The definitions for levels of evidence (A-D) and classes of recommendation (I-III) are provided at the end of the "Major Recommendations" field.
Non-invasive Testing
Moderate-risk patients who will be submitted to vascular surgeries should always have a non-invasive test to detect myocardial ischemia (Class I, Level of evidence D).
Recommendations for Requesting Non-invasive Tests
Class I
- Indicated for patients with intermediate clinical predictors and who will be submitted to vascular surgeries
Class IIa
- Indicated when at least two of the three items below are present
- Presence of angina functional classes I or II, history of myocardial infarction or pathological Q wave, previous or compensated heart failure, diabetes mellitus or renal failure
- Low functional capacity: less than 4 maximum exercise tolerance units (METs)
- High-risk surgeries: peripheral vascular surgeries or aortic surgery, lengthy surgeries with considerable blood loss or shifts in body fluids
Class IIb
- Indicated for patients who have not undergone functional testing in the previous two years and who have
- Coronary artery disease or
- At least two risk factors for coronary artery disease (CAD) (hypertension, smoking, dyslipidemia, diabetes mellitus, positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test.
Recommendations for Analyzing Resting Left Ventricular (LV) Function
Class I
- Clinical suspicion of aortic stenosis; Level of Evidence B
Class IIa
- Patients with congestive heart failure (CHF) without previous assessment of ventricular function; Level of Evidence D
- Grade III obesity; Level of Evidence D
- Preoperative assessment of liver transplant; Level of Evidence D
Class IIb
- Detection of valvular heart disease; Level of Evidence B
Class III
- Routinely for all patients; Level of Evidence D
Recommendations for Requesting a Perioperative Exercise Electrocardiogram
Class IIa
- Indicated when the two factors below are present
- Presence of intermediate clinical predictors of risk: angina functional class I or II, history of myocardial infarction or pathological Q wave, previous or compensated heart failure, diabetes mellitus or renal failure
- High-risk surgery: aortic or peripheral vascular surgeries, lengthy surgeries with considerable blood loss or shifts in body fluids
Class IIb
- Indicated for patients without a functional assessment in the previous two years and
- Known to have coronary artery disease
- With at least two risk factors for CAD (hypertension, smoking, dyslipidemia, diabetes mellitus, positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test
- Routinely for all patients
Dobutamine Stress Echocardiography
Evidences indicate that low-risk patients will not benefit from non-invasive tests unless their functional capacity is low (<4METs) and they are candidates for high-risk surgeries (Level of Evidence B). On the other hand, patients with 3 or more minor clinical predictors should be considered intermediate-risk patients. (Level of Evidence D) All patients with intermediate risk for cardiac events and low functional capacity (<4METs) and those with good or excellent functional capacity (>4METs) who will be submitted to high-risk surgeries (Level of Evidence B) must undergo stress echocardiography. Consider doing a coronary cineangiography in patients with major clinical predictors for cardiovascular events. (Level of Evidence B).
Recommendations for Stress Echocardiography/Stress Myocardial Perfusion Scintigraphy
Class I
- Indicated for intermediate-risk patients who will be submitted to vascular surgeries
Class IIa
- Indicated when at least two of the following factors are present
- Presence of intermediate clinical predictors of risk: angina functional class I or II, history of myocardial infarction or pathological Q wave, previous or compensated heart failure, diabetes mellitus or renal failure
- Low functional capacity: below 4 METs
- High-risk surgeries: peripheral vascular or aortic surgeries, lengthy surgeries with considerable blood loss or shifts of body fluids
Class IIb
- Indicated for patients who have not been submitted to functional assessment in the previous two years and
- Known to have coronary artery disease
- With at least two risk factors for CAD (hypertension, smoking, dyslipidemia, diabetes mellitus, positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test
- Routinely for all patients
Recommendations for Coronary Cineangiography
Class I
- High-risk non-invasive test
- Presence of major clinical predictors
- High-risk acute coronary syndrome
- Positive non-invasive test with proven ischemia and LV dysfunction
Class IIa
- Low- or moderate-risk non-invasive test with preserved ventricular function
Class III
- Patients who are not candidates for myocardial revascularization
Definitions:
Levels of Evidence
- Sufficient evidence from multiple randomized trials or meta-analyses
- Limited evidence from single randomized trial or non-randomized studies
- Evidence only from case reports and series
- Expert opinion or standard of care
Class of Recommendation
Class I: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy
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 for and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmful
