This is the current release of the guideline.

This guideline updates a previous version: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW, American College of Cardiology, American Heart Association Task Force on Practice Guidelines (writing Committee, 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 Biology, Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007 Oct 23;50(17):e159-241. [584 references]

Cardiovascular diseases, including:

• Coronary artery disease
• Myocardial infarction
• Angina pectoris
• Heart failure
• Arrhythmias (high-grade, Mobitz II, or third-degree atrioventricular block; symptomatic ventricular arrhythmia; supraventricular arrhythmias [including atrial fibrillation], symptomatic bradycardia, newly recognized tachycardia, orthostatic intolerance)
• Conduction defects
• Hypertension
• Cardiomyopathy
• Valvular heart disease (severe aortic stenosis, symptomatic mitral stenosis)
• Pulmonary vascular disease
• Controlled arrhythmias (presence of implanted pacemakers and implantable cardioverter defibrillators)

Patients undergoing noncardiac surgery

Risk Assessment

1. Clinical history
2. Physical examination
3. Assessment of comorbid disease (pulmonary disease, diabetes mellitus, renal impairment, hematologic disorders)
4. Ancillary studies, as needed (e.g., laboratory evaluation, chest x-ray, standard electrocardiogram [ECG])
5. Stepwise approach to perioperative cardiac assessment (clinical risk factors, prior coronary history and treatment, functional capacity, and surgery-specific risk)
6. Supplemental preoperative evaluation:
   • Resting left ventricular function
   • 12-lead ECG
   • Exercise or pharmacological stress testing
   • Myocardial perfusion imaging
   • Dobutamine stress echocardiography
   • Ambulatory ECG monitoring
   • Coronary angiography

Management

1. Perioperative therapy
   • Surgical coronary revascularization: preoperative coronary artery bypass grafting (CABG); percutaneous coronary intervention with or without stents (either bare metal or drug-eluting, with or without post-stent pharmacologic therapy [aspirin, clopidogrel]); percutaneous transluminal coronary angioplasty (PTCA)
   • Pharmacologic management: beta-blocker, alpha-2 agonist, and statin therapy; calcium channel blockers (no recommendation)
2. Management of specific cardiovascular conditions
3. Anesthetic considerations and intraoperative management
   • Anesthetic technique and agent
   • Perioperative pain management
   • Intraoperative nitroglycerin
   • Transesophageal echocardiography
   • Maintenance of body temperature
   • Intra-aortic balloon counterpulsation devices (no recommendation)
   • Control of blood glucose concentration
4. Perioperative surveillance
   • Pulmonary artery catheters
   • ST-segment monitoring
   • Surveillance for perioperative myocardial infarction (MI)
   • Management of postoperative arrhythmias and conduction disorders
5. Postoperative and long-term management
   • Surveillance and treatment of MI
   • Cardiovascular medical therapy

The 2007 guidelines writing committee conducted a comprehensive review of the literature relevant to perioperative cardiac evaluation published since the last publication of these guidelines in 2002. Literature searches were conducted in the following databases: PubMed, MEDLINE, and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register). Searches were limited to the English language, the years 2002 through 2007, and human subjects. Related-article searches were conducted in MEDLINE to find additional relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches.

Major search topics included perioperative risk, cardiac risk, noncardiac surgery, intraoperative risk, postoperative risk, risk stratification, cardiac complication, cardiac evaluation, perioperative care, preoperative evaluation, preoperative assessment, and intraoperative complications. Additional searches cross-referenced these topics with the following subtopics: troponin, myocardial infarction (MI), myocardial ischemia, Duke activity status index, functional capacity, dobutamine, adenosine, venous thrombosis, thromboembolism, warfarin, percutaneous transluminal coronary angioplasty (PTCA), stent, adrenergic beta agonists, echocardiography, anticoagulant, beta blocker, coronary artery bypass surgery, valve, diabetes mellitus, wound infection, blood sugar control, normothermia, body temperature changes, body temperature regulation, hypertension, pulmonary hypertension, anemia, aspirin, arrhythmia, implantable defibrillator, artificial pacemaker, pulmonary artery catheters, Swan-Ganz catheter, and platelet aggregation inhibitors.

As a result of these searches, more than 400 relevant, new articles were identified and reviewed by the committee for the revision of these guidelines. Using evidence-based methodologies developed by the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines, the committee revised the guidelines text and recommendations.

For the 2009 focused update, late-breaking clinical trials presented at the 2008 annual scientific meetings of the American College of Cardiology (ACC), AHA, and European Society of Cardiology, as well as selected other data through June 2009, were reviewed by the standing guideline writing committee along with the parent task force and other experts to identify those trials and other key data that may impact guideline recommendations. Literature searches were conducted using PubMed. Recent trial data and other clinical information were considered important enough to prompt a focused update of the "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery". This update addresses predominantly the prophylactic use of beta blockers perioperatively to minimize cardiac risk, but it does not cover other legitimate uses of beta blockers (e.g., as an adjunct in anesthetic regimens, for intraoperative control of heart rate or blood pressure, or to achieve heart rate control in common perioperative arrhythmias such as atrial fibrillation).

Not stated

Applying Classification of Recommendations and Level of Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 1 in the original guideline document for a list of suggested phrases for writing recommendations.)

When considering the new data for this focused update, the writing group faced the task of weighing evidence from studies enrolling large numbers of subjects outside North America. While noting that practice patterns and the rigor applied to data collection, as well as the genetic make-up of subjects, may influence the observed magnitude of a treatment's effect, the writing group believed the data were relevant to formulation of recommendations for perioperative management in North America. The reasons for this decision include the following: 1) The use of detailed protocol-driven management strategies likely reduced treatment variability among sites; and 2) it may be impractical to expect that the thousands of patients undergoing noncardiac surgery who are needed to meet the estimated sample size for contemporary clinical trials would be enrolled exclusively at North American sites.

To provide clinicians with a comprehensive set of data, whenever possible, the exact event rates in various treatment arms of clinical trials are presented to permit calculation of the absolute risk difference and number needed to treat (NNT) or harm. The relative treatment effects are described either as odds ratio (OR), relative risk (RR), or hazard ratio (HR), depending on the format in the original publication.

Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against particular treatments or procedures, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of tests or therapies are considered as well as the frequency of follow-up and cost-effectiveness. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.

See the "Rating Scheme for the Strength of the Evidence" field, above.

Financial Implications

The financial implications of risk stratification cannot be ignored. The need for better methods of objectively measuring cardiovascular risk has led to the development of multiple noninvasive techniques in addition to established invasive procedures. Although a variety of strategies to assess and lower cardiac risk have been developed, their aggregate cost has received relatively little attention. Given the striking practice variation and high costs associated with many evaluation strategies, the development of practice guidelines based on currently available knowledge can serve to foster more efficient approaches to perioperative evaluation.

Implications of Guidelines and Other Risk Assessment Strategies for Costs and Outcomes

The decision to recommend further testing or treatment for the individual patient being considered for noncardiac surgery ultimately becomes a balancing act between the estimated probabilities of effectiveness versus risk. The proposed benefit, of course, is the possibility of identifying and/or treating advanced but relatively unsuspected coronary artery disease (CAD) that might result in significant cardiac morbidity or mortality either perioperatively or in the long term. In the process of further screening and treatment, the risks from the tests and treatments themselves may offset or even exceed the potential benefit of evaluation. Furthermore, the cost of screening and treatment strategies must be considered. Although physicians should be concerned with improving the clinical outcome of their patients, cost is an appropriate consideration when different evaluation and treatment strategies are available that cannot be distinguished from one another in terms of clinical outcome.

One study compared test utilization and outcome for aortic surgery patients before and after implementation of the American College of Cardiology (ACC)/American Heart Association (AHA) preoperative assessment guidelines at the authors' center using a comprehensive educational program. They demonstrated dramatic reductions in stress testing after implementation of the guidelines, mostly with nuclear imaging (88% to 47%), cardiac catheterization (24% to 11%), coronary revascularization (24% to 2%), and overall preoperative costs ($1087 to $171). At the same time, perioperative outcome was actually improved as the death/myocardial infarction (MI) rate fell from 11% to 4%. Of note, implementation of the guidelines had the greatest impact in the preoperative evaluation of clinically low-risk patients. This study supports the ACC/AHA guideline approach of clinical assessment of risk followed by selective testing with stress nuclear myocardial perfusion imaging in higher-risk subgroups of patients, and they confirm that cardiac patients at low clinical risk can typically undergo elective surgery with a low event rate without further testing. The approach of selective testing, based on an understanding of test performance, a clinical patient assessment, and the potential impact of test results on clinical decision making, is supported as leading to appropriateness of testing, as outlined in the ACC Foundation/American Society of Nuclear Cardiology proposed method for evaluating the appropriateness of cardiovascular imaging.

Formal decision and cost-effectiveness analyses of the value of preoperative cardiac evaluation models were created before the publication of the CARP (Coronary Artery Revascularization Prophylaxis) trial and the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-II trial and assumed that coronary revascularization had benefits in clinical populations that differed from center to center; therefore, it is difficult to determine the exact risks of aggressive screening and treatments versus the benefits in terms of risk reduction. Additionally, the models all demonstrate that optimal strategy depends on the mortality rates for both cardiac procedures and noncardiac surgeries in the clinically relevant range. One model, which did not support a strategy incorporating coronary angiography and revascularization, used lower mortality rates than those used or reported in the other studies. Therefore, use of any decision and cost-effectiveness model in a specific situation depends on the comparability of local mortality rates to those of the model.

One report suggested that the cost of a selected coronary screening approach, as described in the present guidelines, was as low as $214 per patient. Resource utilization and costs of preoperative evaluation also decreased in patients undergoing elective abdominal aortic surgery in the period of implementation for the initial version of these guidelines compared with historical controls, whereas outcomes were similar. Several publications have shown a cost per year of life saved for this selected screening strategy of less than $45,000 when applied to patients undergoing vascular surgery. However, none of these studies included a strategy of selected screening followed by aggressive beta-blocker treatment in high-risk individuals, as recently described by Poldermans and colleagues.

Available data suggest that implementation of various strategies of beta blockade in patients undergoing major vascular surgery is cost-effective and even cost-saving from the perspective of a short-term provider. One study used decision analytic techniques to compare 5 different strategies for implementing beta blockade in patients undergoing abdominal aortic aneurysm surgery. These ranged from 1) no routine beta blockade to 2) oral bisoprolol 7 days preoperatively followed by perioperative intravenous metoprolol and oral bisoprolol, 3) immediate preoperative atenolol with postoperative intravenous then oral atenolol, 4) intraoperative esmolol with conversion to intravenous and then oral atenolol in the immediate postoperative period, and 5) intra operative and postoperative (at 18 hours) esmolol followed by atenolol. Using Medicare costs as a proxy, the authors found that the institution of an oral beta blocker a minimum of 7 days before surgery was associated with a cost savings of approximately $500 from the hospital's perspective; that is, beta blockade was associated with both better outcomes and lower cost. All other strategies tested were cost saving, but to a lesser degree. Of note, this decision analysis did not include the performance of any screening tests or the costs of such testing. Another study estimated the impact of a clinical practice guideline for perioperative beta blockers at a medical center in western Massachusetts in high-risk patients with 2 or more cardiac risk factors or known CAD. Using effectiveness data for beta-blocker treatment from another study, the authors estimated that full use of beta blockers in eligible patients could result in 62 to 89 fewer deaths annually at a cost of approximately $33,000 to $40,000. Prophylactic beta blockade also represents an excellent strategy in patients for whom coronary revascularization for long-term benefit is not a serious consideration.

Cardiac Risk of Noncardiac Surgery: Areas in Need of Further Research

The benefit of cardiac testing and preoperative cardiac evaluation, especially in those patients with established CAD, has been established (see Sections 5.2.3. and 5.3. in the original guideline document); what is unknown is the cost-effectiveness and value of the various methods of cardiac testing for reducing cardiac complications. Further studies in this area are welcomed. The implementation of various strategies of beta blockade in patients undergoing major vascular surgery is cost-effective and even cost-saving from a short-term provider perspective, yet the efficacy and cost-effectiveness of various medical therapies for specific subsets of patients (e.g., the role of beta blockers in those patients without a positive stress test) are unknown.

The 2007 guidelines were approved for publication by the governing bodies of the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) and have been officially endorsed by the American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Heart Rhythm Society (HRS), Society of Cardiovascular Anesthesiologists (SCA), Society for Cardiac Angiography and Interventions (SCAI), Society for Vascular Medicine (SVM), and Society for Vascular Surgery (SVS). The 2009 focused update was reviewed by 2 official reviewers nominated by the ACCF and 2 official reviewers nominated by the AHA, as well as 2 reviewers each from the ASE, ASNC, HRS, SCA, SCAI, SVM, and the SVS, and 8 individual content reviewers from the ACCF Cardiac Catheterization Committee and the ACCF Interventional Council. All information on reviewer relationships with industry was collected and distributed to the writing group and is published in this document (see Appendix V of the original guideline document).

The 2009 focused update was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the ASE, ASNC, HRS, SCA, SCAI, SVM, and the SVS.

This document was approved by the American College of Cardiology Foundation Board of Trustees in July 2009 and by the American Heart Association Science Advisory and Coordinating Committee in July 2009.

A list of all peer reviewers (official, organizational, and content) is provided in Appendix 5 of the original guideline document.

The American College of Cardiology/American Heart Association (ACC/AHA) Classification of the recommendations for patient evaluation and treatment (Classes I-III) and the levels of evidence (A-C) are defined at the end of the "Major Recommendations" field.

General Approach to the Patient

*According to Campeau (Campeau L. Letter: grading of angina pectoris. Circulation 1976;54:522-3).

**May include "stable" angina in patients who are unusually sedentary.

***The American College of Cardiology National Database Library defines recent MI as more than 7 days but less than or equal to 1 month (within 30 days).

Clinical Assessment

Stepwise Approach to Perioperative Cardiac Assessment

Class I

1. Patients who have a need for emergency noncardiac surgery should proceed to the operating room and continue perioperative surveillance and postoperative risk stratification and risk factor management. (Level of Evidence: C)
2. Patients with active cardiac conditions* should be evaluated and treated per ACC/AHA guidelines and, if appropriate, consider proceeding to the operating room. (Level of Evidence: B)
3. Patients undergoing low-risk surgery are recommended to proceed to planned surgery.† (Level of Evidence: B)
4. Patients with poor (less than 4 metabolic equivalents [METs]) or unknown functional capacity and no clinical risk factors‡ should proceed with planned surgery.† (Level of Evidence: B)

*See Table 2 in the original guideline document for active cardiac conditions.

†See Class III recommendations in the section on Noninvasive Stress Testing.

‡Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease.

Class IIa

1. It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms§ proceed to planned surgery.** (Level of Evidence: B)
2. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors‡ who are scheduled for vascular surgery consider testing if it will change management.*** (Level of Evidence: B)
3. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors‡ who are scheduled for intermediate-risk surgery proceed with planned surgery with heart rate control.*** (Level of Evidence: B)
4. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors‡ who are scheduled for vascular or intermediate-risk surgery proceed with planned surgery with heart rate control.*** (Level of Evidence: B)

‡Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease.

§See Table 3 in the original guideline document for estimated MET level equivalent.

**Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management.

***Consider perioperative beta blockade (see Table 11 in the original guideline document) for populations in which this has been shown to reduce cardiac morbidity/mortality.

Class IIb

1. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors‡ who are scheduled for intermediate-risk surgery. (Level of Evidence: B)
2. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors‡ who are scheduled for vascular or intermediate-risk surgery. (Level of Evidence: B)

‡Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease.

Supplemental Preoperative Evaluation

Preoperative Noninvasive Evaluation of Left Ventricular (LV) Function

Class IIa

1. It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. (Level of Evidence: C)
2. It is reasonable for patients with current or prior heart failure with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months. (Level of Evidence: C)

Class IIb

1. Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (Level of Evidence: C)

Class III

1. Routine perioperative evaluation of LV function in patients is not recommended. (Level of Evidence: B)

Assessment of Risk for Coronary Artery Disease (CAD) and Assessment of Functional Capacity

The 12-Lead Electrocardiogram (ECG)

Class I

1. Preoperative resting 12-lead ECG is recommended for patients with at least 1 clinical risk factor* who are undergoing vascular surgical procedures. (Level of Evidence: B)
2. Preoperative resting 12-lead ECG is recommended for patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (Level of Evidence: C)

*Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.

Class IIa

1. Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (Level of Evidence: B)

Class IIb

1. Preoperative resting 12-lead ECG may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (Level of Evidence: B)

Class III

1. Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (Level of Evidence: B)

Noninvasive Stress Testing Before Noncardiac Surgery

Class I

1. Patients with active cardiac conditions (see the Table above) in whom noncardiac surgery is planned should be evaluated and treated per American College of Cardiology/American Heart Association (ACC/AHA) guidelines (see the original guideline document for the list of guidelines) before noncardiac surgery. (Level of Evidence: B)

Class IIa

1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery* is reasonable if it will change management. (Level of Evidence: B)

Class IIb

1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B)

Class III

1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery. (Level of Evidence: C)
2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence: C)

*Vascular surgery is defined by emergency aortic and other major vascular surgery and peripheral vascular surgery. See Table 4 in the original guideline document.

Perioperative Therapy

Preoperative Coronary Revascularization with Coronary Artery Bypass Graft (CABG) or Percutaneous Coronary Intervention

Class I

1. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have significant left main coronary artery stenosis. (Level of Evidence: A)
2. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 3-vessel disease. (Survival benefit is greater when left ventricular ejection fraction [LVEF] is less than 0.50.) (Level of Evidence: A)
3. Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 2-vessel disease with significant proximal left anterior descending coronary artery (LAD) stenosis and either ejection fraction (EF) less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of Evidence: A)
4. Coronary revascularization before noncardiac surgery is recommended for patients with high-risk unstable angina or non-ST-segment elevation MI.** (Level of Evidence: A)
5. Coronary revascularization before noncardiac surgery is recommended in patients with acute ST-elevation MI. (Level of Evidence: A)

Class IIa

1. In patients in whom coronary revascularization with percutaneous coronary intervention (PCI) is appropriate for mitigation of cardiac symptoms and who need elective noncardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is probably indicated. (Level of Evidence: B)
2. In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Level of Evidence: C)

Class IIb

1. The usefulness of preoperative coronary revascularization is not well established in high-risk ischemic patients (e.g., abnormal dobutamine stress echocardiograph with at least 5 segments of wall-motion abnormalities). (Level of Evidence: C)
2. The usefulness of preoperative coronary revascularization is not well established for low-risk ischemic patients with an abnormal dobutamine stress echocardiograph (segments 1 to 4). (Level of Evidence: B)

Class III

1. It is not recommended that routine prophylactic coronary revascularization be performed in patients with stable CAD before noncardiac surgery. (Level of Evidence: B)
2. Elective noncardiac surgery is not recommended within 4 to 6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued perioperatively. (Level of Evidence: B)
3. Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. (Level of Evidence: B)

**High-risk unstable angina/non–ST-segment elevation MI patients were identified as those with age greater than 75 years, accelerating tempo of ischemic symptoms in the preceding 48 hours, ongoing rest pain greater than 20 minutes in duration, pulmonary edema, angina with S₃ gallop or rales, new or worsening mitral regurgitation murmur, hypotension, bradycardia, tachycardia, dynamic ST-segment change greater than or equal to 1 mm, new or presumed new bundle-branch block on ECG, or elevated cardiac biomarkers, such as troponin.

Perioperative Medical Therapy

Beta-Blocker Therapy

Class I

1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs. (Level of Evidence: C)

Class IIa

1. Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing (Poldermans et al., 1999; Boersma et al., 2001). (Level of Evidence: B)
2. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.‡‡ (Level of Evidence: C)
3. Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,‡‡ who are undergoing intermediate-risk surgery (Dunkelgrun et al., 2009). (Level of Evidence: B)

Class IIb

1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease.‡‡ (Level of Evidence: C)
2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors‡‡ who are not currently taking beta blockers (Lindenauer et al., 2005). (Level of Evidence: B)

‡‡Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency (defined in the Revised Cardiac Risk Index as a preoperative serum creatinine of greater than 2 mg/dL) (Lee et al., 1999).

Class III

1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)
2. Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery (POISE Study Group et al., 2008). (Level of Evidence: B)

Statin Therapy

Class I

1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B)

Class IIa

1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B)

Class IIb

1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (Level of Evidence: C)

Alpha-2 Agonists

Class IIb

1. Alpha-2 agonists for perioperative control of hypertension may be considered for patients with known CAD or at least 1 clinical risk factor who are undergoing surgery. (Level of Evidence: B)

Class III

1. Alpha-2 agonists should not be given to patients undergoing surgery who have contraindications to this medication. (Level of Evidence: C)

Preoperative Intensive Care

Class IIb

1. Preoperative intensive care monitoring with a pulmonary artery catheter for optimization of hemodynamic status might be considered; however, it is rarely required and should be restricted to a very small number of highly selected patients whose presentation is unstable and who have multiple comorbid conditions. (Level of Evidence: B)

Anesthetic Considerations and Intraoperative Management

Choice of Anesthetic Technique and Agent

Volatile Anesthetic Agent

Class IIa

1. It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. (Level of Evidence: B)

Prophylactic Intraoperative Nitroglycerin

Class IIb

1. The usefulness of intraoperative nitroglycerin as a prophylactic agent to prevent myocardial ischemia and cardiac morbidity is unclear for high-risk patients undergoing noncardiac surgery, particularly those who have required nitrate therapy to control angina. The recommendation for prophylactic use of nitroglycerin must take into account the anesthetic plan and patient hemodynamics and must recognize that vasodilation and hypovolemia can readily occur during anesthesia and surgery. (Level of Evidence: C)

Use of Transesophageal Echocardiography (TEE)

Class IIa

1. The emergency use of intraoperative or perioperative TEE is reasonable to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality. (Level of Evidence: C)

Maintenance of Body Temperature

Class I

1. Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (e.g., during high aortic cross-clamping). (Level of Evidence: B)

Perioperative Control of Blood Glucose Concentration

Class IIa

1. It is reasonable that blood glucose concentration be controlled* during the perioperative period in patients with diabetes mellitus or acute hyperglycemia who are at high risk for myocardial ischemia or who are undergoing vascular and major noncardiac surgical procedures with planned intensive care unit admission. (Level of Evidence: B)

*Blood glucose levels less than 150 milligrams/deciliter (mg/dL) appear to be beneficial.

Class IIb

1. The usefulness of strict control of blood glucose concentration* during the perioperative period is uncertain in patients with diabetes mellitus or acute hyperglycemia who are undergoing noncardiac surgical procedures without planned intensive care unit admission. (Level of Evidence: C)

*Blood glucose levels less than 150 milligrams/deciliter (mg/dL) appear to be beneficial.

Perioperative Surveillance

Intraoperative and Postoperative Use of Pulmonary Artery Catheters (PACs)

Class IIb

1. Use of a PAC may be reasonable in patients at risk for major hemodynamic disturbances that are easily detected by a PAC; however, the decision must be based on 3 parameters: patient disease, surgical procedure (i.e., intraoperative and postoperative fluid shifts), and practice setting (experience in PAC use and interpretation of results), because incorrect interpretation of the data from a PAC may cause harm. (Level of Evidence: B)

Class III

1. Routine use of a PAC perioperatively, especially in patients at low risk of developing hemodynamic disturbances, is not recommended. (Level of Evidence: A)

Intraoperative and Postoperative Use of ST-Segment Monitoring

Class IIa

1. Intraoperative and postoperative ST-segment monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, with computerized ST-segment analysis, when available, used to detect myocardial ischemia during the perioperative period. (Level of Evidence: B)

Class IIb

1. Intraoperative and postoperative ST-segment monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery. (Level of Evidence: B)

Surveillance for Perioperative Myocardial Infarction (MI)

Class I

1. Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome. (Level of Evidence: C)

Class IIb

1. The use of postoperative troponin measurement is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery. (Level of Evidence: C)

Class III

1. Postoperative troponin measurement is not recommended in asymptomatic stable patients who have undergone low-risk surgery. (Level of Evidence: C)

Definitions:

Applying Classification of Recommendations and Level of Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 1 in the original guideline document for a list of suggested phrases for writing recommendations.)

The original guideline document contains clinical algorithms for:

• Cardiac evaluation and care for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk for patients 50 years of age or greater
• Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) requiring noncardiac surgery (based upon expert opinion)
• Proposed treatment for patients requiring PCI who need subsequent surgery

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

The American College of Cardiology Foundation and the American Heart Association.

American College of Cardiology/American Heart Association Task Force on Practice Guidelines

2009 Focused Update Writing Group

Task Force Members: Alice K. Jacobs, MD, FACC, FAHA, (Chair 2009–2011); Sidney C. Smith, Jr, MD, FACC, FAHA, (Immediate Past Chair 2006–2008*); Jeffrey L. Anderson, MD, FACC, FAHA, (Vice Chair); Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA; Harlan M. Krumholz, MD, FACC, FAHA*; Frederick G. Kushner, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA*; Rick Nishimura, MD, FACC, FAHA*; Richard L. Page, MD, FACC, FAHA*; William G. Stevenson, MD, FACC, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC, FAHA

2009 Writing Group 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

2007 Writing Committee Members: Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC

*Former Task Force member during this writing effort

The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all such relationships that might be perceived as relevant to the writing effort. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. These statements are reviewed by the parent task force, reviewed by all members in conjunction with each conference call and/or meeting of the writing committee, updated as changes occur and ultimately published as an appendix to the document.

Table: Author Relationship with Industry and Other Entities - 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade

Note: This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity or ownership of $10,000 or more of the fair market value of the business entity, or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted. *Indicates significant relationship.

See Appendix 5 in the original guideline document for 2009 peer reviewer relationships with industry.

This is the current release of the guideline.

This guideline updates a previous version: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW, American College of Cardiology, American Heart Association Task Force on Practice Guidelines (writing Committee, 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 Biology, Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007 Oct 23;50(17):e159-241. [584 references]

Electronic copies: Available in Portable Document Format (PDF) from the American College of Cardiology (ACC) Web site  and from the American Heart Association (AHA) Web site .

Print copies: Available from the American College of Cardiology, 2400 N Street NW, Washington DC, 20037; (800) 253-4636 (US only).

The following is available:

• 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. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Slide set. 2009. 43 p. Electronic copies: Available from the American College of Cardiology (ACC) Web site .

Print copies: Available from the American College of Cardiology, 2400 N Street NW, Washington DC, 20037; (800) 253-4636 (US only).

None available

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on April 30, 2002. The updated information was verified by the guideline developer on August 7, 2002. This NGC summary was updated on May 12, 2006. The updated information was verified by the guideline developer on June 15, 2006. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on July 12, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Troponin-1 Immunoassay. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This NGC summary was updated by ECRI Institute on November 20, 2007. The updated information was verified by the guideline developer on January 7, 2008. This summary was updated by ECRI Institute on January 4, 2010 following the U.S. Food and Drug Administration advisory on Plavix (Clopidogrel). This summary was updated by ECRI Institute on May 17, 2010 following the U.S. Food and Drug Administration advisory on Plavix (clopidogrel). This summary was updated by ECRI Institute on November 18, 2010. The updated information was verified by the guideline developer on February 10, 2011. This summary was updated by ECRI Institute on June 27, 2011 following the U.S. Food and Drug Administration advisory on Zocor (simvastatin). This summary was updated by ECRI Institute on April 13, 2012 following the U.S. Food and Drug Administration advisories on Statin Drugs and Statins and HIV or Hepatitis C drugs.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA). NGC users are free to download a single copy for personal use. Reproduction without permission of the ACC/AHA guidelines is prohibited. Permissions requests should be directed to copyright_permissions@acc.org.