2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation

The algorithm addresses evaluation of the elecitve patient only and thus does not address interventions such as beta-blockers, anti-coagulant, or anti-thrombotic agents.

Instructions

Nodes in the figure below that are colored light-salmon can be clicked for further guidance and to generate text that can be copied into the electronic health record and then individualized as needed.

Low risk surgery:

 
References
1. Fleisher LA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007. PMID 17901357
 

Revised Cardiac Risk Index:

Yes  
  • Includes "history of myocardial infarction, history of a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves"
  • Excludes: "patients with prior coronary revascularization procedures were categorized as having ischemic heart disease only if they had any of the other criteria"
Other considerations

Duke Activity Status Index:

Yes
(with no difficulty)
 
1. Are you able to take care of yourself, that is, eating, dressing, bathing, or using the toilet?
2. Are you able to walk indoors, such as around the house?
3. Are you able to walk a block or 2 on level ground?
4. Are you able to climb a flight of stairs or walk up a hill without stopping?
5. Are you able to run a short distance?
6. Are you able to do light work around the house like dusting or washing dishes?
7. Are you able to do moderate work around the house like vacuuming, sweeping floors, or carrying in the groceries?
8. Are you able to do heavy work around the house like scrubbing floors, or lifting or moving heavy furniture?
9. Are you able to do yard work like raking leaves, weeding or pushing a power mower?
10. Are you having sexual relations?
11. Are you able to participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
12. Are you able to participate in strenuous sports like swimming, singles tennis, football, basketball or skiing?
Hint: answering yes to first 4 questions qualifies for moderate functional capacity.

Stress testing?

Will stress testing affect decision making or postoperative care (Recs 5.3 and 5.4 of AHA/ACC 2014 Guidelines)

Proposed text to place and edit in the electronic health record

Proposed text will be here.

Additional considerations for this patient

Revise recommendations above based on these and other considerations.
Pending.

References

American College of Cardiology/American Heart Association Guidelines

  1. 2014: 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. J Am Coll Cardiol. 2014 Jul 29. pii: S0735-1097(14)05536-3. doi:10.1016/j.jacc.2014.07.944. PMID: 25091544.
  2. 2007: Fleisher LA et al. 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); 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; Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: 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. Circulation. 2007. PMID: 17901357.
  3. 2002: Eagle KA et al. 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. PMID: 11889023.

Other

  1. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010 Jan 5;152(1):26-35. doi:10.7326/0003-4819-152-1-201001050-00007. PMID: 20048269.
  2. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651-4. doi: 10.1016/0002-9149(89)90496-7 PMID: 2782256
  3. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-9. PMID: 10477528.
  4. Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, Schinkel AF, van Santen M, Simoons ML, Thomson IR, Klein J, van Urk H, Poldermans D. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med. 2005;118(10):1134-41. PMID: 16194645.