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doi:10.1016/j.jacc.2009.07.0102009;54;e13-e118; originally published online Nov 2, 2009;
 J. Am. Coll. Cardiol.
Kersten, Barbara Riegel, and John F. RobbFleischmann, William K. Freeman, James B. Froehlich, Edward K. Kasper, Judy R.E.Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliot L. Chaikof, KirstenSociety for Vascular Medicine, Society for Vascular Surgery, Lee A. Fleisher,Anesthesiologists, Society for Cardiovascular Angiography and Interventions,Society of Nuclear Cardiology, Heart Rhythm Society, Society of CardiovascularForce on Practice Guidelines, American Society of Echocardiography, AmericanAmerican College of Cardiology Foundation, American Heart Association Task  
Cardiovascular Evaluation and Care for Noncardiac SurgeryIncorporated Into the ACC/AHA 2007 Guidelines on Perioperative2009 ACCF/AHA Focused Update on Perioperative Beta BlockadeThis information is current as of February 9, 2010
http://content.onlinejacc.org/cgi/content/full/54/22/e13located on the World Wide Web at:The online version of this article, along with updated information and services, is
 by on February 9, 2010content.onlinejacc.orgDownloaded from 
 
PRACTICE GUIDELINES: FULL TEXT
2009 ACCF/AHA Focused Update on PerioperativeBeta Blockade Incorporated Into the ACC/AHA2007 Guidelines on Perioperative CardiovascularEvaluation and Care for Noncardiac Surgery
A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
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 Society for Vascular Surgery
2007 WritingCommitteeMembers
Lee A. Fleisher, MD, FACC, FAHA,
Chair 
 Joshua A. Beckman, MD, FACC*Kenneth A. Brown, MD, FACC, FAHA†Hugh Calkins, MD, FACC, FAHA‡Elliot L. Chaikof, MD§Kirsten E. Fleischmann, MD, MPH, FACC William K. Freeman, MD, FACC
 James B. Froehlich, MD, MPH, FACCEdward K. Kasper, MD, FACC Judy R. Kersten, MD, FACC¶Barbara Riegel, DNS
C
, RN, FAHA John F. Robb, MD, FACC# 
*SVMB Representative; †ASNC Representative; ‡HRS Respresenta-tive; §SVS Representative;
ASE Representative; ¶SCA Representa-tive; #SCAI Representative
2009 FocusedUpdate WritingGroup Members
Kirsten E. Fleischmann, MD, MPH, FACC,
Chair 
 Joshua A. Beckman, MD, FACC**Christopher E. Buller, MD, FACC††Hugh Calkins, MD, FACC, FAHA‡Lee A. Fleisher, MD, FACC, FAHA‡‡ William K. Freeman, MD, FACC¶ James B. Froehlich, MD, MPH, FACC‡‡Edward K. Kasper, MD, FACC, FAHA‡‡ Judy R. Kersten, MD, FACC#  John F. Robb, MD, FACC, FAHA
R. James Valentine, MD§
**SVM Representative; ††ACCF/AHA Task Force on Practice Guide-lines Liaison; ‡‡ACCF/AHA Representative This document was approved by the American College of Cardiology FoundationBoard of Trustees in July 2009 and by the American Heart Association ScienceAdvisory and Coordinating Committee in July 2009. The American College of Cardiology Foundation requests that this document be citedas follows: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, FleischmannKE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009ACCF/AHA focused update on perioperative beta blockade incorporated into theACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care fornoncardiac surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol2009;54:e13–118. This article has been copublished in the November 24, 2009, issue of 
Circulation
.Copies: This document is available on the World Wide Web sites of theAmerican College of Cardiology ( www.acc.org)and the American Heart Asso- ciation (my.americanheart.org). For copies of this document, please contact the Elsevier Inc Reprint Department, fax (212) 633-3820, e-mailreprints@elsevier.com.Permissions: Modification, alteration, enhancement, and/or distribution of thisdocument are not permitted without the express permission of the American Collegeof Cardiology Foundation. Please contact Elsevier’s permission department athealthpermissions@elsevier.com. Journal of the American College of Cardiology Vol. 54, No. 22, 2009© 2009 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/09/$36.00Published by Elsevier Inc. doi:10.1016/j.jacc.2009.07.010
 by on February 9, 2010content.onlinejacc.orgDownloaded from 
 
TaskForceMembers
Alice K. Jacobs, MD, FACC, FAHA,
Chair 2009–2011
Sidney C. Smith, J
R 
, MD, FACC, FAHA,
 Immediate Past Chair 2006–2008 
§§ Jeffrey L. Anderson, MD, FACC, FAHA,
Vice Chair 
Christopher E. Buller, MD, FACCMark A. Creager, MD, FACC, FAHASteven M. Ettinger, MD, FACCRobert A. Guyton, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHAHarlan M. Krumholz, MD, FACC, FAHA§§Frederick G. Kushner, MD, FACC, FAHABruce W. Lytle, MD, FACC, FAHA§§Rick Nishimura, MD, FACC, FAHA§§Richard L. Page, MD, FACC, FAHA§§ William G. Stevenson, MD, FACC, FAHALynn G. Tarkington, RNClyde W. Yancy, MD, FACC, FAHA
§§Former Task Force member during this writing effort
TABLE OF CONTENTS
Preamble (UPDATED)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e15
1. Introduction/Definition of the Problem(UPDATED)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e16
1.1. Methodology and Evidence Review(UPDATED)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e17
1.2. Organization of Committee andRelationships With Industry and OtherEntities (NEW)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e17
1.3. Document Review and Approval(UPDATED)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e18
1.4. Epidemiology
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e18
1.5. Practice Patterns
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e19
1.6. Financial Implications
. . . . . . . . . . . . . . . . . . . . . . . . . . .
e19
2. General Approach to the Patient
. . . . . . . . . . . . . . . . . . . .
e19
2.1. Role of the Consultant
. . . . . . . . . . . . . . . . . . . . . . . . . .
e19
2.2. History
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e20
2.3. Physical Examination
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
e20
2.4. Comorbid Diseases
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e21
2.4.1. Pulmonary Disease
. . . . . . . . . . . . . . . . . . . . . . . . .
e21
2.4.2. Diabetes Mellitus
. . . . . . . . . . . . . . . . . . . . . . . . . .
e21
2.4.3. Renal Impairment
. . . . . . . . . . . . . . . . . . . . . . . . . .
e22
2.4.4. Hematologic Disorders
. . . . . . . . . . . . . . . . . . . . .
e22
2.5. Ancillary Studies
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e22
2.6. Multivariable Indices to PredictPreoperative Cardiac Morbidity
. . . . . . . . . . . . . . . .
e23
2.7. Clinical Assessment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e23
2.7.1. Stepwise Approach to PerioperativeCardiac Assessment
. . . . . . . . . . . . . . . . . . . . . . . .
e23
3. Disease-Specific Approaches
. . . . . . . . . . . . . . . . . . . . . . . .
e26
3.1. Coronary Artery Disease
. . . . . . . . . . . . . . . . . . . . . . . .
e26
3.1.1. Patients With Known CAD
. . . . . . . . . . . . . . . .
e26
3.1.2. Influence of Age and Gender
. . . . . . . . . . . . . . .
e26
3.2. Hypertension
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e26
3.3. Heart Failure
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e28
3.4. Cardiomyopathy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e28
3.5. Valvular Heart Disease
. . . . . . . . . . . . . . . . . . . . . . . . . .
e28
3.6. Arrhythmias and Conduction Defects
. . . . . . . . . .
e29
3.7. Implanted Pacemakers and ICDs
. . . . . . . . . . . . . . .
e30
3.8. Pulmonary Vascular Disease andCongenital Heart Disease
. . . . . . . . . . . . . . . . . . . . . . .
e30
4. Surgery-Specific Issues
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e30
4.1. Urgency
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e31
4.2. Surgical Risk
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e31
5. Supplemental Preoperative Evaluation
. . . . . . . . . . . .
e34
5.1. Assessment of LV Function
. . . . . . . . . . . . . . . . . . . . .
e34
5.2. Assessment of Risk for CAD andAssessment of Functional Capacity
. . . . . . . . . . . .
e35
5.2.1. The 12-Lead ECG
. . . . . . . . . . . . . . . . . . . . . . . . .
e35
5.2.2. Exercise Stress Testing for MyocardialIschemia and Functional Capacity 
. . . . . . . . . .
e35
5.2.3. Noninvasive Stress Testing
. . . . . . . . . . . . . . . . .
e37
5.2.3.1. RADIONUCLIDE MYOCARDIAL PERFUSIONIMAGING METHODS
. . . . . . . . . . . . . . . . . . . . . .
e37
5.2.3.2. DOBUTAMINE STRESS ECHOCARDIOGRAPHY 
. .
e40
5.2.3.3. STRESS TESTING IN THE PRESENCE OFLEFT BUNDLE-BRANCH BLOCK
. . . . . . . . . . . . .
e42
5.2.4. Ambulatory ECG Monitoring
. . . . . . . . . . . . .
e43
5.3. Recommendations: If a Test Is Indicated,Which Test?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e43
6. Implications of Guidelines and Other RiskAssessment Strategies for Costs andOutcomes
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e44
7. Perioperative Therapy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e45
7.1. Preoperative Coronary RevascularizationWith CABG or Percutaneous CoronaryIntervention
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e45
e14 Fleisher
et al.
JACC Vol. 54, No. 22, 2009
2009 ACCF/AHA Perioperative Guidelines
November 24, 2009:e13–118
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