News | August 28, 2014

Guidelines on Perioperative Cardiovascular Evaluation Updated

August 28, 2014 — The American College of Cardiology and the American Heart Association today released a revised guideline for minimizing the risk of cardiovascular complications around the time of noncardiac surgery after conducting a new review of research and reevaluating data from a controversial trial about the use of beta-blockers before surgery. 
The revised guideline offers current formalized recommendations for clinicians on how to best evaluate and manage cardiovascular risk and function during noncardiac surgery. The guideline was developed based on a thorough evidence review that analyzed randomized controlled trials, registries, case series, cohort studies, and systematic reviews. 
The evidence on perioperative beta-blocker therapy underwent a separately commissioned review by an independent evidence review committee, whose analysis was consistent with or without evidence from the controversial DECREASE trials, though removing the trials decreased the magnitude of the benefit of beta-blocker therapy. After completion, the writing committee discussed its recommendations with the European Society of Cardiology/European Society of Anesthesiology, which have updated their own guideline. Any variation in recommendations were discussed to ensure the differences took into account all available evidence reviewed by both writing committees.
“Given the recent publication of several large-scale trials, including POISE-II, and new risk calculators, as well as the controversy regarding the use of beta blockers related to the DECREASE trials, the writing committee felt it was necessary to reevaluate all of the data on cardiovascular care for the patient undergoing noncardiac surgery,” said Writing Committee Chair Lee Fleisher, MD, Robert D. Dripps professor and chair of the department of Anesthesiology and Critical Care at the Perelman School of Medicine at the University of Pennsylvania “Continuing the ACC/AHA’s initiative to modernize its methodology, we employed the recent recommendations from the Institute of Medicine regarding guideline development.”
The guideline discusses care provided before, during, and after noncardiac surgery. Emphasizing the importance of preoperative evaluation, it offers recommendations on when clinical testing—such as 12-lead ECG, assessment of left ventricular function, coronary angiography, and stress testing—may be 
warranted and advocates the use of validated risk prediction tools. Additionally, a new testing algorithm has been proposed that incorporates the risk calculator while continuing to emphasize that stable patients undergoing low-risk surgery or with a good exercise tolerance rarely need further cardiac studies.
The guideline recommends that beta blockers should be continued in patients undergoing noncardiac surgery who have been on the drugs chronically, consistent with the current hospital performance measure. It notes it may be reasonable to begin perioperative beta blockers for patients with intermediate- or high-risk myocardial ischemia, or for patients with three or more Revised Cardiac Risk Index risk factors such as diabetes mellitus, heart failure, coronary artery disease, renal insufficiency, or cerebrovascular accident. Initiation of therapy, however, should be long enough in advance to assess safety and tolerability before surgery. Dual antiplatelet therapy is also analyzed, and the writing committee recommends that its management should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient; weighing the relative risks of bleeding versus prevention of stent thrombosis. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor inhibitor therapy, such as with clopidogrel, it is recommended to continue aspirin if possible and restart the P2Y12 platelet receptor inhibitor as soon as possible after surgery.
According to the guideline, elective noncardiac surgery should be delayed 14 days after balloon angioplasty, 30 days after bare-metal stent implantation, and optimally 365 days after drug-eluting stent implantation, although the data in this area are evolving. This has resulted in a new class IIb recommendation acknowledging that elective surgery more than180 days after drug-eluting stent implementation may be considered if the risks of waiting outweigh the risks of the patient sustaining a cardiac event. Coronary artery bypass graft surgery should only be performed if it would be indicated independent of the noncardiac surgery.
“Because of the stress of surgery and anesthesia, patients may have heart attacks and other potentially life-threatening cardiovascular complications after 
noncardiac surgery,” said Writing Committee Vice Chair Kirsten Fleischmann, MD, MPH, who is professor of clinical medicine at the University of California, San Francisco. “Ensuring that patients are receiving high-quality cardiovascular care prior to noncardiac surgery and continuing that care throughout the perioperative period are crucial in minimizing the risk of surgery.”
The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery will be published in the Journal of the American College of Cardiology and Circulation and will be available on the ACC and AHA ebsites, and, respectively. The work of the writing committee was supported exclusively by the ACC and AHA without commercial support.
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