2014 ACC/AHA GUIDELINE ON

PERIOPERATIVE
CARDIOVASCULAR
EVALUATION AND
MANAGEMENT OF PATIENTS
UNDERGOING NONCARDIAC
SURGERY
Dr Ezzuddin Akif
Staff Physician
PMBAH
Who Needs Preoperative Cardiac Risk Assessment?

Known CAD: Risk Factors for CAD:

 History of MI  Age >55
 Angina relieved with NTG  Diabetes
 EKG with Q waves  Stroke (CVA/TIA)
 Abnormal stress test or  Heart failure
coronary angiogram  Moderate-severe valvular
 Prior coronary intervention or disease
CABG  Significant arrhythmia
Risk stratification
 1977 - Goldman and colleagues proposed
land mark Cardiac Risk Index .

 1996, 12-member task force of the ACC/AHA

proposed risk stratification.

 Based on new data updated - 2002, 2014

Multifactorial risk indices
 Goldman 1977, 2001
 Detsky 1986
 Larsen 1987
 Mangano 1990, 1999
 Eagle 1996
 Vanzetto 1996
 Simplified LEE
(Revised Cardiac Risk Index (RCRI))
 Review of Evidence Classification

 Classification of Recommendations
 Class I: Conditions for which there is evidence, general agreement, or both
that a given procedure or treatment is useful and effective.
 Class II: Conditions for which there is conflicting evidence, a divergence of
opinion, or both about the usefulness/efficacy of a procedure or treatment
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
 Class III: Conditions for which there is evidence, general agreement, or both
that the procedure/treatment is not useful/effective and in some cases may be
harmful.
 
Level of Evidence
 Level of Evidence A: Data derived from multiple randomized clinical trials
 Level of Evidence B: Data derived from a single randomized trial or
nonrandomized studies
 Level of Evidence C: Consensus opinion of experts

Circulation 2006 114: 1761 – 1791.

 Strength of Recommendation

Class of recommendation: Level of Evidence:

 Class I: Benefit >>> Risk,  Level A: Data from multiple
should be done or RCT or meta-analyses
administered  Level B: Data from single RCT
 Class IIa: Benefit >> Risk, or limited number of non-RCT
reasonable to do or  Level C: Consensus opinion,
administer case report, or standard of
 Class IIb: Benefit > Risk, care only
consider doing or
administering
 Class III: No benefit (or
harm), not recommended or
harmful
ACC/AHA Guidelines
 Provide a frame work
 Best evidence in literature reviewed by experts
in the field
 Regularly reviewed and updated – latest 2014
 Two main cardiac risk predictors
- Surgery
- Patient
 Clinical risk
 Functional capacity
ACC/AHA Perioperative Executive Summary
JACC 39(3) 2002: 542-53
 A quick review…from 2007!!

Fliesher et al, “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” Circulation. 2007. 116:e418-500.
 F ig u r e 1 . S te p w is e A p p ro a c h to P e rio p e ra tiv e C a rd ia c A s s e s s m e n t fo r C A D

2014

Fliesher et al. “2014 ACC/AHA Guideline

on Perioperative Cardiovascular
Evaluation and Management of Patients
Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/ C o lo r s c o rr e s p o n d to th e C la s s e s o f R e c o m m e n d a tio n s in T a b le 1 .
 Step 1:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Definition of Timing of Surgery
Emergent Time-
Urgent Elective
Sensitive

Delay of 1-6
Life or limb is Life or limb is weeks for
threatened if not threatened if further
in operating room Delay for up to
not in operating evaluation
within 1 year
room within would
6 hours 24 hours negatively
affect outcome
 Step 2:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Step 3:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Procedure Type
 Combined surgical and  Any procedure with MACE
patient characteristics risk > 1%
predict a risk of major  No longer distinguishes
adverse cardiac event between intermediate and
(MACE) < 1% high risk because
recommendations the same
 Ex: Cataracts, plastics  Risk can be lowered by less
invasive approach
(endovascular AAA)
 Emergency procedures
increase risk
Low Risk High Risk
Calculators for predicting
perioperative cardiac morbidity
 Class IIa:
 A validated risk-prediction tool can be useful in predicting the risk of
perioperative MACE in patients undergoing non-cardiac surgery

 Class III: No benefit

 For patients with low risk of perioperative MACE, further testing is not
recommended before the planned operation

 RCRI- Revised Cardiac Risk Index

 American College of Surgeons NSQIP Risk Calculator

 Revised Cardiac Risk Index (RCRI) Criteria

 Compensated CHF
 Known coronary artery disease :
 angina or CP  with NTG
 remote MI > 3 -6 months 0 RCRI = <1% mortality
 EKG: pathological Q waves 1-2 RCRI = 2-7% mortality
 abnormal stress test 3-4 RCRI = 9-18% mortality
 abnormal cardiac cath >5 RCRI = >32% mortality
 prior CABG or PCI BNP & CRP improve RCRI
 Hx TIA or CVA accuracy
 Intra-abdominal or high risk surgery
 DM requiring insulin
 Renal insufficiency, Cr >2
Lee, TH. et al. “Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major
Noncardiac Surgery,” Circulation, 1999; 100: 1043.
 Cardiac Risk Stratification: RCRI Criteria

ROC Curves Validation Set, N=1422

1

0.8
Goldman (0.70)
Sensitiv ity

0.6
Detsky (0.58)
0.4 ASA (0.71)
0.2 RCRI (0.81)

1 0.5 0
Specificity
Lee, TH. et al. “Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk
of Major Noncardiac Surgery,” Circulation, 1999; 100: 1043.
 ACS NSQIP Calculator
• ACS NSQIP Calculator
• 21 predictors of risk for major cardiac complications
• NSQIP MICA risk-prediction rule created in 2011
• 525 US hospitals participated
• > 1 million operations included
• Outperformed RCRI in discriminative power (esp. with vascular)
• Calculates risk of:
• MACE, death, PNA, VTE, ARF, return to OR, unplanned
intubation discharge to rehab/nursing home, surgical infection,
UTI
• Predicts length of hospital stay
• Limitations:
• Not validated outside NSQIP
• ASA status
• Functional status/dependence
 RCRI ACS NSQIP Calculator
Creatinine > 2 ARF
H/o heart failure H/o heart failure within 30 days
IDDM DM
Thoracic, Intra-abdominal, or
vascular CPT code
H/o ischemic heart disease Previous Cardiac event
H/o CVA or TIA ASA status
Age
Wound class
Ascites
Sepsis
Ventilator
Disseminated cancer
Steroid use
HTN
Previous MI
Sex
DOE
Smoker
COPD
Dialysis
BMI
Emergence
http://riskcalculator.facs.org/PatientInfo/PatientInfo
 Step 4:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Step 5:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Functional capacity
(Dukes Activity Status index)
 Expressed in metabolic equivalent MET
= areobic demands for specific activities.
 1 MET = 3.5ml/kg/min of O2
consumption at rest.
 Increased periop cardiac risk when
unable to meet a 4 MET during daily
activities.
 Functional capacity is defined as
 poor (<4 METS),
 moderate (4-7 METS), or
 good (>7-10 METS)

 Measurements on a treadmill inducing ischemia

at low-level exercise (<5 MET or heart rate
<100 / min) identifies a high-risk group,

 whereas the achievement of more than 7 MET

(or heart rate >130 / min) without ischemia
identifies a low-risk group.
Functional Capacity
Poor:
 1 MET = ADLs (3.5 mL O2/Kg/min)
 2 METs = walk around house
 3 METs = walk 1-2 blocks, carry 5-10 lbs
Good:
 4 METs = light yard/house work (sweep)
 5 METs = climb >1 floor stairs, lift >20 lbs.,
walk >4 blocks
 6 METs = heavy yard/house work (mow)
 7 METs = golf, bowling, dance, carry 60 lbs,
walk uphill or >1 mile
 8 METs = carry weight upstairs, move heavy
furniture
 9 METs = bike at moderate pace, jump rope
 10 METs = bike uphill, brisk swim, jog quickly
Excellent:
 >10 METs = sustained fast run, competitive
sport
Hlatky, M.A., Boineau, R.E., et. al. "A Brief Self-Administered Questionnaire to Determine Functional Capacity
(The Duke Activity Status Index)." American Journal of Cardiology, 1989; Vol. 64: 651 - 654.
 Step 6:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Step 7:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
Cardiac Risk Assessment Algorithm

Steps 1 - 3: Steps 4 - 7:

MACE = major adverse cardiac event

MET = metabolic equivalent time
GDMT = guideline directed medical therapy
CPG = clinical practice guideline
Comparing Previous and Current Guidelines
Cardiac Risk Stratification: Role of Cardiac Testing

When is it indicated? Cardiac Testing

 Surgery: non-emergent,  Echocardiography
elevated risk procedure  Exercise testing +/- imaging
 Patient: suspected moderate-  Noninvasive pharmacological
severe valvular heart disease stress testing
or unstable cardiac conditions  Coronary angiography
 Unknown or poor functional  (Insufficient evidence for CT
capacity
coronary angiogram)
 Testing will change
management
 Patient may decline surgery
 Preoperative coronary
intervention is needed
 Indications for EKG
Class III-B (No Benefit, Not
Indicated):
 Low risk surgery <1% MACE
Class IIb-C Recommendation:
 Preoperative EKG useful as
baseline
 Q waves, ST changes, long QTc,
LVH, & BBB may be predictive
 Obtain EKG <3 months if indicated
& patient is stable
Class IIb-B Indication:
 Asymptomatic patient without CAD
(+ cardiac risk factors)
Class IIa-B Indication:
 Known CAD
 Significant arrhythmia
 PAD
 Stroke (CVA/TIA)
 Major structural heart disease
 Indications for Echocardiogram
Class III-B (No Benefit, Not
Indicated):
 Routine preoperative screening
 Low risk surgery <1% MACE
Class IIb-C Indication:
 Known LV dysfunction in stable
patient with study >1 year ago
Class IIa-C Indication:
 Unknown cause of dyspnea (or
new Dx of clinically suspected HF)
 Known HF with worsening dyspnea
Class IIb-B Recommendation:
 EF <30-35% predictive of MACE
but no better than clinical prediction
 High specificity but poor sensitivity
Class I-C Indication:
 Clinically suspected moderate-
severe valvular disease if no study
<1 year, or if change in clinical
status
 Indications for Exercise Stress Testing
Class III-B (No Benefit, Not
Indicated):
 Routine preoperative screening
for low risk surgery <1% MACE
If it will change management &
elevated risk surgery, then:
Class IIb-C Indication:
 <4 METs functional capacity,
stress test with imaging may
help
Class IIb-B Indication:
 Unknown functional capacity,
exercise stress test (no imaging)
may help
 4-10 METs functional capacity,
stress test not needed
Class IIa-B Indication:
 >10 METs functional capacity,
stress test not needed
 Indications for Pharmacological Stress Testing

Class III-B (No Benefit, Not Indicated):

 Routine preoperative screening for low risk surgery <1% MACE

If it will change management & elevated risk surgery, then:

Class IIa-B Indication:
 <4 METs functional capacity, then dobutamine echocardiogram or
pharmacological nuclear stress test is helpful

 Moderate to large reversible defect predicts increased risk of MACE

 Fixed defect is not predictive
 Indications for Preoperative Coronary Angiogram
Class III-C (No Benefit, Not
Indicated):
 Routine preoperative screening
If it will change management &
elevated risk surgery, then:
Class IIb-C Indication:
 CT coronary angiography is
lower risk than invasive
angiogram, but insufficient
evidence
 Indication is the same as non-
preoperative setting (defer to
Cardiologist)
Some Considerations if Abnormal:
 Will delay from PCI or CABG
increase risk of surgical
condition?
 Can surgery be done safely with
anti-platelet therapy?
Timing of Elective Non Cardiac Surgery after PCI
 Class I:
1. Elective noncardiac surgery should be delayed:
○ 14 days after balloon angioplasty
○ 30 days after BMS implantation

2. Elective noncardiac surgery should optimally be delayed:

○ 365 days after drug-eluting stent (DES)implantation

 Class IIa
1. When 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.
Timing of Elective Non Cardiac Surgery after PCI
 Class IIb*
1. Elective noncardiac surgery after drug eluting stent
implantation may be considered:
○ After 180 days if the risk of further delay is greater than risks of
ischemia and stent thrombosis

 Class III: No Benefit/Harm

1. Elective noncardiac surgery should not be performed:
○ Within 30 days after BMS implantation if dual antiplatelet
therapy needs to be discontinued
○ Within 12 months after DES implantation if dual antiplatelet
therapy needs to be discontinued
○ Within 14 days of balloon angioplasty if aspirin needs to be
discontinued
 Indications for Beta-Blocker to Reduce MACE

Class III-B (Harm, Not Indicated):

 Do not initiate on day of surgery

If elevated risk surgery:

Class IIb-C Indication:
 Intermediate-high risk ischemia seen on preoperative testing
Class IIb-B Indication:
 >3 RCRI Criteria
 <3 RCRI with primary long-term indication (CAD, HF, HTN)
 Start >1 day preoperatively
Class IIa-B Recommendation:
 May be continued postoperatively if clinically safe (SBP>100, HR>55, no
acute anemia or Hgb >10)
Class I-B Recommendation:
 May be safely continued if tolerated as chronic therapy
 Indications for Perioperative Statin

If elevated risk surgery:

Class IIb-C Indication:
 Consider initiating if undergoing high risk procedure
Class IIa-B Indication:
 Initiate for vascular surgery
Class I-B Indication:
 Continue if chronically using
RCRI-based indication was discarded with DECREASE data
 Indications for Perioperative Alpha-2 Agonist

Class III-B (No Benefit, Not Indicated)

 Insufficient data to recommend
 Benefit seen in those also taking beta-blocker
 Indications for Perioperative Antiplatelet

Class III-C Indication:

 Consider if risk of coronary ischemia outweighs bleeding
Class III-B (No Benefit, Not Indicated):
 Initiating in non-coronary stent patient
Class I-C Indication:
 Continue for coronary stent or PTCA per stent guidelines
 ANESTHETIC
MANAGEMENT
Perioperative Surveillance
 Class I
 Troponin levels measurement recommended if signs or symptoms of MI. (LOE:
A)

 ECG recommended if signs or symptoms ischemia, MI, or arrhythmia. (LOE: B)

 Class IIb
 Postoperative screening with troponin in high risk for perioperative MI, but
without signs or symptoms ischemia or MI, is uncertain (LOE: B)

 The usefulness of postoperative screening with ECGs .(LOE: B)

 Class III: No Benefit

 Routine postoperative troponin levels without signs or symptoms suggestive of
ischemia or MI is not useful (Level of Evidence: B)
 References
 Fliesher et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing Noncardiac Surgery.
http://content/onlinejacc.org/
 McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a
perioperative myocardial infarction following elective vascular surgery in
patients with documented coronary artery disease: results of the CARP
trial. Eur Heart J. 2008;29:394-401
 Fliesher et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery. Circulation. 2007. 116:e418-
500
 http://riskcalculator.facs.org/PatientInfo/PatientInfo
 http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/