ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise 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, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

Fleisher LA, Beckman JA, Brown KA, et al. J Am Coll Cadiol. 2007;50:1707-1732.

Perspective: It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Patient adherence to prescribed and agreed on medical regimens and lifestyles is an important aspect of treatment. The ultimate goal of the guidelines is to improve the quality of care and serve the patient's best interests. The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.

Advances in preoperative risk assessment and surgical and anesthetic techniques, as well as better implementation of medical therapy have served to decrease the frequency of cardiovascular complications associated with noncardiac surgery. Despite these advances, cardiovascular complications represent the most common and treatable adverse consequences of noncardiac surgery.

Ten important recommendations from this document include:

1. The purpose of the preoperative evaluation is not to give medical clearance, but rather to perform an evaluation of the patient's current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, anesthesiologists, and surgeon can use in making treatment decisions that may influence short-and long-term cardiac outcomes.

2. No test should be performed unless it is likely to influence patient treatment.

3. Preoperative resting 12-lead electrocardiogram (ECG) is recommended for patients with at least one clinical risk factor (ischemic heart disease, history of prior uncompensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency) who are undergoing vascular surgical procedures.

4. Coronary revascularization before noncardiac surgery is useful in patients with: left main coronary stenosis or three-vessel coronary artery disease with stable angina.

5- Percutaneous coronary intervention (PCI) before noncardiac surgery is of no value in preventing perioperative cardiac events, except in those patients in whom PCI is independently indicated, such as for an acute coronary syndrome.

6. Beta-blockers should be continued in patients undergoing surgery who are receiving beta-blockers to treat angina, symptomatic arrhythmias, hypertension, or other American College of Cardiology/American Heart Association Class I guideline indications.

7. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued.

8. Elective procedures for which there is a significant risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate course of thienopyridine therapy (12 months after drug-eluting stent implantation if they are not at high risk of bleeding and a minimum of 1 month for bare-metal stent implantation).

9. Postoperative troponin measurement is recommended in patients with ECG changes or chest pain typical of acute coronary syndrome.

10. An effective analgesic regimen must be included in the perioperative plan and should be based on issues unique to a given patient undergoing a specific procedure at a specific institution.

Summary written by: Gilbert Upchurch, Jr., MD, Associate Editor, ACC Cardiosource Review Journal.

Cardiosource Review Journal, December 2007, 16: 21.