ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

Fleisher, Lee A.; Beckman, Joshua A.; Brown, Kenneth A.; Calkins, Hugh; Chaikof, Elliot L.; Fleischmann, Kirsten E.; Freeman, William K.; Froehlich, James B.; Kasper, Edward K.; Kersten, Judy R.; Riegel, Bárbara; Robb, John F.

doi:10.1161/circulationaha.107.185699

Cited by 625 publications

(340 citation statements)

References 641 publications

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“…Our data furthermore support the current American and European guidelines, which acknowledge that AS is a risk factor for adverse outcomes in noncardiac surgery and recommend that noncardiac surgery should be postponed until after aortic valve replacement in case patients are symptomatic. 12,22 …”

Section: Resultsmentioning

confidence: 99%

Noncardiac Surgery in Patients With Aortic Stenosis: A Contemporary Study on Outcomes in a Matched Sample From the Danish Health Care System

Andersson

Jørgensen

Martinsson

et al. 2014

Clinical Cardiology

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BackgroundPast research has identified aortic stenosis (AS) as a major risk factor for adverse outcomes in noncardiac surgery; however, more contemporary studies have questioned the grave prognosis. To further our understanding of this, the risks of a 30‐day major adverse cardiovascular event (MACE) and all‐cause mortality were investigated in a contemporary Danish cohort.HypothesisAS is not an independent risk factor for adverse outcomes in noncardiac surgery.MethodsAll patients with and without diagnosed AS who underwent noncardiac surgery in 2005 to 2011 were identified through nationwide administrative registers. AS patients (n = 2823; mean age, 75.5 years, 53% female) were matched with patients without AS (n = 2823) on propensity score for AS and surgery type.ResultsIn elective surgery, MACE (ie, nonfatal myocardial infarction, ischemic stroke, or cardiovascular death) occurred in 66/1772 (3.7%) of patients with AS and 52/1772 (2.9%) of controls (P = 0.19), whereas mortality occurred in 67/1772 (3.8%) AS patients and 51/1772 (2.9%) controls (P = 0.13). In emergency surgery, 163/1051 (15.5%) AS patients and 120/1051 (11.4%) controls had a MACE (P = 0.006), whereas 225/1051 (21.4%) vs 179/1051 (17.0%) AS patients and controls died, respectively (P = 0.01). Event rates were higher for those with symptoms (defined as use of nitrates, congestive heart failure, or use of loop diuretics), compared with those without symptoms (P < 0.0001).ConclusionsAS is associated with high perioperative rates of MACE and mortality, but perhaps prognosis is, in practice, not much worse for patients with AS than for matched controls. Symptomatic patients and patients undergoing emergency surgery are at considerable risks of a MACE and mortality.

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Section: Resultsmentioning

confidence: 99%

Noncardiac Surgery in Patients With Aortic Stenosis: A Contemporary Study on Outcomes in a Matched Sample From the Danish Health Care System

Andersson

Jørgensen

Martinsson

et al. 2014

Clinical Cardiology

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“…7,8 To reduce perioperative cardiac complications in patients undergoing major vascular surgery, cardiac assessment consisting of electrocardiogram (ECG), echocardiography, cardiology consultation, and, in selected cases, noninvasive stress testing has been advocated by several authors. 9 Noninvasive stress testing is widely used to assess the risk of cardiac complications in the perioperative period, even if its predictive power is controversial. 10 Perioperative beta-blocker or statin medical therapy seems to be associated with a reduced risk of in-hospital death among patients undergoing major noncardiac surgery, 9,11 even if recent large randomized studies did not strongly support these hyphoteses.…”

Section: Introductionmentioning

confidence: 99%

“…9 Noninvasive stress testing is widely used to assess the risk of cardiac complications in the perioperative period, even if its predictive power is controversial. 10 Perioperative beta-blocker or statin medical therapy seems to be associated with a reduced risk of in-hospital death among patients undergoing major noncardiac surgery, 9,11 even if recent large randomized studies did not strongly support these hyphoteses. 12 At the moment, however, there is no strong data to support prophylactic surgical or endovascular myocardial revascularization in reducing perioperative cardiac risk after major vascular surgery.…”

Section: Introductionmentioning

confidence: 99%

“…13 Godet et al 14 demonstrated that preoperative coronary intervention does not seem to significantly reduce the risk of cardiac complications in the perioperative period in patients undergoing aortic surgery. The recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines 9 stated that myocardial intervention is rarely necessary to simply lower the risk of vascular surgery unless such intervention is indicated, regardless of the patients' preoperative status. As a consequence, there is a general agreement that myocardial revascularization before vascular surgery should be reserved for patients with unstable angina or stable angina with significant (left main or 3-vessel) CAD.…”

Section: Introductionmentioning

confidence: 99%

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Preoperative Cardiac Assessment in Patients Undergoing Aortic Surgery: Analysis of Factors Affecting the Cardiac Outcomes

Troisi

Dorigo

Sapio

et al. 2010

Annals of Vascular Surgery

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Background: The purpose of this study was to evaluate the effectiveness of a standardized preoperative cardiac assessment in reducing the rate of perioperative cardiac complications in patients undergoing aortic surgery, paying particular attention to the analysis of the factors affecting perioperative cardiac outcomes. Methods: Between January 2005 and August 2008, a total of 531 elective interventions for abdominal aortic aneurysms were performed at our institution. All patients underwent preoperative evaluation on an outpatient basis, which included a standardized cardiac assessment protocol to evaluate perioperative cardiac risk. A surgical (open or endovascular) intervention was performed in all patients and perioperative (<30 days) results in terms of overall and cardiac mortality and morbidity rates were recorded. Results: Preoperative electrocardiogram, transthoracic echocardiography, and cardiology consultation were performed in all patients. In 348 cases (65.5%), further evaluation of cardiac functional capacity with noninvasive stress testing was recommended. A positive noninvasive stress test was noted in 86 (24.7%) of 348 patients and coronary angiography was performed in 34 (39.5%) of 86 patients. Thirteen of these patients underwent successful coronary revascularization (11 percutaneous transluminal coronary angioplasty, two coronary artery bypass graft) before vascular surgery. Thirty-day overall rate and cardiac mortality rate were 1.1% and 0.6%, respectively, and 30-day overall and cardiac morbidity rates were 11.5% and 6.8%, respectively. Univariate analysis demonstrated that in patients aged >80 years, chronic renal failure, congestive heart failure, valvular heart disease, positive noninvasive stress testing, and open surgical treatment significantly affected 30-day cardiac morbidity; however, only valvular heart disease and positive noninvasive stress testing maintained their significance with multivariate analysis ( p ¼ 0.005; 95% CI, 1.6-14.4; and p ¼ 0.02; 95% CI, 1.2-8

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“…Patients with active cardiac conditions like, unstable angina or severe angina, recent MI (within 30 days), significant arrhythmias (advanced heart blocks, atrial fibrillation with uncontrolled ventricular rate, symptomatic ventricular arrhythmias, and symptomatic bradycardia), and severe valvular disease undergoing planned non-cardiac surgery, need to be evaluated extensively, and at times, this may lead to postponement or cancellation of the planned surgery. 4 Patients with risk factors as indicated by the risk scores but without active cardiac conditions need to be evaluated further to prevent postoperative cardiovascular events. A pooled analysis of several studies found a 30-day incidence of cardiac events (postoperative MI and death) of 2.5% in unselected patients >40 years of age.…”

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confidence: 99%

Revised cardiac risk index—a simple universal tool for peri-operative risk prediction

Deshpande¹

2012

Indian Heart Journal

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Patients subjected to non-cardiac surgery are at a significant risk to develop cardiac complications. With aging populations and improved surgical and anaesthesia techniques, even elderly populations are frequently considered for non-cardiac surgery today. It is estimated that about 40 million non-cardiac surgeries are performed in Europe annually and the perioperative myocardial infarction (MI) occurs at a rate of 1% causing 400,000 myocardial infarcts. Further, the cardiovascular mortality rate of 0.3% gives mortality of 133,000 annually related to non-cardiac surgery. 1 It is also a well-known fact that the peri-operative complications are more frequent following vascular surgery. 2 Number of risk assessment algorithms have been developed and tested, however the revised cardiac risk index (RCRI) 3 described by Lee et al. in 1999, remains the most used risk assessment model. These indices are predominantly based on history and simple clinical tools. Patients with active cardiac conditions like, unstable angina or severe angina, recent MI (within 30 days), significant arrhythmias (advanced heart blocks, atrial fibrillation with uncontrolled ventricular rate, symptomatic ventricular arrhythmias, and symptomatic bradycardia), and severe valvular disease undergoing planned non-cardiac surgery, need to be evaluated extensively, and at times, this may lead to postponement or cancellation of the planned surgery. 4 Patients with risk factors as indicated by the risk scores but without active cardiac conditions need to be evaluated further to prevent postoperative cardiovascular events. A pooled analysis of several studies found a 30-day incidence of cardiac events (postoperative MI and death) of 2.5% in unselected patients >40 years of age. 2 Incidence of postoperative cardiac events varies widely depending upon the tools used to detect myocardial damage as the events may occur silently. Use of sensitive markers like troponins, can detect largely asymptomatic cardiac events. 1 Such patients have higher 6-months event rates as compared to those who do not show elevation of troponins following non-cardiac surgery. Risk assessment prior to planned noncardiac surgery can help in predicting the postoperative events. It also helps the physician and anaesthesiologist to take necessary precautions to minimise the postoperative events.In this issue of the journal Jayakeerthi et al. 5 have reported their experience of pre-operative risk evaluation on 920 patients referred for cardiac assessment. They used RCRI proposed by Lee et al. in 1999 3 for prediction of cardiac events following surgery in 853 patients. The RCRI was described for planned non-cardiac surgery patients, whereas, the cohort described in the current report includes emergent surgical procedures in addition to elective surgeries, which the authors believe reflects the real world. The number of emergency surgeries was relatively small (40/853). Electrocardiogram (ECG) monitoring was done for all patients (pre-operative, immediate postoperative and 1st postoperat...

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ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

Cited by 625 publications

References 641 publications

Noncardiac Surgery in Patients With Aortic Stenosis: A Contemporary Study on Outcomes in a Matched Sample From the Danish Health Care System

Noncardiac Surgery in Patients With Aortic Stenosis: A Contemporary Study on Outcomes in a Matched Sample From the Danish Health Care System

Preoperative Cardiac Assessment in Patients Undergoing Aortic Surgery: Analysis of Factors Affecting the Cardiac Outcomes

Revised cardiac risk index—a simple universal tool for peri-operative risk prediction

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