Top Things to Know: 2014 Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
Published: August 01, 2014
- The focus of the guideline is to inform the clinician about perioperative cardiovascular evaluation of adult patients undergoing noncardiac surgery.
- This guideline includes perioperative risk assessment and related cardiovascular testing, as well as perioperative pharmacological management and perioperative monitoring, including devices and biochemical markers.
- Definitions of urgency and risk help define how this guideline may be applied.
- An extensive review of clinical risk factors, including coronary artery disease, heart failure, cardiomyopathy, and valvular heart disease, is addressed in this guideline.
- Key findings from the systematic review of the use of beta blockers in the perioperative setting include:
- Preoperative use of beta blockers was associated with a reduction in cardiac events in the studies examined; however, few data support the effectiveness of preoperative use of beta blockers to reduce surgical mortality.
- There are consistent and clear associations between beta-blocker administration and adverse outcomes, such as bradycardia and stroke.
- These findings were consistent, even when the DECREASE studies (in question) or the POISE (Perioperative Ischemic Study Evaluation) study were excluded from the systematic review. Excluding these studies did not substantially affect estimates of risk or benefit (due to international concern about the integrity of these studies).
- Risk calculation to predict perioperative cardiac mortality is discussed in this guideline with recommendations on how it should be applied.
- Perioperative cardiac testing is discussed, including exercise and functional capacity, and includes a treatment algorithm for a stepwise approach to perioperative cardiac assessment. Recommendations for supplemental perioperative evaluation are also included.
- Perioperative therapies and recommendations, such as coronary revascularization before non-cardiac surgery, as well as the timing of elective non-cardiac surgery in patients with prior PCI, are discussed.
- Perioperative medical therapies reviewed include: beta-blocker therapy, statin therapy, alpha-2 agonists, calcium channel blockers, angiotensin-converting enzyme inhibitors, antiplatelets and anticoagulants.
- Anesthetic considerations and the intraoperative management of anesthetized patients are covered in this guideline.
Citation
Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print August 1, 2014]. Circulation. doi: 10.1161/CIR.0000000000000106.