AHA/ACC Guidelines (2007) – Perioperative Cardiovascular Evaluation of the Patient undergoing Non-cardiac Surgery
Take Home Message = if assessment and evaluation not indicated irrespective of perioperative context then just crack on (its all about symptoms).
3 factors involved in risk stratification:
- Patient risk factors (high, intermediate and low risk)
- Functional capacity (<4METS= low, >4METS= high)
- Surgery (high, intermediate and low risk)
Active Medical Problems/Major Risk Factors
- unstable angina
- recent MI (< 1 month)
- uncontrolled heart failure
- significant arrhythmias (high grade AV block, symptomatic arrhythmias, supraventricular arrhythmias with a rapid ventricular rate)
- severe valvular disease
- recent CABG or PCI (<6 weeks)
Clinical Predictors (Lee’s Criteria)/Intermediate Risk Factors
- previous MI (>1 month)
- stable mild angina
- compensated heart failure
- renal impairment (Cr > 170)
- DM (on insulin)
Risk of Perioperative Cardiac Events (AMI,APO, CVA, arrhythmia, death)
- 0 factors = 0.4%
- 1 = 1%
- 2 = 6.6%
- 3-5 = 11%
Minor Risk Factors
- advanced age
- abnormal ECG
- low functional capacity
- previous CVA
- uncontrolled HT
- 1MET= personal cares
- 2METS = walk indoors
- 3METS = walk a block on level ground, dusting and washing dishes
- 4METS = climb a flight of stairs or walk up hill
- 5METS = run a short distance
- 6METS = scrubbing floors or lifting heavy objects
- 7-9METS = golf, bowling, dancing, doubles tennis, throwing rugby ball
- >10METS = swimming, singles tennis, basketball, skiing
High Risk (>5%)
- major emergency surgery
- aortic or major open vascular surgery
Intermediate Risk (1-5%)
- intraperitoneal and intrathoracic surgery
- carotid endarterectomy
- head and neck surgery
- orthopaedic surgery
- prostate surgery
Low Risk (<1%)
- endoscopic procedures
- superficial procedure
- cataract surgery
- breast surgery
- ambulatory surgery
- FBC; anaemia
- 12 lead ECG; conduction abnormalities, arrhythmia, Q waves, ischaemic change
- U+E; renal function
- ECHO; LV function, valvulopathy
- Radionucleotide angiography (not predictive of intraoperative ischaemia)
- ETT; good assessment as assesses symptoms and workload but only indicated if there are pre-existing symptoms of concern (sensitivity 70% and specificity 80%).
- Dobutamine stress ECHO;
- Radionucleotide stress testing; can quantify the areas of myocardium that is @ risk
- ANGIO: anatomical nature of lesion and ability to revascularise
Preoperative CABG – if symptoms are stable, CABG doesn’t change risk of MI of death (CARP study & DECREASE study).
Preoperative PCI – again, unless intervention is indicated in and of itself it doesn’t change risk.
- balloon angioplasty -> delay surgery 2-4 weeks and keep anti-platelet agents going.
- bare metal stent -> delay surgery 4-6 weeks (will be on clopidogrel for this time too).
- drug eluting stents -> delay surgery for 12 months (will be on dual platelet therapy).
- if patients must undergo therapy keep aspirin going and restart clopidogrel as soon as possible.
Perioperative management of patients with prior PCI
- see above time frames (4 weeks, 6 weeks & 12 months) -> try and keep dual anti-platelet therapy going.
- if can’t, keep aspirin going and reinstitute clopidogrel as soon as possible -> there is no evidence that other agents decrease risk of stent thrombosis.
Perioperative management of patients who have received intracoronary brachytherapy
- gamma or beta brachytherapy used to treat recurrent in-stent restenosis.
- continue anti-platelet agents if possible.
Perioperative management of the patient who requires PCI and surgery soon after
Use same time lines based on when surgery indicated:
- 4 weeks -> balloon
- 6 weeks -> bare metal stent
- 12 months -> drug eluting stent
- can put stents in and then deal with restenosis if it takes place
- also CABG + non-cardiac surgery is an option
- aim = to decrease perioperative MI and death
- should start weeks prior to surgery
- use longer acting agents
- aim for a HR <65/min
- continue perioperatively
- POISE trial: showed that introduction of betablockers on the day of surgery resulted in an increase in adverse events and mortality therefore acute commencement not advised.
- keep going
- decreased risk of MI and death
Alpha 2 Agonists
- reduction in perioperative MI and mortality
Perioperative Calcium channel blockers
- reduced SVTand ischaemia.
- trend towards decreased MI and death.
Electomagnetic Interference + ICD’s and Pacemakers
- recent evaluation (within 3-6 months)
- reprogram to an asynchronous mode (D00 or V00)
- ICD -> turn off their tachyarrhythmia treatment algorithms, place defibrillation paddles far away from device (AP ideal)
- otherwise standard care
- monitor clinically for MI.
- if develops PCI needs to considered in context of bleeding risk.
- manage acutely with early consultation with cardiology.
References and Links
Journal articles and textbooks
- Fleisher LA et al. 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. Anesth Analg. 2008 Mar;106(3):685-712. Mar;106(3):685-712. PMID: 18292406
- POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47. PMID: 18479744
- Fleisher LA et al. 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. J Am Coll Cardiol. 2009 Nov 24;54(22):e13-e118. PubMed PMID: 19926002