Review of 2014 ACC/AHA Guidelines

and Implications for Clinical Care

Natalea Johnson, MD CA-2

Seth Palesch, MD CA-2
Bernie Miller, MD CA-2
Katie Seligman, MD CA-3

Conflict of Interest

No relevant financial disclosures or conflicts of interests

 Learning Objectives
• Become up to date on national professional
guidelines for perioperative cardiac workup
• Understand levels of evidence and be able to
apply them when ordering perioperative testing
•
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Review new pre-op cardiac evaluation
algorithms
• Understand and apply the use of risk
stratification calculators

Lecture Outline
• Review of evidence classifications
• Pre-operative cardiac evaluation algorithm
• Definition of high & low risk surgery
• Introduction to risk calculator
• Supplemental Preoperative Evaluation
• Coronary revascularization management
• Coronary stent management
• Perioperative therapy recommendations
 The American Heart Association
Evidence-Based Scoring System
Classification of Recommendations
• Class I: Conditions for which there is evidence,
general agreement, or both that a given procedure
or treatment is useful and effective.
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• Class II: Conditions for which there is conflicting
evidence, a divergence of opinion, or both about
the usefulness/efficacy of a procedure or treatment
– Class IIa: Weight of evidence/opinion is in favor of
usefulness/efficacy.
– Class IIb: Usefulness/efficacy is less well established
by2006
Circulation evidence/opinion.
114: 1761 – 1791.

A quick review…from 2007!!

Fliesher et al, “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” Circulation. 2007. 116:e418-500.

2007?!?
• The iPhone debuts…for $599
• The final Harry Potter book (Harry Potter and
the Deathly Hallows) is released
• George W Bush was the President
• The Departed won Best Picture
Fliesher et al, “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.” Circulation. 2007. 116:e418-500.

2014: Now,
with
color!!!

Fliesher et al. “2014 ACC/AHA Guideline

on Perioperative Cardiovascular
Evaluation and Management of Patients
Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 1:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 2:

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Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 3:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 4:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 5:
Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Step 6:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/
 Step 7:

Fliesher et al. “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Fliesher et al. “2014 ACC/AHA Guideline

on Perioperative Cardiovascular
Evaluation and Management of Patients
Undergoing Noncardiac Surgery.”
Undergoing Noncardiac Surgery.”
http://content/onlinejacc.org/

Procedure Type

Low Risk High Risk

• Combined surgical and • Any procedure with MACE
patient characteristics risk > 1%
predict a risk of major • No longer distinguishes
adverse cardiac event between intermediate and
(MACE) < 1% high risk because
• Ex: Cataracts, plastics recommendations the same
• Risk can be lowered by less
invasive approach
(endovascular AAA)
• Emergency procedures
increase risk

Definition of Timing of Surgery

Emergent Time-
Urgent Elective
Sensitive

Life or limb is
threatened if not Life or limb is Delay of 1-6
in operating room threatened if not in weeks for further
operating room Delay for up to 1
within evaluation would
within year
6 hours negatively affect
24 hours outcome
 Calculators for predicting perioperative
cardiac morbidity
• Class IIa:
– A validated risk-prediction tool can be useful in predicting the risk of
perioperative MACE in patients undergoing non-cardiac surgery

• Class III: No benefit

– For patients with low risk of perioperative MACE, further testing is not
recommended before the planned operation

• RCRI- Revised Cardiac Risk Index

• American College of Surgeons NSQIP Risk Calculator

 RCRI Revised Cardiac Risk Index

1. History of ischemic heart disease

• 6 predictors of
complications
• Major cardiac 2. History of congestive heart failure

complications included:
• Myocardial infarction 3. History of cerebrovascular disease (stroke or transient ischemic attack)
• Ventricular fibrillation
• Cardiac arrest
• Complete heart bock 4. History of diabetes requiring preoperative insulin use

• Pulmonary edema
• 0-1 predictors = low risk 5. Chronic kidney disease (creatinine > 2 mg/dL)
• 2+ = high risk

6. Undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery

Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest:0
predictors = 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%, ≥3 predictors = >11%
 http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/

ACS NSQIP Calculator

• 21 predictors of risk for major cardiac complications
• NSQIP MICA risk-prediction rule created in 2011

• 525 US hospitals participated

• > 1 million operations included
• Outperformed RCRI in discriminative power (esp. with vascular)
• Calculates risk of:
• MACE, death, PNA, VTE, ARF, return to OR, unplanned intubation
discharge to rehab/nursing home, surgical infection, UTI
• Predicts length of hospital stay
• Limitations:
• Not validated outside NSQIP
• ASA status
• Functional status/dependence
 http://riskcalculator.facs.org/PatientInfo/PatientInfo

RCRI ACS NSQIP Calculator

Creatinine > 2 ARF
H/o heart failure H/o heart failure within 30 days
IDDM DM
Thoracic, Intra-abdominal, or
vascular CPT code
H/o ischemic heart disease Previous Cardiac event
H/o CVA or TIA ASA status
 Age
Wound class
Ascites
Sepsis
Ventilator
Disseminated cancer
Steroid use
HTN
Previous MI
Sex
DOE
Smoker

Supplemental Preoperative
Evaluation
• Includes
– ECG
– Assessment of LV function
– Exercise Stress Testing for Myocardial Ischemia
and Functional Capacity
– Pharmacological Stress Testing
• Noninvasive
• Radionuclide
• DSE
– Special Situations
 Algorithm

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Review of Evidence Classification

Classification of Recommendations
• Class I: Conditions for which there is evidence,
general agreement, or both that a given procedure
or treatment is useful and effective.
• Class II: Conditions for which there is conflicting
evidence, a divergence of opinion, or both about
the usefulness/efficacy of a procedure or
treatment
– Class IIa: Weight of evidence/opinion is in favor of
usefulness/efficacy.
– Class IIb: Usefulness/efficacy is less well established
by evidence/opinion.
Circulation 2006 114: 1761 – 1791.
• Class III: Conditions for which there is evidence,
Resting ECG
• Reasonable (Class IIa) – known CAD,
significant arrhythmia, PVD, CVD, or other
significant structural heart disease, except for
low-risk surgery (LOE = B)

• May be Considered (Class IIb)–

asymptomatic patients without known CAD,
except for low-risk surgery (LOE = B)

• No Benefit (Class III) – for asymptomatic

patients undergoing low-risk procedures (LOE =
B)

Assessment of LV Function

• Reasonable (Class IIa) –dyspnea of unknown

origin (LOE=C)

• Reasonable (Class IIa) – known CHF with

worsening dyspnea or other change in clinical
status (LOE=C)

• May be Considered (Class IIb)– reassessment

in stable patients with previously documented
 in stable patients with previously documented
LV dysfunction if not assessed within 1 year
(LOE=C)

Exercise Stress Testing for Ischemia

and Functional Capacity
• Reasonable (Class IIa) – to forego further
exercise testing with cardiac imaging and proceed
to surgery in patient with elevated risk and
excellent functional capacity (>10 METs) (LOE=B)

• May be Considered (Class IIb)– for patients with

elevated risk and unknown functional capacity if it
will change management (LOE=B)

• May be Considered (Class IIb) – to forego for

patients with elevated risk and moderate to good
FC (4-10 METs) (LOE=B)
Exercise Stress Testing for Ischemia
and Functional Capacity
• No Benefit (Class III) – routine screening with
noninvasive stress testing for patient at low
risk for noncardiac surgery (LOE=B)
 Pharmacological Stress Testing
• Noninvasive
– Reasonable (Class IIa) for patients at elevated
risk and have poor FC (either DSE or pharm stress
MPI) (LOE=B)
– No Benefit (Class III) for routine screening for
patients undergoing low-risk noncardiac surgery
(LOE=B)

Special Situations
• If your patient has a resting ECG that impairs
diagnostic interpretation
– LBBB
– LV hypertrophy with “strain pattern”
– Digitalis effect
• Concomitant stress imaging with TTE or MPI
may be appropriate
• Pharm stress MPI is suggested for LBBB
 Coronary Revascularization Management
• Class I:
Revascularization before
noncardiac surgery is recommended
in circumstances in which
revascularization is indicated
according to existing CPGs.
(Appendix 3)

Unprotected Left Main Disease

 3 Vessel CAD with or without proximal
LAD Disease
2 Vessel Disease with Proximal LAD
Disease
1 Vessel Disease with Proximal LAD
disease

Perioperative Percutaneous
Coronary Intervention (PCI)
• Performing PCI before noncardiac surgery
should be limited to:
– Patients with Left Main disease who can’t get
bypass surgery without undue risk
– Patients with unstable CAD who are candidates for
emergent or urgent revascularizations (NSTEMI,
STEMI)

• CARP Trial (Coronary Artery

Revascularization Prophylaxis)
McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients
– Showed no difference in perioperative and long
with documented coronary artery disease: results of the CARP trial. Eur Heart J. 2008;29:394-401.

term cardiac outcomes with or without

Timing of Elective Non Cardiac Surgery after PCI

• Class I:
1. Elective noncardiac surgery should be delayed:
• 14 days after balloon angioplasty
• 30 days after BMS implantation

2. Elective noncardiac surgery should optimally be

delayed:
• 365 days after drug-eluting stent (DES)implantation

• Class IIa
3. When noncardiac surgery is required:
• A consensus decision among treating clinicians as to the
relative risks of surgery and discontinuation or continuation
of antiplatelet therapy can be useful.

Timing of Elective Non Cardiac Surgery after PCI

• Class IIb*
1. Elective noncardiac surgery after drug eluting
stent implantation may be considered:
• After 180 days if the risk of further delay is greater
than risks of ischemia and stent thrombosis

• Class III: No Benefit/Harm

2. Elective noncardiac surgery should not be
performed:
• Within 30 days after BMS implantation if dual
antiplatelet therapy needs to be discontinued
• Within 12 months after DES implantation if dual
antiplatelet therapy needs to be discontinued

Choosing Appropriate PCI Intervention

• Urgent Surgery
– Consider CABG combined with noncardiac
surgery

• Surgery 2-6 weeks with high bleeding risk

 – Consider balloon angioplasty with provisional
BMS

• Surgery in 1-12 months

– Consider BMS and 4-6 weeks of ASA and P2Y12
inhibitor with continuation of ASA perioperatively

Antiplatelet Agent
Recommendations
• Class I
1. Urgent Non Cardiac Surgery 4-6 weeks after
BMS or DES
• Continue DAPT unless RR of bleeding outweighs
benefit of preventing stent thrombosis

2. Patient with coronary stent & surgical

procedure mandates discontinuation of
P2Y12 platelet receptor inhibitor
• Continue aspirin perioperatively, re-start P2Y12
platelet receptor inhibitor ASAP after surgery

Antiplatelet Agent
Recommendations
• Class IIb
Non-emergent/Non-urgent, Non Cardiac
surgery:
• If patients have not had previous stenting,
you may continue aspirin perioperatively
 you may continue aspirin perioperatively
when the risk of potential increased
cardiac events outweighs the risk of
bleeding

http://blogs-
images.forbes.com/daviddisalvo/files/2011/1
0/5-aspirin.jpg

Antiplatelet Management Perioperatively

 Sample Case
• 62 male veteran being evaluated prior
sigmoidectomy 2/2 non-metastatic
adenocarcinoma
• 118 kg, BMI 43
• PMH: HTN, HLD, non-obstructive CAD, CHF
with recent hospitalization, COPD, NIDDM
• PSH: 40 PYH, quit ‘11
• Lives with family who help with ADLs.
Minimal exercise tolerance, stops every other
block when walking 2/2 fatigue
• EKG in NSR
 References
• Fliesher et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing Noncardiac Surgery.
http://content/onlinejacc.org/
• McFalls EO, Ward HB, Moritz TE, et al. Predictors and outcomes of a perioperative
myocardial infarction following elective vascular surgery in patients with
documented coronary artery disease: results of the CARP trial. Eur Heart J.
2008;29:394-401
• Fliesher et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery. Circulation. 2007. 116:e418-500
• http://riskcalculator.facs.org/PatientInfo/PatientInfo
• http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/