Perioperative Cardiovascular Evaluation for Noncardiac Surgery

Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Heart Failure, Death)

Major

  • Unstable coronary syndromes
    • Acute or recent MI* with evidence of important ischemic risk by clinical symptoms or noninvasive study
    • Unstable or severe† angina (Canadian class III or IV)
  • Decompensated heart failure
  • Significant arrhythmias
    • High-grade atrioventricular block
    • Symptomatic ventricular arrhythmias in the presence of underlying heart disease
    • Supraventricular arrhythmias with uncontrolled ventricular rate
  • Severe valvular disease

Intermediate

  • Mild angina pectoris (Canadian class I or II)
  • Previous MI by history or pathologic Q waves
  • Compensated or prior heart failure
  • Diabetes mellitus (particularly insulin-dependent)
  • Renal insufficiency

Minor

  • Advanced age
  • Abnormal ECG (left ventricular hypertrophy, left bundle-branch block, ST-T abnormalities)
  • Rhythm other than sinus (e.g., atrial fibrillation)
  • Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries)
  • History of stroke
  • Uncontrolled systemic hypertension

ECG indicates electrocardiogram; MI, myocardial infarction.
*The American College of Cardiology National Database Library defines recent MI as greater than 7 days but less than or equal to 1 month (30 days); acute MI is within 7 days.
†May include “stable” angina in patients who are unusually sedentary.

Cardiac Risk* Stratification for Noncardiac Surgical Procedures

High (Reported cardiac risk often greater than 5%)

  • Emergent major operations, particularly in the elderly
  • Aortic and other major vascular surgery
  • Peripheral vascular surgery
  • Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

Intermediate (Reported cardiac risk generally less than 5%)

  • Carotid endarterectomy
  • Head and neck surgery
  • Intraperitoneal and intrathoracic surgery
  • Orthopedic surgery
  • Prostate surgery

Low† (Reported cardiac risk generally less than 1%)

  • Endoscopic procedures
  • Superficial procedure
  • Cataract surgery
  • Breast surgery

*Combined incidence of cardiac death and nonfatal myocardial infarction.
†Do not generally require further preoperative cardiac testing.

 

 

References:

  1. 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 K, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery; 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. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): 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, and Society for Vascular Medicine and Biology. Circulation. 2006 Jun 6;113(22):2662-74. [Medline]
  2. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC Jr; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002 Mar 12;105(10):1257-67. [Medline]

Created: Jul 21, 2009