patients with known CAD or undergoing vascular surgery may provide increased sensitivity to detect myocardial ischemia during the perioperative period and may identify patients who would benefit from further postoperative and long-term interventions. Class IIb Patients with single or multiple risk factors for CAD. Class III Patients at low risk for CAD.

Anesthetic Considerations and Intraoperative Management (4) Choice of anesthetic and intraoperative monitoring best left to discretion of anesthesia care team

Perioperative Surveillance Post operative myocardial ischemia: Strongest predictor of perioperative cardiac morbidity. May go untreated until overt symptoms of cardiac failure develop. Diagnosis of perioperative MI has short and long-term prognostic value. 30% to 50% perioperative mortality and reduced long-term survival. Intraoperative and post operative surveillance of the high risk patient should also lead to decreased morbidity and mortality. The strongest predictor of perioperative cardiac morbidity is myocardial ischemia, which is rarely accompanied by pain. Therefore, it may go untreated until overt cardiac failure is present. Perioperative MIs are associated with a 30-50% mortality.

Perioperative Surveillance: Intraoperative and Postoperative Use of Pulmonary Artery Catheters Class IIa: Patients at risk for major hemodynamic disturbances most easily detected by a pulmonary artery catheter undergoing procedure likely to cause these hemodynamic changes in setting with experience in interpreting results (e.g., suprarenal aortic aneurysm repair in a patient with angina). Class IIb: Either patient’s condition or surgical procedure (but not both) places patient at risk for hemodynamic disturbances. Class III: No risk of hemodynamic disturbances This slide summarizes the indications for perioperative use of pulmonary artery catheters. Class I: Conditions for which or patients for whom there is general agreement that this procedure is useful. Class II: Procedure frequently used but there is divergence of opinion with respect to its usefulness. Class III: General agreement that procedure is of little or no usefulness

Perioperative Surveillance: Potential Myocardial Infarction (1) Patients without evidence of CAD: Surveillance restricted to those who develop perioperative signs of cardiovascular dysfunction Further evaluation regarding the optimal strategy for surveillance and diagnosis of perioperative MI is required before one method is advocated. In patients without evidence of CAD, surveillance should be restricted to patients who develop perioperative signs of cardiovascular dysfunction.

Perioperative Surveillance: Potential Myocardial Infarction (2) Patients with known or suspected CAD, and undergoing high or intermediate risk procedure: ECGs at baseline, immediately after procedure, and daily x 2 days Cardiac troponin measurements 24 hours postoperatively and on day 4 or hospital discharge (whichever comes first) In patients with known or suspected CAD undergoing surgical procedures associated with a high incidence of cardiovascular morbidity, ECGs at baseline, immediately after the surgical procedure, and daily on the first 2 days postoperatively appear to be the most cost-effective strategy.

Perioperative Surveillance: Arrhythmia/Conduction Disease (1) Often due to remedial noncardiac problems: Infection Hypotension Metabolic derangements Hypoxia. Postoperative arrhythmias are often due to remedial noncardiac problems such as infection, hypotension,metabolic derangements, and hypoxia. Correction of the underlying problem frequently corrects the arrhythmia as well.

Perioperative Surveillance: Arrhythmia/Conduction Disease (2) Cardioversion not recommended in patients without hemodynamic compromise until precipitating causes corrected or modified Electrical cardioversion for supraventricular or ventricular arrhythmias causing hemodynamic compromise Cardioversion of supraventricular arrhythmias is generally not recommended until correction of the underlying problems has occurred. However, electrical cardioversion should be used for supraventricular or ventricular arrhythmias causing hemodynamic compromise.

Postoperative Therapy/Future Management Treatment of Perioperative MI ACC/AHA guidelines for ACS and AMI, with consideration of post-op conditions Coronary reperfusion for ST elevation MI Treat risk factors for secondary prevention

Postoperative Therapy/Future Management Assessment and management of risk factors for: CAD Heart failure Hypertension Stroke Peripheral vascular disease Other cardiovascular disease Whenever possible, postoperative management should include the assessment and management of any risk factors for CAD, heart failure, hypertension, stroke, or other cardiovascular disease that may have been identified in the preoperative period.

Conclusions (1) Perioperative evaluation and management results from good communication between surgeon, anesthesiologist, primary care physician, and consultant

Conclusions (2) Further cardiac testing and treatments same as in nonoperative setting, considering: The urgency of the noncardiac surgery Patient-specific risk factors Surgery-specific considerations

Conclusions (3) Use Preoperative Tests When: Clinical assessment suggests intermediate risk and surgical risk not low Surgical risk is high Results will affect patient management

Conclusions (4) Perioperative evaluation goals: Accurately estimate perioperative risk Lowering perioperative cardiac risk, if possible Assess long-term risk Address modifiable coronary risk factors