Guidelines for perioperative cardiovascular evaluation for noncardiac surgery

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ACC/AHA TASK FORCE REPORT --

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Guidelines for P&operative Cardiovascular Evaluation for Nonckdiac sqrgery Report of the Ahericau College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) COMMIll’EE

MEMBERS JEFFREY A. LEPPO. MD. FACC THOMAS RYAN. MD. FACC ROBERT C. SCHLANT. IMD. FACC WILLIAM H. SPENCER 111, MD. FACC JOHN A. SPITTELL, JR.. MD. FACC RICHARD D. TWISS. MD. FACC

KIM A. EAGLE, MD, FACC. Chair BRUCE H. BRUNDAGE. MD. FACC BERNARD R. CHAITMAN, MD. FACC GORDON A. EWY. MD, FACC LEE A. FLEISHER, MD, FACC NORMAN R. HERTZER. MD

TASK FORCE MEMBERS JAMES L. RITCHIE, MD, FACC, Chair MELVIN D. CHEITLIN. MD, FACC KIM A. EAGLE, MD. FACC TIMOTHY J. GARDNER, MD. FACC ARTHUR GARSON. JR.. MD. MPH, FACC RICHARD P. LEWIS, MD. FACC RAYMOND J. GIBBONS, MD. FACC ROBERT A. O’ROURKE, MD. FACC THOMAS J. RYAN. MD, FACC

Preamble Clearly it is important that the medical professjon play a sign&ant role in criticaUy evaluating the use of diagnostic procedures and therapies in the management or prevention of disease states. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes. and

impact the overall cost of care favorably by focusing resources on the most effective strategies. The American College of Cardiology (ACC) and the American Heart Association (AHA) have produced such guidelines in the area of cardiovascular disease jointly since 1980. This report was directed by the ACC/AHA Task Force on Practice Guidelines, which has as its charge to develop and revise practice guidelines for important cardiovascular diseases and procedures. Experts in a given field are selected from both organizations to examine subject-specific data and write guidelines. Additional representatives from other medii practitioner and specialty groups are included in the writing process when appropriate. Each writing group is specifically charged to perform a formal literature review. weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patientspecific modifiers, comorbiiities, and issues of patient preference that might inlluence the choice of particular

tests or therapies are considered along with frequency of follow-up and cost-effectiveness. These practice guidelines are intended to assist physicians in clinicai decision making by describing a range of generally acceptable approaches for the diagnosis management, or prevention of specihc di or conditions. These guidelines attempt to defmeprac3icesthatmeettheneedsofrnostpatientsinmost circumsmnees. The uhimate judgment regarding care of a particular patient must be made hy the physi&n and natient in light of aU of the cimrmstanees presented by that patient. The ACC”‘iJiA &.&~:io~ J, IL and 111 are used in this report to summarize indications for a particular therapy or rrcatment as follows: Otnss I: Conditions for which tnere is evtdence for an&or general agreement that a procedure be performed or a treatment i\ of benetit. Class Ii: Conditions for which there is a divergence of evidence dnd%rr opinion about the treatment. Class 111: Conditions for which there is evidence andor general agreement that the procedure,%eatment is not necessary. Tlte Committee to Develop Guidelines on Perioperative Cardiiascular EvaJuation for Noncardii Surgery wa chained by Kim A. Eagle, MD, and included the folknvmg rneabers: &tree H. Rnmdage, MD. Bernard R. Chartmart, MD. Gc;d~n A. Ewy, MD, Lee A H&her, MD, Norman R. Hertz.; MC, retfrey A. leppo, MD. Thomas Ryan. MD, Robert C. :t%Jant MD. William H. Spencer JR, MD, John A. SphteJJ, Jr. MD. and Richard D. Tw&, MD. Tbii document was approved by thr AK Roard of Trustees and the AHA SACC&ering Committee and is being pubhhihed simultanwusly in the lownal of.& .4mt+‘can Co&g of Cardiidogv and Circulati in March 1996. The dockment wm aJso endorsed by the tiety for Cardiovascular Anesthesiologkts. the Society for Vascular Surgery, and the North American Chapter of the Internatkrnal .%ciety for Cardicwmlar Surgery. This document was reviewed hy three outside reviewers nominated by the XC and by three outside reviewers nominated by the AHA, as well as reviewers nominated by the American Academy of Family Physicians, the Sociity for Vascular Surgery, the American Sodety of Anesthesiiogists. and the Society of Cardiovascular AnesthesioJogists. The document will be +viewed Z years after the date of publication and year& thereafter and considered current unkrs the Task Force publishes a revision or withdrawal. James L. Rirchie, Chair, ACC!AHA

MD. FACC Task Fwce on Ractice

Guidelines

Exebutive Summary Purpose of These cuidehes These guidelines are intended for phy&ans involved in the preoperative, operative, and postoperative care of patients undergoing IKMWK%W surgery. They provide a framework for consideringeardiaeri&ofmmcardiisurgeryinavarietyd patient and operatrve situations. The overriding theme of these

guidelines is that intervention is rarely necessary to lower the risk of surgery. The goal of the task force is the rational use of testing in an era of cost containment.

General Approach Successful perioFerative evaluation and trea:ment of cardiac patients undergoing noncardiac surge? requires careful Learnwork rind communication between patcnt. primary care physician. cnesthesid*l. and surgeon. In general, in&ations for further cardtac testing and treatments are the same as those in the nonoperative setting. but their timing is dependent on such factors as the urgency of noncardiac surgery. the patient’s risk factors, and rpeeibc surgical considerations Coronary revascula&zation before noncardiac surgery to enable the patient to “get through” the noncardiac procedure is appropriate only for a small subset of patients at very high risk. Preoperative testing should be limited to circumstances in which the results will affect patient treatment and outs A xuxervative approach to use of expensive tests and treatments I+ recommended.

Preoperative Clinical Evaluation ‘Ihc initial history. physical examination. and &ctrocudiographic (ECG) assessment shot&J focus on i!rc!:!!rs!%r of potentiaJJy ssrious cardix din ixhrding coronary artery disease (CAD) (eg ptix myocardi.aJ infarction [AIR. angina pectoris). congestive heart failure (CHFJ. and eJect&J instability teg. symptomaticarrhythmias). In addrtton to identifying the presence of pnxxisting manifested heart disease. it is essentral to define disease serf&. srufiliy. and prior hwafmcnr. Other factors that help determine cardiac risk include functional capacity. age. cxrmnrbid conditions (eg, dies melbtus peripheral vascular dii. renat dysfunction. chronic puhnonary disease). and type of surgery (vascular procedures and prolonged. comphcated thora&. abdominal. and head and neck procedures considered higher risk).

Further beoperative Testirrg to Assess CoruuaIy Risk Whid, patient5 are most likely to benefit from preoperative coronary mrtt and treatment? The lack of adequatel) controJJed or randomized clinical trials to &tine the optimal evaJua&mstrategyhasJedtothepropJsedaJgorithmbasedon collected observational data and expert opinion. A stepwlre Bayesian stmtee, tbt relies on ac-essment of clinical markers. prior coNmary evanlatiar and treatment. htnaioorl rapcrity. and surgery-specific risk is outlined b&w. A fnmrrwlr fur determining which patients are c2uxUates for cardiac t&ing is presrnted in algorithmic form. SulQssfufusedtheargoritbm rcquim an appre&tion for tierem Jevek of risk a@nBabR levels d fimcthnal rauadty. to certain diniil e&u-

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and types of surgery. These are detined below, after which the step&y--step aigorithm is reviewed. CfjuW f&&us. The major clinical ~~Iiciorx of increased perioperative cardiiascular risk are unstable roronary syndromes stteh as recent MI with evideax of important ischemic risk and uuatabk or severe angina; decompensated CHF, sign&ant arrhythmias (high-grade atrioveotricular block, symptotmtic arriqhh in the presence of underlying heart disease, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease. Iprzdictars of increased risk are mild ingina peetoris, prior MI, compensated or prior CHF, ski diabetes meltitus. Minor pmdiaops of risk am advanced age, abnormal e-, rhythm other than sinus, low functional capachy, history of stroke, and uncontrofled systemic hypertensioo. l%u&uul Cap&y. Thi measurement can be expressed in metabok equivalent (MET) levels. Multipies of the basehneMEXw&ecaubeusedtoexpressaerobicdemandsfor spedic atski&. Perioperative cardiac and tong-term risk is inmased in patients onable to meet a 4-m demand during most ootmal daily activik The Duke Activity Status Index andothera&itysc&sprovidetbedinih5anwithasetof qicdons to determine a patient’s fm&onal cap&y. Energy expe.mlitnre for activities such as eating, dressing, walking amuudthehouse,anddi&wash@cantangefrom1to4 ME&. Chbing a Right of stairs, walking on level ground at 6.4 kn& ruaniuf ~ashort dii, scrubbing flooq or playing agane~f~equals4to10NIETEShenuoussportssuchas ~~~~ and football exceed IO METS. Surgery-spedfKcardiactiskofnoneardlaesargetyisre tohvoimpormntfactor%thetypeof surgeryitxeIfaodtbedegreeofhemodymu&stremassociated with sni-geqe procedures The dmatioo and irttensity of awonaryand~s&essorsGlnbehdpfldinestimating thehkeMmndofperiopemtivecmdiaceveo~piu&Myfor emer%ncy sqery. Surgery-specific risk for noneardiac surgery call he stratified as hi%, intermediate, and low. ffig4t&k r3ufgtq indudes major emergency surgery, par&uMy in the ekkrlyiaortieandotkrmajorvasadarsurgery;peripheral ~surgery;andan~pmlongedprocedures~ datedwithktrgeRuidshiftsandlorbloodtos.inren?iediale-risk pItndlmindudeearotidendarteratomy,beadandnedt surgery, intraperitoneal and intmthom&, orthopedic. and pstate surgery. buvisk proixhres indude emkucopii and

pe&tmfdorstre&meutisofbenef&aassII,amditiomfor whichthereiadivergeuceof~au&uopiniiabout the tIMmel@ and c&s III, cooditiom *aadhwgenemlagnementthattheprocedunisnot 8ecessary.

angina pectoris unresponsive to medical therapy; unstable angina pectoris in most patients: and nondiagnostic or equivocal noninvasive test in a brgh-risk patient undergoing a high-risk procedure. Class II indications (may be helpful) are intermediate-risk results during noninvasive testing, nondiagnostic or equivocal noninvasive test in a patient at lower risk undergoing a higher risk procedure; urgent noncardii surgery in a patient recovering from acute Ml; and perioperative MI. Class III indications (not necessary) are low-risk noncardiac surgery in patients with known CAD and low-risk results on noninvasive testing; screening for CAD without appropriate noninvasive testing: patients who are asymptomatic after coronary vascularization and have excellent exercise capacity; mi!d, stable angina in patients with good left ventricular function and low-risk noninvasive test results; patients who are not candidates for revascufariration because of concomitant illnw; prior technically adequate normal coronary at@gram within 5 years; severe left ventricular dysfunction in patients not considered candidates for revascularization; and patients tmwihing to undergo revascularixation. The folknving steps correspond to the algorithm presented in Fig 1, page 921. Step 1. What is tbe urgency of noncardii surgery? Certain emergeucies do not allow time for preoperative cardiac evafuation Postoperative risk stratification may be appropriate for some patients who have not had such an asr6sment before. Step 2. Has the patient undergone coronary revascularization in the past 5 years? If 50, and if co ical status has remained stable without recurrent symptoms/stgns of ischemia, further can&e testing is generaity not necessary. Step 3. Has the patient had a coronary evaluatiin in the past 2 years? If coronary risk was adequately assessed and the findings were favorable, it is usually not rtexxswy to repeat testing unless the patient has experienced a change or new symptoms of coronary ischemia since the previous evaluation. Step 4. Does the patient have an unstable coronary syndrome or a major clinical prediior of risk? When elective ooucardmcsurgeryisbeingcooslderedtheprcsenceofumtable coronary dii, decompensated CHF, symptomat+ arrhythm&. an&or severe valvutar heart dii usually leads to cancellation or delay of surgery until the problem has heen identified and treated. Step 5. Does the patient have inbmediare clinicalprrdiam qf tsk? The presence or absence of prior hit by history or ECG, angina pectoris, compensated or prior CHF, and/or diabetes meltitus helps further stratify dinical risk for periop erative coronary events. Cottsideration of jiu&oaal cafnrciry and level of e+@c r+sk allows a rational appmach to ideutifying p0tient.s most likely to benefit from further noninVaoivetcstmg,

for which

there

is

step 4 Patients without major but with intermediate predictors of dinical risk and moderate or excellent fuuctii capacity can getteridly undergo imermediate-risk surgery with lixklikdiiofpemprativedeathorM1.CaMlody,~ waiwarive~bofbwcoosidercdforpRRentsnitepoor

JACC Vd. 27. No. 4 MarcJi 15.19%%0-423

functional capacity or moderate functional capacity but higberrid surgery and e-specialty for patien& with two or more intermediate predictors. Step 7. Noncardii surgery is generally safe for patients with neither major nor intermediate predictors of clinical risk and moderate or excellent fimctional capacity (4 METS or greater). Further testing stay be cons&red on an individual basis for patients without diiical markers but prior fumiional cap&y who are facing higher-risk operatiom, particularly those with several minor clinical predictors of risk who are IO undergo vascular surgery. !%epS.Theresultsofnoainvasivetestingcanbeuwdto determine further preoperative management. Altemativety, tberesultsmayleadtoa recommendation to praxcd with surgery. In some patients, the risk of coronary intervention or corrective cardiac surgery may apprnacb nr even exceed the risk of the proposed noncardiac surgery. Thb approach may k appropriate, however, if it also sign&antfy imprwes *e patient’s long-term prognosis. For some patients, a careful comideration of clinical, decision

to proceed

to coronary

aqiogmphy.

Management of Specifw hpemtive tlbdiovasculrrr cooditions Hypertwion: Severe hypertension should 5e contrdkd before surgery when possible. 3%~ de&ion to delay surgeq because of elevated blond pressure should take into account the urgency of surgery and potential be&t of more interrsive medical therapy. Continuatioa of preopemtive antihypcrtensive treatment througb the perbperative period is critical. v*r huvr diIcu.fe: rndications for evaluation and treatnlentofvalvularheartdiseaseareidentkaltothoseintbe nonoperative setting Symptomatic stenotic lesions are aswxiatedwitbriskofperbpemtivesevereCHFnrshatandoften require percutaneous vabutmq or valve qkwment before nmtcardiisuqeiytolowercardiacrisk.SymPormricregur&ant valve disease t5 usually better tolerated pcriqrcrativcty and rray be stabilized preoperatively with intensiw medical therapy and monitoring. Regurgitant valve disease is then mated de&&My with valve repair or qlacement after fwncdiic surgery. This is apprqiate a&tx~ a wit of several weeks or months &fore noncardiac surgery may baw severe c%Jlt?qlJelKcs E.w@ots may indude SKIe valvda3 Ieguh gjtation f&h rcduccd kft ventriadar furbon, in vhidr werall hemw+miinzserveissolimitedtbatdeSaMWiiduring petioperatk-isveryLiLety.

Anfn’rhmraa and rundtutiun atvmmdtihr The prewncc of an arrhythmia or cardxac cwduction dLurhance chwid pw voke a careful evaluation for underlying cardicypulmonar), disease, drug toxicity. or rnetbolic abnurrnalie. Therap should be initiated for symptom& or h&nodynamiAl~ sig nificant arrhythmias. fix! to rmersc an underlying LXUUZ and second to treat the arrf.jthmia. Indications for &arrhylhmk: therapy drd wdlac pacmg arc identical IO the r~mqnx.+~ne utling.

Soppkmeatd

Preoperative

Evahtioo

No specific recummendatiom can be made fclr indi\idual patients. The folkwing &Ad be awkiered app3ophe as indicated in specifd situations: re5ting left wwicular function, exercise stress testing. pbannx>4 sIr6s t&i* ambulatory ECG rnnnitoring and corunaq ang@@y. In ricst ambulatory patients the test of chk j F, cxerciu ECG te\ting. whkh cm both p3wide an estimate of functiof& capxiI) and detect myocardial ischemia through changes in the ECG and hemodynamic respne. In patients with unpoflanurt &normal. ities on their resting ECG (kft twndk brash hbck. kft ventricular hypcrtrophy with swam pattern. diitAn cllect, etc). nther techniques wh as exercise ecbardiqraphy or exercise myocdhl petiion imaging sbmdd be ax&bed.

Impliitioos

of Risk Assessment oacosts

Stratqgies

The degm uf idri&h~ wmnnnling prwfxr4nr te5ting before noncardiac urrgep ir wuhslanri.4, CcM-ektiwnes anatps of va3km methods of preoperative testing and tre.31. merits have also yiekkd highly wkd results. it k important for theclinbantoc0nsiderthecW+nplicatiomnfscreening suat~and,wbenpossihle.t03elyongelle~aceepled stratqk for treating pa&n& in the nonopnuiw retting.

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d;sty, including emergency CABG in some patients. Until father data are available, indications for PTCA in the perioperative setting are similar to those in the ACCAHA guidclikes for use of PTCA in general.

Medical

T&ram

for Cotmaty

Artery Disease

‘Ike are very few randomized trials from which firm conclusions or recommendations can be drawn. However, if patieots require f3-blockers. calcium channel blockers, and/or nitrates before surgery, continuation of the preoperative medical fegiokeo into the operative and postoperative period may ah protect agdnst kchemic tendencies caused by perioperative stremes. The same is true for therapies to control symptoms of CHF. Observational stud&s also suggest that k blockers reduce frequency of postoperative ischemia, and in one study reduced incidence of perioperative MB. Protection against kheoia may also reduce risk of MI.

Amesthetic Considerations and intnroperative Management Aneshic apt: All anesthetic techniques and drugs have koowncardiace&ctsthatshouklbeconsideredintheperioperative plan. There appears to be no one best myocardial pmective anesthetic technique. Therefore, the choice of anesthesia and iotraoperative monitors is best left to the discretion of the anesthesia care team, which will consider the need for postoperative ventilation; cardiovascuhu effects, including ngomdhl depression, sympathetic bloclade; and dermatomal levelofthepmcedme.Advocatesofmonitoredanmthesia,in Whidtlocallwslhesiaissuppteme~tedbyintravewussedation/M have argued that use of this technipe avoids the undesirable etkts of general or oemaxial techniques, but no studii have established this. Failure to produce complete IocaIamWe&/analgesiacanleadtoincreasedstresirespoltse,myocardiiischemia,ordepresJion. Pe&pemnve pain manngcnicnc Patient-controlled iotravenous and/or epidural analgesia is a popular method for reducing postoperative pain. Several studies suggest that effective pain management leads to a reduction in postop erative catecholamine surges and hypercoagulability. i~~ti T&e are iosu&cieot data about the c&ctS of prOph$h intraoperative intravenous oitrogiycerin in patients at hi risk. lUitrog,Iycerin should be used only when the hemdynamii effects of other agents in use are cTcmideTed. echacw ci7x): There are few ue of m-detransient wall motion ~&Jpredict&morbidity~~surgbIpatier#s.~ilQtodate~thattheiTIcre~otal vahteofthistedmiqWforrisk~issmatl.cuidelines forappm+teuseofTEEarebeiidevelopedbythe AatekansoktyofAnesthesiologishaodthesocietyof

Perioperative Surveillance Pulmonary arrery cathetererr: Although very few studies that have been reported compare palient outcoroes after treatment with or without pulmonary artery catheters, the following three variables are particularly important in assessing benefit versus risk of pulmonary artery catheter use: disease severity, magnitude of anticipated surgery, and practice setting. The extent of expected fluid shifts is a primary concern. Patients most likely to benefit from perioperative use of a pulmonary artery catheter appear to be those with a recent MI complicated by CHF, those with significant CAD who are undergoing procedures associated with significant hemodynamic stress, and those with systolic or diastolic left ventricular dysfunction, cardiomyopathy, and valvular disease undergoing high-risk operations. Intraopemtive and postopemtive ST-segment monitorihg: Intmoperative and postoperative ST changes indicating myocardial ischemia are strong prediiors of perioperative MI in patients at high risk who undergo noncardiac surgery. Similarly, postoperative &hernia is a significant predictor of loogterm Ml and cardiac death. Conversely, in patients at low risk who undergo noncardiac surgery, ST depression may occur and Accumulating evidence suggests that proper use of computerixed ST-segment analysis in appropriately selected patients at high risk may improve sensitivity for myocardial ischemia detection. Surveilfanceforpehywrative MI: Few studies have examined the optimal method for diagnosing a perioperative Ml. Clinical symptoms postoperative ECG changes, and elevation of the MB fraction of creatine kinase (CK) have been most extensively studied. Newer myocardii-spe&c enzyme elevations such as tropooin-I, troponin-T, or CK-MB isoforms may also have value. IO patients with known or suspected CAD undergoing high-risk procedures, ECGs obtained at b&reline, immediately after surgery, and the first 2 days after surgery appear to be cost-effective. Use of cardiac ew:s is best reserved for natieots at high risk and those with clinical, ECG. or hemodynamic evidence of cardiiascular dysfunction.

Postoperative Therapy and Lung-Term Management When possible, postoperative management should include assessment and management of modifiable risk factors for CAD, heart failure, hypertension, stroke, and other cardiiasCuIar dii For many patients. the proposed noncardiac surgery may be the first opportunity for a systematic cardiovascdar evaluatinn. Assessment for hyper&olesterolemi somkir& hypertension, diabetes, physii bmctivity, peripheral tasadar disease, cardii murmur(s), arrhythmias. amduetii almomdties, perioperative ischemia, and postoperative MI may Icad to futther evaluation and treatments that reduce hdure cardii risk. In particular, patients who sustain a perioperative Ml and/or experieace repetitive postoper&e

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myocardial ischemia are at substantially high risk for MI or cardiac death during long-term follow-up. These patients should be a narticutar focus for risk facror intervernions and future risk stratification and therapy.

Development of Guidelines These gnidelines are based on a Medline search of the English literature from 1975 through 1994, review of selected journak from 1995. and the expert opiniins of I2 committee members representing various disciplines of cardiiascular care, including general cadolo~, noninvasive testing, vascular mediche, vascular surgery, anesthesiology and arrhythmia management. In addition, draft guidelines were submitted for critical review and amendment to ph&ians representing internal medic&. family practice, nuclear cardiology, general surgery, and anesthesiology as well as executive ot3icers representing the American College of C%diologyatldtheAmericanHeartAssociationlbefiMldoCument represents the eighth iteration over 18 months which includedsixdraftsincommitteeandtwoadditionaldraftsto incorpomte key tinding horn external review. Alargeproportionofthedatausedtodeveloptheseguklelii is based on observational or retroqeztive stndii or know)edge of management of cardiovz&ar dii in the nonop erativesetting.Whilethea3Uectiieknavledgesutxm>he identihcation of &h- and low-risk patients using p&operative climcalandnonim~evaluationissubstantiakveryfewprospestive or randomized studii have been performed that establish the value of tests or treatments on perioperative outcomes. Therefore, data are presented in a tabular format. and whenever pie ret&t the value of a test or intervention for similar outcomesofaperioperativeMforcardiacdeath.Becausethe stndiiwererarelyrarandomcuacontrolledtriaJs,defimtiarsda perioperative event vaii investigators were rarely bhi and many inherent selection biases extsted. the task force has chosen nottoprovideanaggregatesynthesisofthedataintheformda point estimate or meta-analysis. On the other hand. presentation of the original data provides substantial support for these recommendations.

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery I. DetMtioi*

of the Prablem

Purpose of TheseGuidelines These gtridelines are inter&d for phy&ians who are involved in the preoperative, operative, and postoperative care ofpatientstmdergoingnoncardiacstugmy.lheypmvidea framework for considering cardiac risk of nommdmc surgery inavarietyofpatientandsu~smutiwrTBetaskforee thatpnpaledtheseguidelhtesstlivedtoinaaporate~tis curlemJyknowtlaboutpeliopelattiliskandbowtlti5twwledgecattbensedittlbeindividual*nt.Metlmdslised,to ale6ilsmaditlAppea8hI. devebp-

915

The tables and algorithms provide quick references for decision making The overriding theme of this document is that ~~tervsntion is rarely necessilry simply to lower the risk of surg:ry ur.!css such intcncntion is indicated irrespective of rhe preoperative context. The purpose of preoperative evalua&3n is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status. make recommendations concerning the risk of cardiac problems over the entire perioperative period. and provide a clinical risk profile that the patient. his or her primary ph-tician. anesthesiologist. and surgeon can use in making treatment de&ons. No test shouhi be pfotmed unkss it is like!v IO infhence phi rreurmenr. Therefore. the goal of the consultation is the rarenal use of testing in an era of cost containment.

Epidemiology The prevalence of cardiiascular disease increams with age, and it is estimated that the number of persons older than 65 years in the United States will increase 2% to 35% over the next 30 years.’ Coincidentally. this is the same age group in which the largest number of surgical procedures are performed.’ Thus. it is conceivable that the number of noncardiac surgical procedures performed in older persons will increase from the current 6 million to nearly 12 million procedures performedper,year,andneartyafourthofthese-majorintraab&mimt tlmlack vascular, and orthopedic pt-axdules havebeenrmociatedwithas&n&cmtperioperative~ aJlal?lmwityandmoltality.

Pmctice Patterns There are few reliable data available regarding (I) how often a family ph+ian. general internist, subspecialty ittternist. or surgeon performs a preoperative evaluation on his or her own patient without a formal consultation and (2) bow often a formal preoperative comadtation is requested from eitheragewralistora&9speM&~asacardiifor ditferent types d sqical procedures and different categories of patients The patterns of pm&e vary signiitly in dillerent locations in the country and vary between patients receiving care under diaerent healthcam provider systems3 There is an important need to determine the relative costeffectiveness of different shategies of periopetative waltration. In many institutions, patients are evahtated in an armsthe& preoperative malpion setting If sufficient informatin about the patient’s c?admadar status is available, the symptoms arestabte.andhrrtberevahmtiiwiUnotintIuenceperiofXrative management. a formal consultation may not be required nor obtained. This is facihtated by commtmication between anesthesiaperr4mnelandphysiciamraponsiMeforthepaGent’s cardii lalcale.

Fthanci$Impkatiws lllefinancialimplicrtioesdrbkulatiliQtioucaJmotbc ~i%eneedforbettermethodsofobje++memmkag ~rkskhasledtotbedRicbpmwtdmuftf#e

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noninvasive techniques in addition to established invasive procedures While a variety of strategies to assessand lower cardiac risk have been developed, their aggregate cost has received relatively little attention. Given the striking practice variation and high costs associated with many evaluation’ strategies, the development of practice guidelines based on currently available knowledge can serve to foster more ethcient approaches to periopemtive evaluation.

Role of the Consultant The consultant should review available patient data, obtain a history, and perform a physical examination pertinent to the patient’s problem and the proposed surgery. A critical role of the con&ant is to communicate the severity and stability of the patient’s cardiovascular status and to determine if the patient is in the best reasonable medical condition, given the context of the surgical illness. The consultant may recommend changes in medication and suggestpreoperative tests or procedures. In some instances, an additional test is necessary based on the results of the initial preoperative test In general, preoperative teats are recommended only if the information obta&dwiUreaultinachangeinthesurgicalprocedureper~acbangeinmedicnlthempyormonitoringduri.ngor aftersurgety,orapos@onementofsutgetyuntilthecardii amditioncanbecorre&dorstab&ed.Beforesuggestingan addit& test, the con&ant slmld feel co&dent that the u&matkmitpmvideswillprovidea~tadditiontothe ~~~~ ba%e potential to impact treatment. avo’ .

II. General Approach to the Patient ~cardiacevahtationmustbecarefnllytahoredto tlte~thathaveprolnptedtheconsl!ltatkmand ltameaftheslngicaliilnessGivenanacute~emergency, pmopem&Rmhrationwillbelimitedtoarapidamemmentof carhmakvitaisigwvolumestahs,andelectrocardiogram (JXf3).Onlythemostessentialtestsandinterventionsare tmtiltheaarte.surgimlemergenyismsolved.A evahmGmcanbecondu&daftersurgety.ln surgeiyisnotpe6rmedrtranemerge~ ptxlah%butgcKnicaredictatespromptsurgely.lnpatientsin whommyocardial~isnotanopt&itisoftennot ~~performateat.Underother,lesaurgentc&mrpreoperativecardiacevahtationmayleadtoavariety ofrt+mseasometimesthissituationmayincludecancellationof

otherwise healthy patient may require no further workup or special precaution, whereas suspicion of previously unsuspected CAD or CHF in a patient scheduled for an elective procedure may justify a more extensiveworkup.& The cardiac consultant must also bear in mind that the perioperative evaluation may be the ideal opportunity to impact long-term treatment of a patient with sign&ant cardiac disease or risk of such disease. The referring physician and patient should be informed of the results of the evaluation and implications for the patient’s prognosis. The consultant can also assistin planning for follow-up.

Histoy A careful history is crucial to the discovery of cardiac and/or comorbid diseases that would place the patient in a high surgical risk category. The history should seek to identify serious cardiac conditions such as prior angina, recent or pat Ml, CHF, and symptomatic arrhythmias. Modifiable risk factors for coronary heart disease (CHD) should be recorded along with evidence of associatedd&eases,such as peripheral vascular disease, cerebrovascular dii, diabetes mellitus, renal impairment, and chronic pulmonary dii. In patients with established cardiac disease, any recent change in symptoms must be ascertained. Accurate recording of current medications and dosages is essential. Use of alcohol and over-theeounter and illicit drugs should be documented. The history should also seek to determine the patient’s functional capacity (Table 1). An assessmentof an indiidual’s capacityto perform a spectrum of common daily taskshas been shown to correlate well with maximum oxygen uptake by treadmill testing.7A patient classihed as high risk due to age or known CAD but who is asymptomatic and runs for 30 minutes daily may need no further evaluation. In contrast, a sedentary patient without a history of cardiilru disease but with clinical factors that suggest increased perioperative risk may benefit from a more extensive preoperative evaluation.s~6~9It is important to emphasize that the preoperative consultation may represent the first careful cardiovascular evaluation for the patient in years,and in some instances,ever. For example, inquiry regarding symptomssuggestiveof angina or CHF may establish or suggestthese.diagnoses for the lirst time.

FSysicalExamination A careful cardiovascular examination should include an assessmentof vital signs (including blood pressure in both arms), carotid pulse contour and bruits, jugular venous pressure and pulsation auscultation of the lun)qs, precordii ~n4IRisuscultatasm~andenami7a-fnredemaand~integrity.More -willbedidaredlyspecitic~. lhefollovdngpointsareworthen@ta&in~ *negeneraiappearaIkccpmvides-evidence regarding the patient’s overall status. Cyano& pallor, dy!qneaduriugconvem~orwitbminimalactivity, puor nutritional stam nhesily. skeletal defOrmitii

JACC Vol. 27. No. 4 March 15, 1996910-48

e

a

@

a

EAGLE ET AL. ACCIAlIA TASK FORCE

tremor, and/or anxiety are just a few of the clues that can be recognized by the skilled physician. In patients with acute heart failure, pulmonary rales and chest x-ray evidence of pulmonary congestion correlate well with elevated pulmonary venous pressure. In patients with chronic heart failure, however, these findings may be absent. An elevated jugular venous pressure or a positive hepatojugular reflux are more reliable signs of hypetvolemia in these patients.‘uJr Peripheral e&ma is not a reliable indicator of chronic heart failure unless the jugular venous pressure k elevated or the hepatojugular test is positive. A careful examination of the carotid and other arterial pukes is essential. The presence of associated vascular disease should heighten suspicion of occult CAD. Cardiac auscultation will often provide useful clues to underlying cardiac disease. When present, a third heart sound at the apical area suggests a failing left ventricle, but its absence is not a reliable indicator of good ventricular functionn Ifamurmurispresent,theclmicianwillneedtodecide whether or not it repreaenk sign&ant valvuhu disease. Detection of significant aortis stenosis is of par&c&r importanoebecausethisleaionposesahighrkkfornoncardiac surgeiy.12 Sit mitral stenasis or mgmgitatkXtitlCSWSriskofCHF.AottiC~gurgitationandmitral regurgitatioilmaybeminim~yetpredispasethepatientto infective eixharditk should bacteremia occur fobowing smrgery.Intheseconditio~espaialhifmitralmm;ll tionisrheumaticinoriginorduetomitralvalveprolapse, consideration must be given to endomrditis pmphyk&r3

should heighten suspicion of CAD, particularly because myocardial ischemia is more likely to be silent in the patient with diabetes mellitus. Management of blood glucose levels in the perioperative period may be difficult. Fragile diabetic patients need careful treatment with adjusted doses or infusions of short-acting insulin based on frequent blood sugar determinations. More stable diabetic patients may be treated with long-acting insulin or oral hypoglycemics. It is acceptable to maintain blood glucox at relatively high levels perioperatively and it is far preferable to tight control with its attendant risks for hypoglycemic episodes RenalIF Azotemia is commonly associated with cardiac disease and often complicates its management. Maintenance of adequate intravascular volume for renal perfusion during diuresis of a patient with heart failure is often challenging. Excessive diuresis in combination with initiation of angiotensin converting enzyme (ACE) inhibiton may result in an increase in blood urea nitrogen and plasma creatinine concentrations. Discldm imposes a stress on the cardiovascular system that may exacerbate myocardial ischemia and aggravate CHF.r4 Preoperative transfusion, when used appropriately in patients with advanced CAD and/or CHF. may reduce perioperative cardiac morbidity. Hmever, with current concern about possible transmission of HIV and hepatitis through the use of ccmervative approach with respect to transbbodproduct$a fusioniswarraoted. Po~~~andork-thatinillmasetheliskofthromboembdi aeasebloodviscositymay an%rhlmohag.AnnopriatestepstoreducetheserisLs should be cousidered and taiiod to the illdad ptient’s pamcukr-

Comorbid Dbeases The coosuitant must evahrate the c&&ax&r system within the kmework of the patient’s overall health. Associated conditionsoftenheiitentherir.kofanm&siaandmay~ cardiacmanagement.Themostcommon Ofthesed~ille: rice of either obstructive or rt&ictive pmmomuy dii places the patient at increased risk of developing perioperative respiratory compliitions. Hypoxemia, hy,?ercapt&acido@andincmased~workofbreathingcanalllead to further deterioration of an already compromised card@& monarysystem.Ifsigni6cantp&onarydkeaseissuspe&dhy history or physii examination, detetmination of functii a&or evaluation for q-=@, respoose to bron&uhlato& thepresenceofcarbondioxideretentioo~arterial bloodgaaanaIysismayhej&i6ed.Iftherekevi&nceof infeet& appropriate anare critical. steroids and bronhdiiolamaybeindicatedaltboughtheriskofproducinga&ythmiiormyocanWkchemiabyBagonisamtktbe

Avarietyofrnetab&-may~cudiac .DiabetertuelIiiktIteiaost

917

aJmmm.

Its presxnx

Anci&ty Sauiks The amsuhant should rev&v ah available laboratory data. Inthiieraofcostcontainmen~thelaboratorydataavaiWe may be mbliid. Therefore, the amsuhant may require additionaItestssuchasbloodchemkt&andacheatmdiogn+ basedonhistoryandphysi&examinatinn.Bloodlevekof cardiacdrugs,indu&gdiin.sbouldbeobtamedonIywben therearespesc remntchangein In patients re ahnostalwaysindieatedaspartofapreoperativeevah&onIn faa.anaItmmaIECGreportkoftentIlereasonthateonsldtationbquestedMetaholkandeiectdyledisturbaaEes . . medKam&in-disesre.pufmnnaryd~ete.can alter the ECG. conduction rtirttnbanocs such as bude bIanchbloctorIirstzkgree-Morr,rnayie8dto

amcembutusualiydonotjusrifyfurthrrworkup.Thesameis often tme sigiaani htmd,s&tleECGcIueseanpointthe~nytoachnieaIlysiIent -ofmajorimporL

JACC Vol. 27, No. 4 March 15,19%910-48

EAGLEETAL

918

ACC,AHA TASK KUtCE

Table 1. Clinii Predictors of Inneased Perioperative Cardiovascttlar Risk (Mvocardial :nfaraioo, CIxtResdve Heart Faihtre, Death)

U~eoronarYW~ . Iteeent myoeardisl irdamkd with evidencz of important i&&c bydhdcalsymptnmoraoniwasiveshldy . uttnable ot we& angina (cmmdii’claa III or IV)+ Dearmpeosated congestive heat failure sl!@caltarrbyrhmiar l

Highqade

. r

atrioventticldm

risk

block

veatdctdat mThyutmias in the prcseace of underlying heart

. Sapmventtie&r arrhythmias with uttm~%~~Iledventricular rate scvmevslvulvdii Mod angina pecmis (canadii class I or II) Pdor ttpadid ittfarctmn by history or patholqical Q waves Compensated or prior cottgestive heart failure Diabetes meUittts Miaa A-age Abaomal ECG (leti ventricular hypertraphy, left bundle branch black, ST-T abnormalities)

UttlWtltlOlledsystemichypenensioo

The basic clii evaluation obtained by history, physical examination,andreviewoftheECGusuallyprovidesthe consuItant with sufficient data to estimate cardii risk. Table 1 lists diuii predictors of increased perioperative risk of MI, CHF, and death established by several authors based on mtdtiwiate anaIy~is.~~~~~AIthqh some authors have suggested a scoring system that assigns more weight to some factors than others and sums these to arrive at a composite r&lmost recent art&s have suggestedsimpler criteria.t5-2t In dii pmtice. more weight is attxhed to active cotlditions than dormaot Mes$ whii the degree of deviation T&k lb4Er I

I 4METa

% Wmated

Energy

Requirementsfor Vartous

cm )W lake cam of yomelf? Ea~,d?e&oruscthetoikt? Walkiadmsarmmdthcbouoe? Wdkablockorlwonle*el gouodat2-3mpb~332-4.8kmRt? Dolightwortrarotmddtcbwrelike dWtiUgWss;lshiogd

from the normis used as an implicit modifier. Table 1 attempts to deal with this practice by placing the predictors in the following three categories: @ Major predictors, when present, mandate intensive management, which may result in del;iy or cancellation of surgery unless it is emergent. l Ipredictors are well-validated markers of enhanced risk of perioperative cardiac compiiitions and just@ carelid assessmentof the patient’s current status. l Minor predictors are recognized markers for cardiovascular diseasethat have not been proven to independently increase periopemtive risk. It should be noted that a history of MI or pathological Q waves by ECG is listed as an intermediate predictor, whereas a recent MI* is a major predictor. In this way the separation of MI into the traditional 3- and 6-month intervals has been avoided.‘= Current management of MI provides for risk stratification during convalescence.~If a recent stresstestdoes not indicate residual myocardium at risk, the likelihood of reinfarction after noncardiac surgery is low. Although there are no adequate clinical trials on which to base firm recommendations, it appears reasonable to wait 4 to 6 weeksafter MI to perform elective surgery. Table 2 presents a validated method for assessingfunctional capacity from a carefully obtained history. Thii method representsan important aspectof evaluating overall cardiac risk and planning appropriate preoperative testing. Table 3 strati&s the risk of various types of noncardiac surgical procedures. This risk stratification is based on several reported studies.lZ15J1Ja*8-M It is clear that major emergent operations in the elderly, ie, those violating a visceral cavity and those likely to be accompanied by major bleedii or fluid ShLFts,place patients at highest risk. Vascular procedures appear particularty risky, and, primarily because of the liketihood of associatedcoronary disease, justify careful preoperative screening for myocardiai ischemia in many instances.This aspect of decision making is covered more extensively in section IV.

Activities’

4 METS

Climb a flight of stairs ot walk up a hill? Walkottlevelgrmmdat4mphor6.4km/h? Rtmaahmtdiaxmux?

JACC Vol. 27, No. 4 March 15.19%:910-4s

Fig 1 (seeExecutive Summary) presentsin algorithmic form a framework for determining which patients are candidates for cardiac testing. For clarity, categories have been established as black and white, but it is recognized that individual patient problems occur in shadesof gray. The clinician must consider several interacting variables and give them appropriate weight. Furthermore, there are no adequate controUed or randomized clinical trials to help define the process. Thus, collected observational data and expert opinion form the basis of the proposed algorithm. Step 1 (FII 1). The consultant should determine the urgency of noncardiac surgety. In many instanca patient or surgeryspecilic factors dictate an obvious strategy (ie, immediate surge& that may not allow for further cardiac assessmentor treatment. In suchcases,the consultant may function best by providing recommendations for perioperative medical management and surveillance.Selected postoperativerisk stmtification is often appropriate in patients with elevated risk for long-term auonary eventswho have-never had such an assessment before. This is usually initiated after the patient has recovered from blood loss,deconditiorti~, and other postop erative complicati that might confound interpretation of tmimsive test reds. Step 2 (Fig 1). Has the patient undergone coronary revascularization in the past 5 years? If the patient has had complete surgical revascularization in the past 5 yeam or coronary angioplasty from 6 months to 5 years ago, and if hi or her clinical status has remained stable without recurrent signsor symptomsof ischemia in the interim, the likelii of perioperative cardiac death or MI is extremely low.“r Further cardiac testing in this circumstance is generally not necessary. Step 3 (Fig 1). Has the patient undergone a coronary evaluation in the past 2 years? If an indiiidual has undergone extensive coronary evaluation with either noninvasive or invasive techniques within 2 years and if the findings indite that coronary risk has been adequately amessed with favorable lindings, repeat testing is usually unnecessary. Art exception to this rule is the patient who has experienced ?.definite change or new symptoms of coronary ischemia mce the prior coronary evaluation. Step 4 (Fii 1). Does the patient have one of the unstable amnary syndromes or major dinical predictors of risk (Table l)? In patients being considered for eIective noncardisc surgery, the presence of utWable wmnary d&ease, or decompensated CHF, hemo+ramic&y sif@cant anhythmias,and/orseverevalv&rheartdiseaseusuabyleadsto cancellationordelayofsurgeryuntilthecardiacproblem hasbeen&ifiedandapprqniatelytreated.Exam*of unsWecoronqsjodnwesincl~etecentblIwithevidenceofischemicrisk$&iciilqmptmnsorrm&va+e study,unstabk~sevt~arrgina,aod~Ol&COtltrouedis4bka~cHF.Manypatiegaiothese

ACGAHA

1hbIe 3. Cardiac Risk’ Stratification I‘rocedures

EAGLE ErAL.. TASK FORCE

for Noncardiac

919

Surgical

circumstances are referred for coronary angiography to further assesstherapeutic options. Step 5 (Fig 1). Does the patient have intenne&e cliniral p&crors of risk (Table l)? The presence or absence of angina pectoris, prior MI by history or ECG, compensated or prior CHF, or diabetes mellitus helps to further sttiatilj clii risk for perioperative coronary events For patients with or without these intermediate chnical risk predictor consideration ofjiuhmd capacity (as determined by hii toryofdailyactivities)andlevelof5urgqsgeo~fcallotvs arationnlapproa&toidentifyingwhichpatientstttaymost benefit from further nonim&ve testing. Functional status has been shown to be a reliable predictor of future cardiac events3r If the patient has not had a recent txen5setes&thiscanusuauybEestimatedfromthe~tyto performtbeactivitiesofdaiIylivingF~~can beexFmsedinmetaboIic~t(M~kveb;the oaygenconsuqion(YO~ofa7C+4O-year-oIdmanina resting state is 3.5 ml& per minute or I MET. For this purpose,functiicapacityhacbeencknihcdasacellmr (greaterthan7METs),mo&mte(4to7METs),poor(less than4METs),orun&rmvR MultipIesoftheba5euneMET vahmcanbeusedtoexptessaembicdemamisforspeci6c activit&andtheuseoftheMETlevelisamoremeaningful exeee!~than~to andusefldt?xgJmhd eapresfia3ctional~ioterlnsofpotocdtimeandstttges reachedduring~enacise-Ille~pediatdlevelfa

920

JACC Vol. 27. No. 4 March 15. 1996:910-48

EAGLE ET AL ACClAtiA TASK FORCE

mph. Activities that require more than 4 METS include moderate cycling, climbing ‘hills, ice skating, roller blading, skiing, singles tennis, and jogging The Duke Activity Status Index (Table 2) cm~tains questions that can be used to estimate the patient’s functional capacity.l,3’ Use of the Duke Activity Status Index or other activity scales” and knowledge of the MIS levels required for ‘physical activities, as listed above, pvide the dbician with a rekitively easy set of questions to estimate whether a patient’s functional capacity will be less than or wr than 4 METS (Table 2). A clinical questionnaire, howe&, on!yesainnies timctional capacity and does not provide as objectiie a measurement as exercise treadmill testing or m ergornetry. Sorgery-Spdie Risk (%bIe 3, Fig 1): The cardiac fisk of noncardiac surgery is related tant factors. First, the type of surgery itself patient with a greater likelihood of underlying Perhaps the best example is vascular surgery, lying CAD is present in a substantial portion

surgery-specific to two impormay identify a heart disease. in whiih underof patients. The d aspect iS the &grtX Of k~iiit cardiac StiCSS assodatedwithwrgety-specific technique.s.cetiopetations may be associated with profound alterations in heart rate, blood press~, vascular volume, pain, bleeding, clotting tendencies, oxygenation, neurohumoral activation, and other permrbat<heintensityofthesecoronaIyandmyocaKW strm help determine the likelihond of perioperative cardiac events. l&s is partiahly evident in emergency surgery, where theriskofcardiaccompUcationsissubstantiaUyelevated Examples of nonca&c uugery and theii surgery-spe& riskaregivenbelow.Hi$rerswgeryspec@wdioc&k(eg, combined periopemtive Mi and/or death rate equal to or greater than 5%) is present in patients undergoing aortic surgery, peripheral vasmlat surgety, and anticipated prolonged surgicplprrladmarsociatedwithlargefluidshiftsar%r bloodlossinvdvingtIleahtanen,thoram,head,andnedL I-surgiurlrickpraceduresinctude~Orthope-

diGaaduncomplicated~,head,neckandthomcic sltrgely.~~hldudecataractresection,dennatdosicoperationsendoscopicprocedures,~~surgev

(TabIe 3). Patients undergoing low-risk pl-ocedures do Ilot requirefurtherevaluation. StepQfEg1):Patientswithoutmajorbutwithintenne&ue predicto!sofGnicalri&(Table1)andwithmodeiateorexceuentfimetionalcapacitycangeneJauyondergointemlediater&surgezywithlittklikelihoodofperiopemtiwdeathorM1. Ontheotherhand,patientswithpoorftm&malcap&tyor thmewithacombinationofonlymoderatefum%nalcayadty ZUldhighH-dSltsurgery~oftenmnsideredforfurthertIOtli(lwde~lltisis~tmeforforts~ lvmormoreoftheaboveintermediatemarkers.

!%p 7 (Fig 1). Noneardiac surgery is genmliy safe for patientswithminororm,dinicaip&iuorsofeli&ilrisk ~F~~)~~~~~or~t~~~ (equaitoorgmaterthan4METs),mgar&asofsmgical type.Paientswithpuorhmukmal~faciog~r-

risk operations (vascular, anticipated long and complicated thoracic,;abdominal, and head and neck) may be considered fdr further testing on an individual basis. To reiterate, it is important to emphasize that the concept of “medical clearance” for surgery is short-sighted. The real issue is to perform an evaluation of the patient’s current medical status, make recommendaticns concerning the risk of a cardiac problem over the entire pezioperative and postoperative period, and provide a clinical risk profile that the patient, anesrhesiologist, and surgeon can use to make management decisions. The overall goal of cardiac assessment should be a consideration of both the impending surge9 and, more important, the long-term cardiac risk, independent of the decision to go to surgery.j5 It is almost never appropriate to recommend coronary bypass surgery or other invasive interventions such as coronary angioplasty that would not otherwise be indicated in an effort to reduce the risk of noncardiac surgery. Step 8. The results of noninvasive testing can then be used to derermine further perioperative ma,iagement. Such management may include intensified medical therapy or cardiac catheterization, which may lead to coronary revascularization or potentially cancellation or delay of the elective noncardiac operation. Alternatively, results of the noninvasive test may lead to a recommendation to proceed directly with su:gery (Fig 1). In some patients, the risk of coronary angioplasty or corrective cardiac surgery may approach or even exceed the risk of the proposed noncardiac surgery. In rare instances, this approach may be appropriate, however, if it also significantly improves the patient’s long-term prognosis (Table 4).

III. Disease-Specific Approaches Coronary Artery Disease Plmntsw&KnowncoroAorp~Disrrrse In some patients, the presence of coronary disease may be obvim such as an acute Ml, bypacs grafting coronary angioplasty. or a coronary angiogram showing luminal irregularitifi. On the other hand, many patients without cardiac symptoms may have severe doable- or triple-vessel dii that is not cl&aUyobviousbecausethepatientsarefunctionallylhnitedby were arhitis or peripheral vascular disease. &h patients may benefit from non&a&e testing (Fig 1; Table 3) for d+nosis if the patient is a candidate for myocudii revasarlaritation. In petientswithlrnownCAD,asweUasthosewithpreviously~t comnaty~,the~bealme(1)whatisthearnoontof nlyocanliuminjeop&y?(2)Whatisthekche&cthre+o&ie, theamoWofstressrequiredtoproducei&emia?and(3)What isthepatients~hmdion?~tkalof~questiobskanimponaolgoaIofllle preoperativehistory,physical . . ~andse~nonimrasive te5tbgllsdtothepatieot'S~grsdiemOfischemic~dlUiltg

stress pbIe5).chldteotkerhar@manypl3tiemdooot reqoire-~~if~areootcamtidates formyom&irev;raartam9bon.

JACC Vol 27. No. 4 March 15. IY%YIIt-4X

EAGLE ET AL. .\CC AHA TASK FORCE

921

______-__________---____________________--------__---_-----------------------stmr--*

-P-

‘*bvancedap Funcbmal lapamy

Eg 1.

sepwise

ipprd

to fn-eqmative

surgery, a~mnarj,revas~~lari7.atbn

folbwcd

ediae

hy noncardii

nt. Steps are diiuzd swgety, or intemifkd

in text. ‘ant care.

care ma! include cat&latiwor

dtlly

of

JACC Vol. 27. No. 4 March 15, 1996~910-48

EAGLEETAL. ACUAHA TASK FORCE

922

‘@We 4. Indieatiuns

for Corontuy

Angiography*

in Perioperative

Evaluation

Before (or After)

Noncardiac

Surgery

classIt:Patimtswttbsappededorp-cAD: s High-d& results during noninvasim testhag(Tables 6-9) . Angiaa peaoris ualespo~ to adequate tnedkal therapy . MOM patieats with unstable angina peclulis . Noadis@ or equivocal wnipvasive test in a high-risk Patient (Table 1) undergoing a k&h risk noncardiac surgical procedure (Table 3) ClassLIt: mminvmiie

mhlg

(Tables

69)

l

latermediate&rearltsdudng

0

Nklm@mkorequivoeal

.

urgeM-noneardiac ArgeTy in a patient comalescing from acute MI

aoninvasive test in a tower-risk @eat

(Table i) undergoing a high-risk noncardiac surgical procedure (Table 3)

0 PerioperativeMI classuIt: a Low-risk noncardiac mugery (Table 3) in a patient with known CAD 3rd &-risk msnlts on noninvasive testing (Tables 69) e smewiag for CAD witbout appropriate noninvssive tSing l Asymptoroatk after coronary revas&arhation, rvith excellent exercise capacity (27 METS) l Mild stable an@na in patients with good LV function, low-risk nooinvasive test results (Tables 69) a Patient is not a candidate for wronaq mvam&imtion becanse of conwmitant m&al irlnem l

Rior

twbnically

mleyate

mxmal

comnmy

aogiogram

within

5 years

a Severe LV dysfa&on (eg, ejection fraction ~20%) and patient not considered candidate for revascularization prcced.re l Patient unwilling to wtmider coronary revazmdariration Procedure *If resnlts wih a&et nmnagement. tch%I: Cond&ns for which there ls evidence for and/or general agreement that a procedure be performed or a treatment is of benefit. Clam 11:Conditions for which there h a divergence of evidence and/or o@don abnnt the treatment class 111:Conditions for which there is evidence and/or general agreement that the pmwdQreisnutnecesnmy. MI, mvogldial i&r&on; MFT, metabolic equivalent; LV, left ventricular. cADiadfcates eomnarv artery W

Table 5. F’mgnostic Gradient of Ischemic Responses During an ECG-Monitored Eszrcise Test*

Isebemis indud

by low-level exerciset (~4 MET’s or heart rate
Fiiormre*uoosIlesds

. Per&en1 hehemic reqmnse >3 min after eaertion 0 Typicaangina IntereKdiateRlsk ~indueedbymodenteleveteXe~'(66h~SMheart~le1uO130

bpm[7O@%agePredieq)manifenedbymteormoreofthef~ l Horimtal or dcmdopiag ST depmsii Sl.1 mV . Ty~icalangitta l Persistent ischemie respmme >l-3 mitt after exertion l Tbree10fonrabmnmalloads

LawRisk No ischda or imhemia indnced at high-level eaerdse’ (>7 METS or heart rate >130 bpm [X75% age Pmdict&)) manifested by. l Horimmalordovmsloping!Sdepremionjo.1 mV l

Typicalaagina

l onetowsbnmmalk4ds laamte

Test

bmbihtytorea&adeqnamtargetworkmadorheartraterespmueforage &hotttimiS&mii~.F~patiensundergoingMm?lrdiaCswgety, mtermediate-rishlcvelwitltmaisehemia i?kizlLzkaatbe. atlowrhkforperiqrativehdtemicevents. EcGiadiwtweiecboovdmgrapbieagy,,~equiralen$bpm, bwtsperxtiimle

‘bedoorefawoes3237-43. twortbsdsQdheartrateatisrrteskKrt6ksevedty~llire

mirpc.

targetheartralesfar~aad~~

for

JACC Vol. 27, No. 4 March 15,19%510-48

EAGLE ET AL ACCL4HA TASK FORCE

Peripheral vascular disease presents a special problem because it is associatedwith a higher incidence of CAD and because the limited acrivity imposed by daudication may mask coronary disease. A full discussion of the implications of peripheral vascular disease can be found in section IV. Hjpertension Numerous studieW5J~r-Q~2 have shown that moderate hypertension is not an independent risk factor for perioperativs cardiovascular complications. 00 the other hand, as a universally measureJ variable with a recognized asscciation with CAD, hypertension servesas a useful marker for potential CYID.~~In addition, several investigators have demonstrated exaggerated intraoperative blood pressure thtctuation with associated ECG evidence of myocardial ischemia in patients with preoperative blood pressure elevation.~s7 This effectcan be modified by treatment5~ Smce intmoperative ischemia correlates with postoperative cardiac mo&dity,5r*r it follow that control of blond pressure preoperaSvety may help reduce the tendency to perioperative ischemia. Although an elevated blood pressure on an initial recording iu a patient with previously undiagnosed or untreated hypertension has been show0 to correlate with blood pressure labihty under anesthesiap* the definition of the severity of hypertension rests with subsequent recordings in a noustressful e.nvironment.53 In patients on therapy for hypertension, a careful review of aurent medications and dosage,along with known intolerance to previousfy prescribed drugs, is essentiaf.‘the physical examination should include a search for target organ damage and evidence of awciated cardiovascular pathology. In pat&&u, a funduscopic examination may provide usefuf data regarding the severity and cbromcity of hypertension. The physical examination and simpie laboratory tests can rule out some of the rare but important causesof hypertension. Further evahmtion to exclude secondary hypertension ISrarely warranted before necessarysurgery, but in patients with severe hypertension, particularly Of tc;Leni OnSet,it may be appropriate to delay elective surgery whii the patient is evaluated for curable causes of hyperteusion. If pheochromocytoma is a serious posibdity, surgery should be delayed to permit its exchtsion. A long abdominal bruit may suggest renal artery stenosis A radial to femoral artery pulse delay suggests coarctationoftheaorta;hypok&miaintheabsenceof diuretic therapy raises the possii of aldosteronism If the initial evahiation estabbb hypertensiou as mild or moderateandtherearenoassoc&dmetaboticoroudkwas CUhZlbtlO~the~iSllOdtO&hySlUg~.~seWd investigators have e&bWed tbe value of effectitie preoperative.bloodpresurecontro&~7~@@andan~ensivemedicatiom should be contiuued during the periopetative period. Pa&ularcamshouldbetakentoavoidwiMmwalof~ blockemauddonidiae~ofpotentialheartrateandlor bloodpreswerebo&.iopatientsunabktotakead medieaw patenteral f3aodLers and traBs&tmai may&d

dooidine

923

If more severe hypertension (eg, diastolic blood pressure greater than or equal to 110 mm Hg} exists before elecbie noncardiac surgery, it is prudent to control it before surgery.In many such instances,establishmentof an effectiveregimen can be achieved over several days to weeks of preoperative outpatient treatment. If surgery is more urgent, rapid-acting agents can be administered that allow effective control in a matter of minutes or hours. @-blockersappear to be particularly attractive agents. Several reports have shown that introduction of preoperative @drenergic blockers leads to effective moduia~ tion of severe blood pressure fluctuations and a reduction in the number and duration of perioperative coronary ischemic episodes.S5-60 Interestingly, patients with preoperative hypertension appear more likely to develop Waoperative hypotension than nonhypertensive persons In some patients this may be related to a decrease in vascular volume. In one report, hypotension durieg anesthesia correlated better with perioperative cardiac and renal complications than intraoperative hypertension, although other studies hdve not shown thiss7 Congestive Heart Failure Congcdve heart failure has been identiged in sevetal studiesasbemgassociatedwithapooreroutcomewben nosurgery is performed. In Goidmads study>* the preseuce of a third heart sound or signs of CHF were associatedwithasubstant.iallyincreasedriskduringnoncardiac surgery. Detskyn identihed afveobu pulmonary edema as a significant risk factor, and in cooperman’s ~p~q*4 cHF ak0 bestmvedasign&antrisk.Everyeffortmustbemadetodetect mwspec&heartfaifumbyacarefulhistoryandphysi& examination.ffpo&le,itis@ortanttoidentifytheetiology ofCHF,becausethismaybaveimpbcationscomxrningriskof death versuspetioperative CHF. For instana, prior CHF due to hypertensive heart disease may portend a different risk compared with prior heart faihue resulting ftom CAD. caniiomyopnthy lliereislittleiuf~ onthepreopemtiveduatialof patients with cardiwnyopathy before tummud& surgery. At this*preopaativereamnneadprnmntwtbebasedona undcrstmdingofthe~ofthe~ tIiXXeSEVenre;rpoo9bte&dtmlkJbernadebcRxe~to

924

JACC Vol. 27, No. 4 March IS. 199k91n-4n

EAGLE ET AL ACUAHA TASK FORCE

&reasedvenouscapacitancemaycauseareducdoninleft ventrkadar v&me and thereby potentially increase a tendency to obsmdon with potentially untoward results Furthermore, reduced tilling pressures may result in a signilicant fall in stroke v&me because of the decmaxd compliance of the IyprtqW ventricIe. Cam shot&J be avoided bethedegreeofdynamicohs@uctionand CmIsetheymayinaease decream diastolic IiIling In a relatively small series of 35 patients witJ~ hypeqhk cardiomyopathy with obstruction there were no deaths or se&us ventricular arrhythmias during or immediately after gemal surgkal procedu~ one patient had major vasadar surgery. In the 22 patients who underwent cathetetition, the mean rest and peak provokable gradiints were 30 mm EIg and 81 mm H& respectively. The only patient suffering a periuperative MI had twc-v-1 coronary disease. Siguihcant adythmh or hypotenskm requiring vasocotiots arurred in 14% and 13% of patients respecuvely.~ Patients with hypertmphic cardiomyopathy are also at an increased rirk for periop eratk CHF.

Vhhdar Heart Disease Cardiac murmum are common in patients facing noncardii surgery.Thecons&mtmustbeabletodistinguishorganicfrom fimctkm~.sig&amtfromiosignificant,andtheetiologyofthe mmmurinonSertodetennlnewhiipatientsrequireprophylaxis ‘for endocarditis and which patients require further quantitation oftheseverhyofthevalvularlesion. Severe aortic stenosis poses the greatest risk for noncardiac surgery.:2Iftheaorticstenosisissevereandsymptomati$eleaive rmncardiacsurgeryshouldgenerallybe~monceled. !SUCIIpthts require aortic valve rqhxment before elective but 0~noneardiacsurgery.Inraminsrancegpercutaneons haIloonaortics&uh@s&maybejustihedwhenthepatientk notaca&Iateforvalvere@acement. Mii stenos~ ahhough increasingly rare, is important to recognize. When stenosis is mild or moderate, the cons&ant must ensure coutrol of heart rate during the operative and perioperative period because the redttction in diastolim filling period that acoompanies tadaycardia can lead to severe putmonary mmg@ion. When the stenosis is severe, the patient ltUy betk&t from balloon mitral valvuloplasty or open surgical repair before high&k stugery?* Aortic regurgitation needs to he identifmd, not only for appropriate ptophylaKis for bacterial endocarditis, but also to ensure appropriate medii treatment. Careful attention to volume cuntnd and aftehad reduction is recommended. In amtmstto0~sevemawticregurgitatjorlisnot beoefitedby~slowhearrateawIticllcan~the . . ~byincreasiilgtheammmtoftimein ~.~~ pikduminantly afFeets CliaFtole and thus E?xlasthetimeaf~inswereaortjc~ mraIregurgitationhasmalyc;lmes,themostcommoo ~~~l~~~~rnj~~~. PerIoperative antibiotic pmphyh& ls reammended for pa~~~~~~b~e’~rn~~~-

diographic evidence of mitral valve regurgitation or thickening and/or redundancy of the valve leafletsi Since perioperative volume shifts may cause a patient with an isolated click to devc iop mitral regurgitation, auscultation in the sitting, standing, squatting, and standing-post-squatting positions may identify a tendency to volume or stress-related regurgitation. Patients with severe mitral regurgitation (often manifested clinically by an apical holosystolic murmur, a third heart sound, and a diastolic flow rumble) benefit from afterload reduction and administration of diuretics to produce maximal hemodynamic stabilization before high-risk surgery. Occasionally this therapy can best be accomplished by treatment in an intensive care unit using a catheter to monitor pulmonary artery pressure. It is also important for the consultant to note even mild reduction of left ventricular ejection fraction (LVEF) in patients with mitral regurgitation. Because the low-pressure left atrium acts as a pressure runoff in patients with severe mitral regurgitation, LVEF may overestimate true left ventricular performance. In such patients, even a mildly reduced LVEF may be a sign of reduced ventricular reserve. Patients with a mechanical prosthetic valve are of concern because of the need for endocarditis prophylax9 when undergoing surgery that may result in bacteremia and the need for careful anticoagulation management. The Fourth Gmsensus Conference on Anticoag&tion recommends the following+ For patients who require minimal invasive procedures (dental work superticial biopsies), we recommend brie@ reducing tbe INR to the low or subtberapeutic range, and resuming the normal dose of oral a&coagulation immediately following the procedure. Perioperative heparin therapy is recemmeruJed for patients in whom the risk of bleediig on oral auticoagulation is high and tbe risk of tbrombuembelism OR anticoagutatien is also bii (major surgery in tbe setting of mitral valve prosthesis). For patients between these hvo extremes, pbysiciam must assess the risk and benefit of reduced anticoagulation versus perioperative heparin therapy.

Arrhythmias and Conduction Defects Cardiac arrhythmias and conduction disturbances are common findmgs in the perioperative period,izi6”7 particularly in the elderly. Although both supraventricular and ventricular arrhythmias have been identhied as independent risk factors for ccronary events in the p&operative peri0d,~~7 they are probably signilicant only in that they either reflect or occur in the presence of underlying serious cardiopuImonary disease whii by itself, increases the risk of surgety.M The presence of an arrh@mii in the perioperative setting should provoke a thorough search for underlying cardiipuhnonary disease, drug toxicity, or metabolic derangements. Manycardiac arrhythmias, although reIativeIy benign, may umnasktmde#ngcardklcpnoblems;farerample,supraventricUkUildlphkCUIproduct:Gehemiaby~myocardial axygendewmdin~withcomnmydisease.Rarety,, mia%heotuseofthehemodyllamiormetabolic theycaus%may-intonmrelife

JACC Vol. 27. No. 4 March IS. 1!?%910-48

EAGLE ET AL ACC AHA TASK FORCE

disturbances; for example, atriaf fibrillation with a ular rtspnse in a patient with an w bypass degenerate into vennicufar fibriflation. Ventricular whether single premature ventricular contm tricularcctopy,ornom&a&dventricukuta&ycardiiusuaUydo notrequirethe~exceptiJlthepresenceofongoingorthreatenedmyoc&afbchemiaormoderatetoseverck.ftventricuku

rapid venbicpathway may arrh@mias, complex ven-

isfikelythatsucharrhythmiashavethesamebenignprognc& pekperatively as that demon&d in fx@atkm studiesB.m High-grade cardiac conduction abnotmahties, such as complete atrioventricular block, if unanticipated can increase operative risk and necessitate temporary of permanent ttansvenous pacing. On the other hand, patients with intraventricufar conduction delays and no history of advanced heart block or symptoms rarefy progress to complete heart block pe+peratively7r The availability of transthoracic pacing units makes the decisiin for temporary transvenous pacing less critical.

pulmonary Vic&r

Disease

lherearewllqmedstudiesthatspecatcailyassessthe

aticstudiesoftberiskofnomx&acsurgcryforpatiemswitb

surgeryforcongenitalheartdkease.Fnreycarsaftcrsurgetyfor ventriadar septaf defect or patent ductus atteriaay vasoreaalvityoftenremainsabmmnal,&masingtohighfevek

pulmonary

Patients with congenital heart disease have ako demonstrated a reduced cardiac reserve during exercise.73 Postoperative studies of patients with coarctation of the aorta or tetrafogy of Faffot have demonstrated fittdmgs consistent with tmdedying impairment of ventricufar function.74~~ These ob servations should be kept in mind when evahrating such patients before noncardmc surgery. Patients receiving primary cardiac repair at a younger age in the present era may be fess prone to postoperative ventricular dysfunction because of improved slrgid techtlii~ whiimostexpertsagreethatptlkmmy~pertemiooposes anincrea&riskfor~surgery,noorgammdstudyof theprobkmhasbeenperformed.~orltyanalogorssltoatialk faboranddeliwxryforsvDmeawhh~rsymhomeduet0 atxmge&li@acm&cshunt.Periparhunmmtahtywasteportedtobcbatwcen3o%and7ft%inlWl,hutnorcccntdata exkttoc&rifywornotthkhasfaBenwitJl~~in care.~Inpatkntswithscverepuhmmmybypertmukntamfa cardiaccshlmfhypotehypotelaiooreauhshincreasedrightto left.dmltingand~the~todevelopnentof t3CidO&WhiChCaOleadt0hirtherdcaeas*,iOsystnnicMpa;ltar

re&ancelltisrydcmustbemcogni&artdappopiatdy lteatd’

93

IV. Type of Surgery hwwv In a recent review- Mangano’ deterinined that cardiac complications are two to five times more likely to occur with emergency surgical procedures than with ekctrve operations. This finding is not surprising since the necessity for immediite surgical intervention may make it impossiite to evaluate and treat such patients optimally. For instance, collected data have confbmed that the composim mortality rate for elective repair of patients with arymptomatic abdominal aorttc aneur~zms is signitantly tower (358) than that for ruptured aneuryxms (42%)” The mortality rate for graft replacement of symptomatic but intact abdominal aortic aneurysms rzmnins relatively high (19%) despite the fact that, like elective cases. they are not associated with antecedent bfood loss or hypotension. Unfortunately, most true surgical emergencies (eg. symptomatic abdominal aortic aneurysms perforated v&us, major trauma) do not permit more than a cursory card&c evahration. In adottion, some situations do not tend them&es to comprehensive c&ii evaluation. ahhough surgical care may qualify as semielective. In some patients the impendiy danger of the d&ease is greater than the anticipated perioperative risk. Exampb inch& patients who require arterial bypass proceduresforfiisdvageormemmenc~toprevent intestinal~.Patientswithmalignantneopbsmasopose adiagno&andtbcraprutictbkmmawahrespadtopmopemtivecardiaf~~,whenitis~todaermine vels&~~~kaoaMehefore~~ satuadm~theimportanoeof~ umtm~amoug-ssurgeoRand~ toplananafgxoa&forcardioc amczmcntthatisappopiatefor theidividdpatjentandtheunderlyntgdisease.

EAOlI. ET AL ACCIAStA TASK FORLZ

926

&at peiiqeral&

czadac

morbidity

is particularIy

concentla*~

amollgpetientsWbOUndergOmaprthoracic,awoniinaLOr

vmnJarsurgly,~wtKntheyare7Oyearsordd a>.As&on et aP prmpdvely studied the incidence Of perioperativeMI~witbtho~abdominal,urdogie, ~andvascularsurgeryinacohortof14#menoider than 40. ne highest idaruiml rate (4.1%) (odds ratio, ‘1039 %%c3nMenceintenal[q23to475)oawredintheslbset d*ntsWitbiUIestablisbeddiagnosisOfCAD.Nerertklesr, mdepe&msi;;liticamriskfaetorsformfamtkmakoimhtded agegreaterthan75years(oddsm~4.n:%%:,1.17to19.41), mdtheneedfure-kaive~surgerywenintbeabsenced suspeaedCAD(~odQmtio,3.n:%tCI,l.l2tolU7). Few pmcedureqeeific data are available regarding periop t=ralkcardiae~inmostsurgkaIspeciahiesperhapa because~ageandserious,ineidelltalcADared tobedistriitedraadomlywithingroupsofpatKntswiloundelgo Ilcmadii operaiJl such fiekis as germi surgery, thoracic surgery,0rtlqdburdogy,gyoeodogy~~aadneurosurgery. kdersenetaPfotmdbyiogi®maGnthatagegreaterthiulor equaito7Oyear5MIwitbintheprec&lg12monthSandcHF weret3timadwithaninaeasedineiderceofpostoperative cardiaccomphcationsinaseriesof73JBpatierttswhounderwent amixofboth”mapr”and”miaoSgastminte&nai.urok@e ~Bop~pmcehms*~~~apu~ amehmemtnamucbsmafiersertesof52paWntswfm remriredekcuvehipartt8opbsty,the11frauemsinthisstudy w4luhadplxvimseliniadiodicatiomdcA.Dslrrtained~ can~higilerratesof-ischemiaorMldmirlgthe ~period(~odrkm~,l.e,%%C/0.7to52) andiateeardiaceventsdming4yeamoffoBow-up(adjt&dodds ratio35;%%~,13io9~)thandidtheremaining41pluients. As shown by Ashton et airs and many othefs, however, patients who require vasadar surgery appear to have an irlcm?driskforcardiaeeom~Mzryoftberiskbtctorsamuibutmgtoperipheral vascular disease (eg. diabetes meIli;us tobacco use, hyperlipidemia)areakoriakfaetorsforcAD. * TRe UsuaI syrrytomatic presentation for CAD in these

l

prevalent in the infrainguinai bypass group. L’italien et al* have preserted comparable data regarding the perioperative incidence of fatal/nonfatal MI and the dyear a*en!-free survival rate following 321 aortic procedures. 177 infrainguinal bypass grafts. and 49 carotrd endarterectomies. Slight differences in the overall incidence of MI among tbe three surgical groups. which may have been related to the prevalence of dia’ :tes meiiitus, were exceeded ahnost entirely in significance by the influence of discrete cardiac risk factors (previous MI, angina, CHF. tixed or reversible thallium defects. ST-T depression during stress testing).W These and other studiesS suggest that the clinical evidence of CAD in a patient who has peripheral vascular disease appears to be a better predictor of subsequent cardiac events than the particular type of peripheral vascular operation to be performed. In a selective review of several thousand vascular surgical procedures (carotid endarterectomy. aortic aneurysm resection, lower extremity revascuiarization) reported in the English literature from 1970 to 1987, Hertree found that cardiac compiiitions were responsible for about half of ail perioperative deaths, and that fatal events were neariy five times more likeiy to occur in the presence of standard preoperative indications of CAD. Furthermore, tbe late (S-year) mortality rate for patients who were suspected to have CAD was twice that for patients who were not (approximately 40% versus 20%). Ii is notewortby that both the pertoperative and S-year mortahty rates for the smaii groups of patients wbo previousiy had coronary bypass surgery were similar to the results reported for larger series of patients who had no clinical indications of CAD at tbe time of peripheral vascular surgery. Published mortality rates from large referral centers may not reBect the results at thousands of other hospitals througbout the United States in which, coiiectiveiy, most vascular sugpies are performed on an indiiduai, tow-volume baGs Hsia et aig have cakuiated that fewer than 10 carotid endarterectomies were performed an. naiiy at 45% of ail hospitals in which Medicare be&ciaries received this procedure from 19t35 to 1989, and Fisher et al* demonstrated that the perioperative mortality rate (1.1% to 3.2%) had an inverse relation to the low volume of earotid ettdarterectomies rn 2tJ?+9 Medicare patients at 139 New England bospitais. Simdar trends @gh vobmdow risk, low vohune~gh risk) have been continned by statewide audits of aortic aneurysm resection in Vermont. Kentucky, and New York.IR9r In New York, for example. Hamtan et aP reviewed 3570 ctec+~, aneurysm resections from 1985 to 19Vand found a linear, inverse relation between case voitmte and mortality rates for surgeons Go annually petfomled two or fewer operations (11% mmtabty). three to nineopemuom(73%mort&y),or1ttormoreoperattotu(5.o% mortaMy).Nocompau&dataareavaiWefmiowerextremity bypampmc&ma,butacamkngtotbeNatiooaiCenterfor HeaIthst2htiqthepotentialmagr61udeofthisprobIemis iIIismdbytheErttImteadlyearapproxima(eIy1ooollo fromUSfmspkakafter~ex&emby

l Majorrdelialoperatinosoftenaretimeawsumingaod maybeassoeiatedwitbsubstantialfluchIation5inintra-~vdulaes-~F-yy temicbIaKIprrzme,beartratr;andthmarbo%enmy T@oreeentstudiihaveattempted tostratifytheincidence of periopemtive and intermediate-tetm Ml acanding to tbe tigirmitypeofvaseukusurgeryperformed.Inapmspe&e aetieaof53amtiepro&umsartd87iu~bypass gdtSkUWhiChogerativemortaiirjrates~~nearfyiC&IltiCd (9%aud7%,rq.le&efy),KrugnkietaN5fomtdtbattberiak forfaWmmfatalMIwitbina2-yearfoUow-upperiodwm35 timeahigher(21%wXmta65&)amongpatienbwboreceived **-PnJbJ%i--d mefittm (44% versus 11%) ad a ofptm6ousMI(43%wXWa2&%), l5%),orcxF(29%-9%)alsoweI

CItamiuetaP~coBeuedl9%tdatafatbe30mosteommott were

st&dled

JAC C Vol. 27, XI. 1 March IS. lY%vIl~-w

from nearly 5 @JO000 admissionsto over 5000 bospitals. Of48 homogeneous medical and surgical conditions developed from a statistical model. only four had adjusted mortality rates that clearly could be correlated from one condition to another. three (carotid endarterkaomy. aortic reconstruction. lower extremity revascularization) involved vascular surgery, ar.d the fourth (total hip repkement), orthopedic surgery. Thus, if a hospital did well or txxniy with one of these operati it tended lo do equally well or poorly with the rest of them. Considering the fact that the prevalence of CAD contributes substantiaIly to the perioperative risk of vascular surgery, at least Salk: of the differences in surgical outcome from one hospital to another may be accounted for by variations in the degree to which it is recognized and appropriately treated. The level of this awareness aIso has impkations regarding late survkd. In the prospe-ctivelyrandomii Veterans Adminktration trial of carotid endarterectomy versus nonaperative management for asymptomatic carotid stenosis,for example, morethan2O%ofbothmndomiAcohortsdiifromcardiacrelated compliitions within a follow-up period of 4 years% AsFleiiand8arash95have~~edthf!spedftc~ calsettingmustbeakderedwitbinanya@ithmregard& preopprativecardiacevaluation.-Ilietermnrnrrmikrr~is e?roeodingtybroafIinitsde~it~8giagpatientswim compleKtechnicalprdIletns8swellasyoungerpaiieolsIorstraightfonvardsurgicalpoceduresAs&se4aedaboue, -morbidity8nd~notodyv8ry8moug pl‘cmhshntamongforthesameprWedWe. lkrefore,inasseGngtkrkkrandbenefitsofa~ ilttervention~,*aprociatcdwith-surgery nmstbeindii1tsimportantto-,however. thattheindkaksforfflmnatyinterwntionsbaddmtbc redefinedsimplykauseapatientwbohasCADofmargiA s@kanceakohappenstorequireamajorrtoncmkpoct dure.~,the~implicatiagdsevereleftluain OrBipk-vesSeldise;seand-letiWntricuhrhtnon arenolesomincus fdlowingaminurnomxdbc~operarian theyareinanyotherpatient.IntheIinalan+konedthe dtimateobje&rsdtbepeoperatkrecardiacassanoentkto exhldetheptk%ncecf~semurcADthatsmpformof diIectimerventionwotddbewarr8ntedcwnifmoperatimweretvasiuy.Inthisreg8td.tipnsartataafor nonc&acsurgetymaysimplyqxsentthefkttimethata ptietltwiIhoKrtorslispmedaKauryhcart~h8s8tl opportunity for m In summary, the stugial procedures have been dassifted as low, intermediate. and high risk as shcwn in Table 3. Although CYXOMlydiseaseiqttte~nvhebnirrgrirlrfilCtCWfor~~etivcmorbidity,proceduraddiferrntleKkdstrr%me&sod8tedwithdi&rent~d~8nd~.slperfichl 8nd~procedraesrrpeseDtthelowestrislc8ndgc ntrdy-with-~atidmatatity.Mspr Vasarta~~repaent~hibbesl-cislrpaeduerWIthhr theinewcdiarpriEL~,rrmtrirfitymIdantsliryvmy, nuiddrifalihle cbnrpatmdbg:tlftilt

928

I%eLFErAL A4lxm-w TASR FoRa

JACC Vol. 27, No. 4 March IS, 199651048

heart rate crater than 75% of age-predied maximum can be expected in approximately half of patients who undergo treadmill exe&, with supplemental arm ergometry when mxessmy for patients limited by daudicatkm.lw The frequency of anahormdexerciseECGrespomebdeperKienton$nio? dinii history.~~~~~~ In patkrm without a cardiac history and a normal resting ECG. approximately XI% to 25% of patients wiUhaveanahnordexerckECG.lXefrquencyisgreater (3S%to5O%)inpatientswitbapriurhistqofM1oran abmrmalrestE(xi.IberiskofperkpmhcaKliaceventaalKi Li3qtemrisbisBignificantry~in~withanalmord ekapise m a loq# ~“‘“113

v--W-f l3rmckr ‘85”’

48

cl&f ‘81’” l+klcJlel ‘88” r+adswn bg!eW’ McEmca 9o’B Ycarnk 90’2’ h!fagamPi’~ suam91* WaneIs PI’” FfeIukl92’” &tle 92’” lAad.m 92” i3lwn 93”

116 67 46 2lB 95 111 60 68 26 327 355 65 231

16 (33) 54 (47) 15(2) 14(31) 82 (411 34 066) ww 22 (3-0 da 15 m 167 (51) 161(45) 45 (69) n (33)

3 (6) ll(10) 3 (4) 2(4) 15 VJ 7 (71 8 (7) 3 (5) 4 (61 3 (12) )? (9, WI.1 5 (8) 12(5)

Icremik 93’s* I%cmn 9P

IA) 45-l

67 (39) l@(W

5(3) WJ

4% wq 4% (7/1f#)

ElQ W’Y

?37

ilO(46)

17VI

11% (12mO)

*s (-J 96% U9sItm) -I* lat% (m97J

-wacrJlt CanQ -xi”5 lqbai 9:‘s cdq -92’9

u) 31 loo

9(t3) II (41) ww

6W 3(iO 4 (4)

61‘? (69) *n% (3’11) 8% m6)

160% am3) low (JUP) WI ww

sii¶w 92” Taka3e 93’3

60 53

B(47) i5 (W

6U‘J) 6(11)

21% (628) ,nx (1115)

1m (lV19) KWi (3332)

Yamis W”

161

5u(3U

15(9)

ifJ% VW

Rd-~a*,numberdp**ob*hoqacardid~t,sndiEs~phrnsdobifa~arcirc~~ ABIluslescreptembyC’~~~‘~~~~~.~~~~~~~~~’~~~~ fromz3lmdiqpsddnr Raiamwitb6ra3ddearsrrreomitIaifm~dpdiKidrpliKpreddivcn*c

19% (306) 2lX(lll34) m&(3/15) 14% (Yi4) 16% (1382) 9% (x34) 15% (WJ) 5%&22) wa aI% (X15) 13c; a-1 XT :..$‘t, ii% (i45) 13% (wn)

lfNl% (35X) IO@%(@6OJ lao% (5656) low (3l24) 98% (6Mq %9 (4446) im (51.51) 951(1M) loopr (2121) lax (11,‘ll) 99% (97%) 99% (ibLy1621 iw (2wo) m (12w21)

wx (8789)

?ar@q?~~sperdbl~TE&lracrgLapr~~l~

JACC Vol. 27, No. 4

EAGlsErAL

930

MaId

A6XJAJiA TASK FORE

15. 19%z!J10-4a

T&&g $. Summaryof Stkdia Exmikg tbe Value of DobotaminestressEcbocardiographyfor Preoperative RiskPredictive Valwt

EVMS Aptbar

n’

%enkwitb wemia (%)

hfVDwb (W

Lane 9l’G

38

50

Lab %!‘a

60

50

3 (8%) 9 (15%)

Eichaqer%‘*

75

36

2 (3%)

lagan pclbmak

‘93” w=

Dhila Ron&l 93”

74

24

3 (4%)

131

27

5 (4%)

88

23

2(294

criteria for -Test

Ptitive/Ml or Death

Neptk

NWWMA New or worsening WMA Neworamrscning WMA NewwMAcs -changes Neworworseamg WMA

16%(3/19) 23% (mo)

100% (19ii9) 93% c?w3o)

7% (2q

lam (48148)

Neworwotming WMA

lrbmathn obtahed is aetkely used to select patients for suebasanvnaryrevaseu~tionas tlleqtentic itlteweUastoadjustpe.Soperativeme&altreatmentandmordtoring and to select different surgical pcedures. The negative predhiivalueofanormalscanremainsanifomdyhigbat appxhteely!B%forMfand/orcar~df!atk.~the ri&ofa~~eventkl~tavdtbfba!ddefeus lEenecdforcautkminrontinescreehgwithadipyrhmoktldimnstreastestofaupatieotsbeforevascularsurgery Intbisreviewof457 agegreatertbm4Syeu5were tbanperfusion i-t3@3 inseve&pobticatioosbyHer&let~*~Letteet~l~and tiollof!xanabnmma& ri&-ntand thatasthesixof

Cwtmnk

vasadar and general slrgery tshhiwia(em ManagingphysieiamtdindedtoDsE results

179 (3/18)

Ial? (56/56)

14% (5135)

lc: ,i (96196)

IL% (x0)

~~

ww

MldIivaria1e allal& managing physicim blinded IO DSE resnhs lnclti long-term fd)orvup

The we ofdob&amhe stresse.chocadiogra~y in popemtive risk assessmentwas evaluated in sis studies,all published since 1991 and ident&ed by a computerized search of the English language literature (Table 8).1”J47-‘s1 The populations ineluded pdomimmtly. but not exeltiely, patients mdergohg pelipberal vascular 8wgical procedures= only twu titudks blindedtbepbysiciansm’d~wllotreatedtltep;ltients to tbe dobutamine stress echocaritim results’m.‘e In tberemainingstudkstberestdtswereusedtoiaftuenee preqeratiwmanagcmeri~parhhlytbedfxisionwketheror nottoproax45withawonarym&gmphyorwonatyteva.+ cukuiza~beforeekaivr:surgery.~studyusedshnilar, lnitnotidehc&proWokxTbedeIinitionofapositiveand negativetestrestdtdiffered~rably,basedon~ riualy&of~waumotion;ie,wwseningof~ WdlDKlth-waSCOllSideredbysOmeillV~torsasapitiveandbyothersasanegativehdirig.Theend pOht8USWJtOdefuKdiniraloutoaKVaribdand*~udedbOth

“soft” (ie. adythmii heart failure, and isdtemia) and “hard” (ie,Mlorca?dIaedeath)m+ktllts. Thedataill&atetbatdobutaminestress canbeperfolmedsafelyaDd~~

lAcCVd27.No.4 rhcb Is, 19%z910-48

wile 9. Prediak value of PIrnpelative i3OdCdk7CDdlAf&MaiorV~surtsen,

ExGlEErAL ACUAHATASKFORCE

!Trcsegment

changes

Detected

by Ambulatory

Mcmitoring

for f%soperative

hfyamdd

931

fllbmim

932

EAGLEETAL. ACUAHA TASK FORCE

wInJmadditiw;rl-

ormedicaIinte~mig4tt!e notsupporttheuseof odydiagno&testto

may be appropriate to angiopphy rather than perform a example, preoperative consultation may umtableanginaorevidenceforresidual recent MI for whom coronary angiography is indicatfd. In genera& indications for preoperative coronary an&pphy are similar to those identified for the nonoperative setting Table 4 provides a summary of indications for rtive amnary aqbpphy in patients being evaluated rumadac surgery. These are adapted from the ACC/ MM guideks for comnary angiogr : $ty published in 1987.36 pmyd

w$tznary

JACC Vol. 27, No. 4 March 15. 19‘%910-48

ment of this strategy in 201 consecutive patients being considered for aortic surgery is presented in Fig 2. In this series,only 58 (29%) of patients considered for aortic repair underwent further noninvasive testing with exercise andior dipyridamole thallium study.Siieen patients (8%) were referred for cardiac catheterization, with preoperative coronary revascularization performed in 13 (6.5%). This selected use of noninvasive testing and very selected use of revascularization resulted in an overall perioperative cardiac mortality of just 0.5%. To illustrate the cost implications of noninvasive testing and its potential cost-effectiveness,information from the Medicare databaseswas applied to the series by Cambria et al in Fig 2. If a cost of $567 per nuclear stress test is assumed, the accumulated costs of the selective screening of 58 patients is $32 886. In contrast, the cost of screening all 201 patients would have been $113 967, a net increase of $81 081 over selective screening. Based on an annual incidence of 500000 major vascular surgical procedures in the United States,selective testing could result in a savingsof more than $200 million, compared with a p&cy of routine testing. If the accumulated costs of the tests and coronary interventions are taken into account, the overall cost of using this particular selected screening strategy in the 201 patients was approximately $590 206, or $2936 per patient. As described prekusly, there are no randomized trials demonstrating the etbcacyof screening and coronary interventions versusvascular surgery only. However, the low mortality qorted by Cambria et al and ot’lers in patients who had undergow coronary revasadarization suggeststhat such strategies improve survival. Using the Cambria data set as an example and assumingonly one life wassaved asa result of this strategy,the strategy would be at the expensive end of medical cost-effectiveness.lf long-term benefits are considered and thh patientlived10yeam.tbkstrategywouklhavecost559020per yearoflifesaved([email protected]).lfthe screening strategy was more s2xxud& per4aps resulting in twoIkressaved,thecostperyeardlifesavedwMlidhavebeen $29510, a figure that is much more consistent with other currently accepkd mediil therapies. Importantly, many of tbeseeostswoukllike.lybeincmvedatsomepointregardlessof consideratioo for vascumr surgery. In addition, Ribal e-t al** ~along4ermsurvivalheneLofc4mmaryartery bypassgrafthginpatientswitht4e-ofperipheral vasadar disease and triple-vessel CAD. Therefore, by inchnJing both sboit- and long-term benefi& such a strategy might prove to be cost-effeuive. Formal de&ion and coststTectivenessana@s of this partMarquestionhavebeendoneandbaveyieldedhii varied res~Its.~J@-~@-~@ Bccaw tltc exact amount of, risk red~bomcomnary~tionandt4ccliaical populationsdiEerssontncbfmmoentertocenter,itisdi&ult todetermhrethe~ristsof aggrkwEcreeningalld treamem-tbebeaefitsintem?sofrisiredudioa .. ~,tIIenuJdeIsalI~0ptieoal-m reImau~.t3Jterecubtapadd,

JA‘X Vol. 27. No. 4 M?-ch IS, 1956910-46

EAGLE ET AL ACC’AHA TASK FORCE

Nudcarsbesstesting

933

532666

$457+11o=t567

527 600 16 patlen@ (6%) t

PTCA: 2 PabjenLs CABG: 11 fmtimts

$43 520 (6.5%)

+ TotalpMlphW?GildiaCardiacdeath 1 palJenl(O.5%)

wJ6200 s590206

asessment of a screening arategy for major vascular surgery patients. ‘1993 Medicare average alhed cbarge~ global kes. ‘Metlife. 1992 ckims data from insurance pool. srarirticnl B&h. JanwMarcb 199U3. “Metlife. 1992 daimr data fmn inwpd. Siewicfz/ lkdkrin January-March 1994;lO. %ktIife. 19!&!daimsdarakom iasurancepool.S&&jn. Jaauuy-March W&35. CPTmndkatecCurrenr F’mcedd Termindogy, FTCA, pera~taneous @amhtmii coronary angioplasty CABG. m utety I?lplrs surgeq.

Ft2.cosl

wbicb did mt support a strategy incorporatiog coronary aogiograpby and wascuhrization used lower mortality rates than the used or reported in the other studies,“‘.J”.‘* Therefore, use of any decision and costeffectiveoess model ia a specitk situation defnmds on the comparability of local mortalityratestothosedtbcmodel. Fig 2 is meant to ihstrate tbe potential costs versus effectiveness of one such screening strategy. It is vitally important for the dinician to consider tbe axt impliitions of screening strategies, partiadarly in a field in which there are no randomired clinical trials evahmtii tbe impact of therapies on

in tbe CAS registryfrom 19-B to 1981and evelu* UndclweLlt major rloMmi& operatiom, 113 (7%) of wbkb werevascuhrprocedurerl%e&udygmupioch&d399 parieots ai&a~t aogiographic evidence of a&axed CAD (group l), 743 patkots Mo had prior cownary bypasr gratiii beforeooocardiacpoadures(gnxrp2~aod458~wbo bad r+ign&m al@ppbk CAD (xi% bmi5al stamsis) but mpriorbjpaSsllrgery(gmup3).Theqx?Iativemor&y rates for norkwdii m in these tbree groups vere 0.5%. 0.9%. and Z4%, recpeclively, aml m glwp dikreaa wcremledintbe-dperiapentiwMlorurdLc anil@lhTh!eoperaMlllortqrateingoup3was sigoificandybigkr(P=.(Kl9)tbaniaeitkroftkotkrtwo

934

JACC Vol. 27, NQ. 4 March 15, 1996:YlO-48

EAGLE ET AL. ACUAHA TASK l=ORLZ

tations of CAD (f<.OOl). Of these, 216 undement coronary bypasssurgery (before vascularsurgery) with a related mortality rate d 5.3% followed by a mortality rate of 1.5% for vasdar surgery. Operative deaths with vascular surgery ocaimed in 1 (1.4%) of 74 patients with normal coronary arteries, in 5 (1.8%) of 278 with mild to moderate CAD, in 9 (3.6%) of 250 with advanced but compensated CAD, and in 6 (14%) of 44 with severe, uncorrected, or inoperable CAD.175Studii such as these have generated interest in the posdble protective influence of coronary bypass surgery on subsequent surgical risk, even though interpretation of most retmqx&e studies is limited by failure to define the criteria for nonfatal MIS and 10 indicate whether or not serial ECGs and cardiac enzymes were obtained perioperatidy. In attempting to baIance the potential risks versus benefits ofc!oroayarterybgpass~(oQBG)befofenowardi !3wgeay, the rddihml rdlort-term risks and long-term

benefits

shod be mderstood Long-term benefits of such strategies were not incorporated into two recent decisiin models’*iW If the long-term benefits were indude the value of preoperative revz&x&tionwouIdbebeForimtance, theEuropeanCoronqSurgeryStudyGroupl~basreported &enSing6nding5inasmallsubsetof58patientswith peripheralvasudardiseasewithinamuchlargerseriesof768 menwhoweremndomly&gnedtoreceiveeithercomnary ntmgemmt for angina pectoris. bP=surgety~wbiIethepreselmdinci4jentalperiphem)vascuIardise;sfe wasasso&edwithred&ionsintbe@eiuawivalratesfor eitkrsmgicalormedicaImaaagement dCAD,itskthence -fJespoeially -inpatientswhoreceivedmcdicaI therapyakwle.mti5thelong-termawivalratewas85% coromuy bypass surgely, lxnnpad with 57% for tTeamt (f=.uq. Rihal and lzdeagw’” have illZlbOlTthan2OOOptkOtS

thenwkcompzlred witIlaJsumuy~aurgelyinpatien~witbbo&bcoroaary heartdiseaseandperipberalMsarlardii,~

include patients with the following conditions: acceptable coronary revascularization risk and suitable viable myocardium with left main stenosis,three-vesselCAD in conjunction with left ventricular dysfunction, two-vesseldiseaseinvolving severe proximal left anterior descending artery obstnxtion, and intractable coronary ischemia despite maximal medical therapy. In patients in whom coronary revascularization is indicated, timing of the procedure depends on the urgency of the ~onardiic surgical procedure balanced against stability of the underIying CAD. l%e decision to perform rexascnlarization on a patient before noncardiac’surgery to “get them through” the noncardiic procedure is appropriate only in a small subset of very high-risk patients. Patients undergoing elective noncardisc prooxiures who are found to have prognostic high-risk coronary anatomy and in whom’ long-term outcome would likely be improved by coronary bypass grafting,*? should generally undergo revasc&ization before a noncardiac elective surgical procedure of high or intermediate risk (Table 3). -cororrnrJ?tammq ajtdaee. At present no randomized clinical trials have documented whether or not prophylactic coronary etasdkation with angioplasty before noncardiac surgery ieduces the incidence of perioperative cardiac events.Several retrospective series, however, have been repoficd. In a 5(rpatient series reported from Mayo Clinic,‘n coronary an+ @astywas perfolmed before noncardiac surgely (52% Wscadar pmc&ues)inp&ntsathighrSiforperioperativeam@icati07*(62%werec&SedhighertbanCan&anHeartClassIfI, -%hadmulWsselctisease,andauhadabnomminoniwasive tests).Tenpercentreqdredurgentcoromuybypass~after

mte19%.Whetherornotthisresultdilfersfromwhatmighthave dwithoutPTcAk~ EImoreaaI’~eonrparedthedtsdpreoperativeanvnary zu@opky and tommy bypass surgery in patients identifkd foi elective abdominal aortic aneqsmorrhaphy. ‘Ibis stud pr;.xospectively analyze the records of 2452 patients do UndLrwent abdomiil aortic surgery between 1980 and 1990. orfy 100 (4.1%) had revascularization before aortic SWgl3&.and%%doftheseSylltpt~CAD.Eightyaix hadcWmarybypSssurgeryand14had~.lbere werenope@e&vedcathsinthisgronpattbetimeofaoi?ic surgery, mmpared with 29% pe* entire jp7mp (n=i452). Tbe patients is signScantly more c4xe-and two-vesxl Iceveiaeldiseasethandidthebypamgmup.Iatec+iacevenls weremorefrequentiiltheaagioplast),gnmp.TllesmaIl oumbelsinIheao%ioplaJtrgToupaRdtbereuospectivcanaIysisoveralongperioddtimcnmkeintqreWonofthe

huiJldkmmyoerdialinIarctim. *MpcardhtP-c.05 for drug wm% canml.

Ailen et aP performed a retmpe4.tii am&is of 148 patients who underwent angiopiasty before tmcardii surge9 (abdominal 35%. vascular 33%. and orttPopedic 13%). surge9 oectmedwithin9OdaysafterangioplastyinRTherewere four operative deaths (one cardiac), and 16 patients experienced cardiac cumpkahons during the tmcardiw surgery. cardiaccomplicationawerewereaJmmon illpatietJIso&kr rbanayeaatitIieinfomtationcanbegieanedfromthissman retmspeaivestuclyexoepttollotetbeiow~nceofeardiac deatbinpatietlIswhnhadcoronafyangioplastysolneIime before their itonwdii surgery. GivcnIheselimiteddata,tkdeoffat@ykbpnoperativeaxxmarya@ophtyinreduchguntwardphpe&ve cardiac c4?mpkatiarts remains iifampktely delkd. UnId fwtherdataareavaiMe,tkindicationsforiXAint&e periopetativeseningareidcntifalIothoscdevc~lrytke jointACUAHATaskFonxprwidiagpidclinesfortheureof PTCA in generaLi FOrptientswhohaveondergaK~cOrararyaa&piastyjustbeforepqosedooncatdiacsurge9,thereis kltmttainty~~mlldl~shcmld~betoretbe noocardiac~iSperfaaleb&~oarudirWgeryformLuethamlto2montllawouldleadtoa~ater sikdtllus elmnceofeotnna9-att tlmclfatmsofperiopastiKisdwaha -iDense mAIIltcotkrrsmlte,,uterhlKmoilra#nraaltcthroat lf#isatIile*ofmislnoaIlih!fyIooaaIl~lnn8sto 1to2*afteralawmly andtltmid

936

JACC Vol. 27. No. 4 &Id, 15,1!3%610-48

EAGlEElAL ACf3WA TASK FORCZ

dejx&ion than treated patients (2%). In a nonrandomixed g&y, &tfxnackass gave oral metoprolol immediately before surgery and foBowed with intravenous drug during abdominal aortic aneurysm repair. Only 3% suffered an acute MI, compared with 18% for matched controls. In a later report the same author reported less intraoperative ischemia in patients treated with orai metoproIo1 before peripheral vascular surgeWss There has been onIy one study examining the role of caIcium chamtel blockers in this situation. The study was too smaI1to allow definitive conch&m (Table 10). The use of nitrates is discussedin the section on intraop erative management. There are very few randomixed trials of medical therapy befotc nonarrdiac surgery to prevent perioperative cardiac compliitions, and they do not provide enough data from which to draw tirm amchrsions or recommendations. Prehminary studies,however, suggestthat appropriately administered &blockers reduce petioperative iscbemia and may ultimately be shown to reduce risk of MI and death. Cleady, this is an ah&e. recent past to control sympmmsof angina or patients with symptomatic arrhythmias or rative a.wsment identifies untreated hyzs mmnary disease, or major factors for C&m UL Contraindication to @lockade.

v&e surgery There is little informaticm about the appropriateness of vabtdar repair or repiaQment before a nonmud& surgical proc&re is undettakeu Clinical experience indites that patientswithvabnlarheartdiseaseseveteenoughtowarrant .wgical treatment should have valve surgery before elective zhcmcdk surgery. RecentIy it has beea suggested that patients with severe mitral or aortic stenosiswho require urgent ltoncdknulpry,suchaaintestinal resedon for ksii causingserkmsgastrohttestma~maybenefitfrom catheterba&onvaWopUyatleastasatemporizmgstep to &ace the operative risk of di surgeryamJ~ unfortuoateqr, there are no coatNued studies, and the risks of baIloon aortic valvuloplasty in older patients are with managing Avular heart disease during labor atd detivcry pKwides bights into the appmach to

tion. Therefore, increases in blood pressure should be prevented. and left ventricular afterload should be optimized with vasodilators. In contrast, patients with significant aortic or mitral stenosisoften do not do well with the increased hemodynamic burden of pregnancy. If the stenosisis severe,percutaneous catheter balloon valvotomy should be considered as definitive therapy or as a bridge to carry the patient through ; .egnancy, labor, and surgical delivery. Excessivechanges in intravascular volume should be avoided (see also section III, “Valvular Heart Disease”).

ArrhythmiaJConduction/Device In the perioperative setting cardiac arrhythmias or conduction disturbances often reflect the presence of underlying cardiopulmonary disease,drug toxicity, or metabolic derangements. In patients with documented hemodynamically signihcant and/or symptomatic arrhythmias, ambulatory ECG monitoring or specialized electrophysiological studies of the heart with guided drug therapy may be indicated to reduce recurrences of arrhytbmias.190~i91 Supraventricular arrh@m& may require either electrical or pb armamlogid card&et&m if they produce symptomsor hemodynamic compromise. If cardioversion is not possible,satisfactoryheart rate control should be accomplished with oral or intravenous digitalis, @adrenergic blockers, or calcium channel blockers. In patients with atrial fibrillation who are on oral anticoaguUon therapy, it may be necessaryto discontinue the anticoagulant several daysbefore surgery. If time does not allow and it is important that the patient not be on anticoagulants, the effect ofwarfarin can be reversed by parenteral vitamin K or fresh froxen plasma.& Ventricular arrhythmias, whether simple premature ventricular mntractio~ complex ventricuhu ectopy, or nonsustained ventricuhu tachycardia, usualIy do not require therapy except in the presence of ongoing or threatened myocardii ischemia or moderate to severeleft ventricular dysfunction in which such arrhythmias represent a significant risk factor. Sustained or symptomatic ventricular tachycardia shoukl be suppressed preopzratively with intravenous lidocaine or procainamide. The indiitiorts for temporary pacemakers are ahnost identical to those previous& stated for long-term permanent cardiac pacing.i~ Patients with intraventricular conductii delays, bifascimdar block (right bundle branch block with left anterior or posterior hemibiock). or left bundle branch block with or without lirst degree atrioventrictdar block do not require tempotaty pacemaker implantation in the absence of a bistoty of syucope or more advanced atrioventriadar bloiAri Permanent pacemakers may need to be checked for end-of-life indicators and programmed to verify qormaifunctkmandthepatient’sievetofpacm&erdependency.InpatientswhoaretotaIly eiectmcauteryposesaspeciaIpm&mandsbotddbeusedonly brietly.wiihtheinditferentpoleplaeedasfarawayfmmthe paammhrand heart as paJebIe. In gtlamdmdept patiea~aofbipolarpacingwiIiminimiaetberiskoftaaed c-Iety..AlsqtItet&toboti~

JACC Vol. 27, No. 4 March IS. 1996:910-48

ited mode such as AOO, VOO, or DO0 with programming or a magnet prevents unwanted inhibition of pacing. Implanted defibrillators or antitachycardia devices should be programmed off immediately before surgery and then On again postoperatively to prevent unwanted discharge due to spurious signals that the device might interpret as ventricular tachycardia or fibrillation.

PreoperativeIntensive Care GewemlcoRddrmtiorss Prcoperativc invasive monitoring in an intensive care setting can be used to optimize and even augment oxygen delivery in patients at high risk. It has been proposed that indexes derived from the pulmonru) artery catheter and invasive blood pressure monitoring can be used to maximize oxygen delivery, which will lead to a reduction in organ dysfuuction. *dEOnly me study has pmspectively evaluated tbe ekacy of preoperative jmhnouary artery catheter utilization and optimization of hemodynami in a randomii trial with cardii complications as a major outcome. Eighty-nine patients undergoing infrainguinal arterial bypass procedures were randomly assigned to groups that received a pulmonary artery catheter aud (I) p: prative optimizaion overnight in the intensive care unit, (2) for 3 hours preoperativeiy by the aue&esk care tq or (3) intraopefative monitoring based sole@ ou el%cai irldicationa’~~ When MI or tlunarrhythmogenic rardiic death was used as the outcume, no significant differences were demonstrated. Based cm the scant wide=, preoperative preparation in au intensive care unit may benefit certaiu high-risk @en& particularly those with decompensated CHF. Preparation of such patients should occur under close supervision.

Vew~~h/Peripheml

937

EAGLE ET .AL ,+CC AHA TASK FORCE

Armial LXsease

Two pe.ripbed vasdar disorders that merit attention pzeoperatively are venous thromboembofism an4 iu the elripherd arterial disease. wed to be planned ai,d in some lyforperyomwithchuicalcizWmstances assuciated with postopetak venous thrombocmboiisut.TlleseawrelatesofthromboembdierbLhdudead-

pneumatic compression--will depend on the risk of venous thromboembotism and the type of surgery planned. Table It provides recently published recommendations for various types of surgical procedures.‘“l-lW The noninvasive techniques-impedance plethysmography and real-time compression ultrasonography-are effective objective tests to exclude ciinically suspected deep venous thrombosii and are best used for this purpo~.~~7J* Routine screening of all postoperative patients with a noninvaskr technique is not as cost-eflective or efkient as appropriate antithrombotic nrophylaxis for moderate- and high-risk patients.~‘+ IvI The prevalence of chronic occlusive peripheral arterial disease rises with increasing age. atkcting more than 10% of the general population older than 65 year+ and as many as half of persons with CAD.~‘l Protection of the limbs from trauma during and after surgery is as important for those with asymptomatic arterial disease as for those with claudicatiou. VIII.

ADestw Iwaoperative

coosidelatioas

The pat-1 events thaw occur with the trauma of surgery and the perioperative administration of anesthetic and pa&relieving drugs ofien affect the pbysiorogy of card& functionaJld~iootogreatdegrees.specificintegratkm oftbesechaagffwirhtbe~hamieaalllalionlsa~unro itselfaruibeyoudtbescopeoftbeseguideliiTheinformatirmprovidedbythecardioyarularcou5uhantneedstobe integrated by the w surgeon, and postoperative caregivers in preparing an individualized perioperative maruge=nt * lllcrearemanydiuere~tappoadrestothedetailsdthe ancslheticcareofthecardcardiacpiuienLEachhasimplications regarding anesthetic and intt-aopemtive mattitoring. a~iaautmnu tic4t.msudyh&cieatiyde~

statesban4p* bytkremtt 19s

IO addi-

fnmt&lazdthefobwiugtechaiqua:apllmooaryartery cathe,sT~munita.tramsopbagcat~ ph~@),~w aocsthetirandiaavlpentive timoftheane~eauetearn~~tmy

llim#uk-.tbe~of rmnitrsk&rtkfttutheGsae-

choinof~re?c~dAgrrrl

ties~obes&vrm35E pefvi&hipalegc4Jnphde8aoprdnd-iab

and

M4umgement

Mdtjp&mdaahm~tbeinducmdraattKtk: rhJgsand~ooardbEmorbidky.la~ slLldk50iuarc~potienq~-d~~~ ppcairtlralcthemu6t~~

itapparrthcreisooonebest~~potcdivc 4iaed~k?Knm~tbd~beaariacndie*

JACC Vol. 27. No. 4 15. 1936:910-48

EAGtxEl-AL ACCJAHA TASK FORCE

938

Taft& Il.

General Guidelines

for P&operative

March

Prophylaxis

for Venous ThromboemMism* Recurnmendation Early ambulation. Es: LDH (2 h preopxatie@ and ewy 12 h after). or IPC (intraqxratively poaperativcly). LDH (every 8 h) or LMWH. WC if prone to wound bleeding.

and

LDH, LMWH, or dextran combined with IPC. In selected patients, perioperatiw warfarin (INR 2.0 3.0) may be used. LMWH (postoperative, subcutaneous hvice daily. lixed dme unmonitored) or w&tin (INR 2.0-3.0. started preaperatively or immediate!y after surgery) or adjusted dose &ractiinated heparin (started preoperatkly). ES or IPC may provide additional e6icacy. LMWH (pcatoperatiie, s&cutaneous. t&e daily. faed dose unmonitored) or IPC. LMWH (preoperative, subcutaneous. tixed dose unmonitored) or warfarin (INR 2.03.0). IPC may pr&le additional benefit. IPC with or without ES. Ccmider addition of LDH in high-r& patients. Adjusted dcse heparin or LMWH for prcphylaxis Warfarin may abo be effective. LDH. ES. and IPC may have benefit when used together. IPC, warfarin, or LMWH when feaii. serial surwiIIaap with duplex ultmay be useful. In selected vev high-risk patients. consider prophyiactic caval filter. Esil%dica~~

elastic stocldngc LDH. low&

subcuraneaa heparin; IPC, intermittent pneumatic compressiq

LMWH, low molecular Weight

+ili&J amditk atwciated +tb iacrwed risk of emus thmmbwmbdbm: z&anced age: prolonged immobility or paralysii previous venous tlmmtbwmmajot smgery of awnneh p&is. ot Iowa extremity; ohedty; varimse veins; connive beart failure; myocardii infarction: St* fmcture(s) of bolisn: sMesaltd~~csmrgenusc. ~pelrisW~ork&

pioperative plan. opioid-based anesthetics have become popular because of the cardiovascular stability associated with theii use. The use of high doses, however, is associated with the need for postq-Jerative ventib#ioo. sii weaning from the ~&atorinaniatetGxcaresettiqhasbeeaassociatedv4th myoc&ial i&em& this featare is important in the overall riskkftteqnatioa All iobalatiooal agents have eardiovaseular effect!+ iodudof nymdial eontradlity and afterload reduc-

etlamn%

aud isotlurane-did not iutluence outtiiak.~Tbeeardiavsscularsafetyofthe -, is tlot as well

prcload becomes Bornpromised or blockade of the cardioaccelericon oams. Monitored anesthesia care by an anesthesia caregiver inch&s the use of local anesthesia sy#mented with intravenous sedation/aualgesia and is believed by some to be associated with the greatest marginal safety. In a large-scale shrdy, however, monitored anesthesia care was associated with the highest incidence of 30day mortality.~ This finding may reflect a strong selection bias io which the patients with signdicant coexktiig disease were selected for surgery with tmmitored anesthaia cm rather than other anesthetic techniques. Although this tech@ can eliminate some of the undesirable effects of general or neuraxial anwthesia, it providespoorbkxkadeofthestres4responseunlessthelocal anesthetic provides profound anesthesia of the affected area. If the local anesthetic block is less than satisfactoty or cannot be used at all, monitored aoesksia care could result in an inmat& iacideoce of qvcardial ischemia and cardiac dysftmuionaxopaAwithgetteralorqioaalaae&&a.To adkvethedesifedeReeCewsssedathieanoceur.Therefore, there may be 110 sigoikant difkence ia overall safety withmo&tmedanesk&aeare,andgeneralorregkmalanesthesiamaybepreferable.

EACLEETAL

JACC Vol. 2. No. 4 March 15. i9%910-48

ACCAHA

cardiac events in noncardiac surgical patients occur postoperatively, the postoperative period may be the time during which ablation of stress, adverse hemodynamh and hypercoaguIable responses is most critical. Although no randomized, controUed study specihcally addressing analgesic regimens has demonstrated improvement in outcome, patientcontrolled anatgesia techniques are associated with greater patient satisfaction and tower pain scores. E@hual or spinal opiates are becoming more popular and have several theoretic advantages. Several studies have evaluated general anesthesia!iitravenous analgesia compared with epidural or epidurzi cor.:bined witb &II4 aner&eWepidural analgesia. The patiens having epidural anesthesia/analgesia have demonstrated lower opiate dosages, better ablation of the cated&mme respome, and a ieshyperooagulablestate.honeshIdyofpatiennImdergoing lowerexkmityvascukrbypossproeedures,thelIscofepidural ane&csia/analgGawasassociatedwithaknwxinc&oceof cardiac~,however,thishndingwasnotco&medin another study.mm Most @ortan& an etTeUive an&e&z (ie, onethatbhmtsthestressrespome)regimenmustbeindudedin &eperiopmtiveplan.

Intmopemtive

Nitqfyccmin

GemedNitroglycerin has been shown to reverse myocardial ischemia intraoperatively. fntraoperative prophylactic use of nitroglycerin in patients at high risk may have no effects hovvcver, or may actually lead to cardiivascular decompensatioo through decmmes in preload. Additionally, nitrog&erin paste or patch may have uneven absorption intraoperatively. Afcordinglyn~nsbouldusuaflybeadministeredinthe intravenous formulat* if required. Ike venodifating and arterial dilating effects of nitrogfycerin are mimicked by some anesthetic agen& so tbat UK combiition of agents may lead to sigoiticant hypotemioo and myocdd ischemia Therefore, nitt@ycerin shouid be used only when the hemodynamie effects of other agents being used areconsidered ieshaveevahJatedthevahieofpta phyiactic nit@ycerin infusmns for hi-risk patients, ioduding two studies in noncardiac surgery patients (Table 11). Is*l~oBDR Only one study, perfomed in patients with stabkanginaundngoingQIotidemiarterectomy,~stratedareducedioc&aceofmtmoperativempcardialiscbemiaintbegroupreceiving1.0lrgllyperminuteofrdtrog&erin.Neiidtk+nOsmai:PEldies-tedany

TASK FORCE

939

angina. The recommendation for prophylactic use of nitroglycerin must take into account the anesthetic plan and patient hemodynamics and must recognize that vasodilation and hypowlemia can readily occur during anesthesia and surgery. Gha III. Patients with signs of hypovolemia or hype tension.

Use of Tmmesophageal Echowrdiogmphy GeftdThe USC of TEE has become increas~ngty common in the operating room for cardiac surgery hut is less frcquentfy used in noncardiac surgery. Multipk investigations have documented tbe improved sensitivity and specific&y of TEE for detection of myecardial ischemia compared with electroczdiography or pulmonarycapilkuy wedge pressure measurements Most studies have used off-line analysii of the TEE images, however, and automated on-line detec&n may increase its value. S-FYofETherearefewdataregardingthevah4eofTEEdetecied wall motion abnwmalities to predict cardiac morbidity in noncantiaf surgical patients. In two recent studies from the samegmIp,intraoperativewaomo6onabr~iwere puorprediiofcardiacmo&dity.~~“~lrfnooestudyim&ing332menundergoingrroncm&smgeries,TEEdemoo strated an odds ratio of 2.6 (95% CL 12 to 5.7) for pcdicting perioperative cardiac events.210 requires additional presenttherearenoannmer&iyavaiWere&irnemonitom ofquarItitatirewaomotion.~rrgioarlwallmotkln abnom&itiesinahigh-riskpatientsuggestmyocPntialischemia.resohrtionofmyocanWischemiamaynotresuhin iirqowmntofwaumotioa.

traini~

At

940

JACC Vol. 27. No. 4 March I.(. I996iWO-4R

EAGLE ET AL ACCM,A TASK I-‘XXX

There is currently insugicient evidence to determine the vahte of prophylactic placement of an intra-aortic balloon ~nte+dsation device for nigh-risk noncardiac surgery. IX.

Perioperative

SurveiMance

Although much attention has been foeused on the preoperative preparation of the high-risk patient. intraoperative and postoperative surveillance for myoeardial isehemia and infarction, anhythnii and venous thrombosis should also lead to reductions in morbidity. Postoperative myocardial irhemia has been shown to be the strongest predictor oi perioperative cardiac morbidity and is rarely accompanied by pain.’ Therefore, it may go untreated until overt symptoms of cardiac failure develop. The diagnosis of a perioperativs .?r_! has both short- and Iong-term prognostic value. Traditionally. a perioperative MI has been associated with a 30% to 50% perioperative morta!ity and has recently been associated with reduced long-term stnvival.*~~~~4~~5 Therefore, it is impormnt to identify patients who sustain a p&operative MI and to treat them aggmsively since it may reduce both short- and long-term risk.

htmoperative and Postopemtive Use of Pulmonary

cry catheter can provide siguificmt information critical to the care of the cardiac patient. Its use, however, must be balanced against the cost and risk of compkatious from insertion and use of the catheter, rhii are low when the operators are experienced. Several studii have eduated the benefit of pulmonary artery catheters in both -aiabandthosetISiIlghiStO~COIItlOlS.Illpdents with a prior Mk when pedqe&ve care included puImomqarteryandintensivecaremouitoringfix3days postqemtively,therewasalouerhk4eneeofrehtfar&m tbaniI4-amtrok.~otherehaagesinmanagemeat axurreddmingthepetiodtmdersMy,ho98ever,inel~gthe iweaseduscof&aQewrgicsympatheticblocbade.Inpaftie!2!ar,pati+swithsigt6andsymp@msofheartfaihuepreop. eradveIy,wbhaveaveryhigh(35%)pmtoperativeiueidence ,mightbe&tfromiIlvask ~modynamic

bidity in infrainguin-l surgery patients when monitored by a pulmonary artery catheter either from the evening before surgery. 3 hours before surgery, or only if clinically indicated; however, the soups with the pulmonary artery catheter had fewer intraoprative hemodynamic disorders.‘9J Reromm~ Practice parameters for the intraoperative use of a puhnonary artey catheter have recently been published by the American society of Anesthesiologists.riX These parameters approach the decision to place the pulmonary artery catheter as the interrelationship between three variables: patient disease, surgical procedure. and practice setting. With regard to the surgical procedure, the extent of intraoperative and postoperative fluid shifts is a dominant factor. use t?fplrlRwwrJ Artery cathdm2’8 IC&xcr i. Patients at risk for major hcmodynamic disturbances that are most easily detected by a pulmonary artery catheter who are undergoing a procedure that is likely to cause these hemodynamic changes in a setting with experience in interpreting the results (eg, suprarenal aortic aneurysm repair in a patient with angina). Fuss II. Either the patient’s condition or the surgical procedure (but not both) places the patient at risk for hemodynamic disturbances (eg, total hip replacement in a patient with chmnic renal insu%ency). Cks LfX. No risk of hemodynamic disturbances.

Intmoperotive and PostoperativeUse of ST-SegmentMonitoting GmmliconriQlrrrions Some contemporary operating rooms and intensive care unit monitors incorporate algorithms that ,&orm real-time anaIy& of the ST segment. in &&tion, realtime ST-segment maiming via telemetry or ambulatory ECG (Holter) monitars with alarms is being developed. Numerous studies have demonstrated the poor ability of physicians to detect sign& cant ST-segment changes compared with computerized or o64ine analysis If available, computerized ST-segment hendirtg is superior to visual interpretation. Although proprietary, martyofthesea@ithmshavebeenvaIidatedfortheirability to aecurateIy deted ST-segment shifts syI*IprldE+-@ VirtuaIly all studies examining the predietii value of intraoperative and postoperative !lT-segment changes have been performed using ambulatory ECG recorders. Using fehospeche analys& investigators have found PQulperatiw sr-segment changes indiicative of #lqam&l ii?hmia to he the~h&pendentprediiofperiopaativccardkx eventsinhi$l-Iisknoncar~surgeIypadentsinlmdtiplc shIdkwitfl~ofpm&mgcddmationking~ e@(j

*

&fea$ed

&&‘“‘9tBo

&f&j@gy,

pQg(qep

atksr~dMuIgeshavebcenshowntopredictu¶rsc

JACC Vol. 21. No. 4 Maah 15. 1996c9l(J-48

occur during elective Cesarean sections in healthy patientr”! Because these changes were not associated with regional wall motion abnormalities on precordial echocardiiaphy, in this low-risk population such ST-segment changes mzy not be indicatiie of my-dial ischemia and C4D. Proper use of computerized ST-segment anarysb in appropriate hirisk patients may provide increased sensitivity to detect tnyocardial ischemia during the perioperative period and may identify patients who might benefit from further postoperative and long-term interventions. Therefore, computerized monitoring of rhe ST segment cdn provide useful information in appropriate high-risk patients, if available. The cost-effectiveness of annputerized ST-segment am&is for reducing perioperative morbidity, however. bas not been documented. Further research is required.

Sutveiliancefor Penbpemtive Mpcardial Infarcti Multiple studii have evaluated prediiive factors for a pe.r&erative MI. Ilie presence of clinical evidence of mm my artery or peripheral vascular d&se has been associated with an kreased incidence of perioperative MI. Factors that inmase tbe risk of a perioperative MI have been discus& previously. Because of the incmas;d risk of both short- and long-term mortality from a perioperative MI, accurate diagmv sisisimQomnL be documented by serial ekctmcardii~ cardi@ enzyme adyses, mmpadve vcntricdo* studies before and after surgery, and radio& topic studies speeilk for myocardial necro&PublishedECG criteria for MI vary, however, with some authors IMe5otamde&ria,othensimply~new Qwaxs,andotbersnotspeeifjkqtheECG&eria.NonspecificSTandTwavechangesarecommonintbeimmediate postoperative period but have not been assnciarti with increased m4rkdity.~ la the analyskofcardiac ew2yme criteria numennfs‘~are-toCK-* and tbethnsboldatwtkhanenzymefiseis4xmsi&&abnormal iSVakbk.l~addiiCK-MBhasbeensbav7~obenkaxd ffomnonc&ksoumsinpatieatswithi&emiclimb5w undergoing amtic sqefy, the group at highest risk for a pcriopcntiJc MI. Fii, new mvoardiaGsptciFr enzyme5 tbaI2recuRentlybtingdcvclopkdlmdcvaluatcdiIlthe pelioperative patient. slcb 8s card&E tlupdn-I a troponin-T orcic-MBisof~requinfurtberstudybeforedete~ theirusefulnemin~~* sa*rurd-

EAGLE t I AL ACC USA TX% FORCE

941

pending on the diagnostk criteria used. A stra:egy usmg an ECG immediately after the sor@cal procedure and on the finr and wcond da y’ pos:operativeh had the hignesi sensiti\i+. Qrategies inciudirg the serial measurement of CK-UB had higher false-mtive rates uithout higher sewhi\ it&. la contrat. Rettke”’ reported ihat orerall wnival war aszmiatfd with the degree of CK-MB elevation in 348 patients undergo. ing abdominal aortic aneurysm repair. Gth higher levels associated with worse survival. Yeager et al’l’ cvaiuatsd th prognostic implications of a pzrioperatk Ml in a uxi63 d IS61 major vascular prwcdures. l%ew autbon found that the incidence of wkquent VI and coinnary arter) rmwxtarritation uas $@icanrl) higher rn patients who suffered a pnoperalive MI. except in rhe Wt who or@ demonrtra:ed an elevated CK-MB uitbout ECG change< or wrdimawurlar symptoms. Further ewluarion regarding the optimai btrareg for .i ‘: veillance and diagnosis of perioperative MI is requmxl b&.ne ooe method is advocated In patients u;itbout evidecr of CAD, suweiltance shwld be restricted to patienrs who dewb periopxative signs of cardiiascular ~sfuxtion. In p.&ent~ with known or wrpeaed CAD undergomg surgical procedt.m associawd with a high inckknoe of cardknasular morbi&y. ECGs at baseline, immediate~ after the SurgicA prc4xdurr. and daily on the fim 2 days postoperative& appears to k the most cost-effde urategy. Measurement5 of cardiac en are best resewed for patients at high risk or those &J demonstrate ECG or berm@namic ekknce of cardi~ascular dys-.

942

t:Al;I IS t.T Al Al77AIIA TASK FOR< k

channel b&ken+ or @ldien with sbwvit& of henn ra~c dnd a~rdiovetim. Un~foa~l or multifocal prrnwture ventricular amtMctkma do not merit vigorous therapy Cotnpkx venlricular ectopy such aa mxm&ned or sustained venttie&u tachycardia fUpiKSmKeVigOtUUStherapy.~itldrepmenceOf

ongoingatbreatenedmyocardialischem&kftventriaJar* limtim, or valvdr heart dii. Ventricu&r arr~hrnias may nqond to &awxous &Hock* liiine. pm6namii. or ammdam~.‘~ Electrical carditwersion should be used for supraventricular or ventricular arrhythmia5 cauting hemodynamic a)mptxwn&.

X. Postoperative Therapy/Future Management Whenever fcasihle, postoperative management should include the assessment and management of any risk factors for CAD, heart failure, hypertension. stroke, or other cardiovascular disease that may have been identified in the preoperative period. Such factors include hypercholestcrolemia, smoking, labile or sustained systemic arterial hypertension, borderline hyperglycemia or diabetes mcllitus. obesity. physical inactivity, FUXW alcohol consumption, carotid bruit, peripheral vascular disease, heart murmur\, abnormal EC’G, cardiac arrhythmia or conduc$on abnormality, perioperative &hernia, postoperative Ml. abnormal pulmonary function tests, or a positive family history of premature cardiovascular disease. Appropriate plans &hot&l be made for the postoperr;livc evaluation of any of these findings and the imtitution of appropriale diagnostic tests and management plans. In particular, patients who SUMtain a perioperative Ml or develop evidence of myocardial ischemia should be carefully evaluated. These patienb have a tuhtantial risk of .MI an&or cardiac death over the subsequent 5 trl It1 years. Accordingly. whew patients should be csrefully cvdhtcd ty noninivsivc testing 1~ determine left ventricular fun~non attu whether or not they huve c%dcnce of myocardial &hernia on exertion or during pharmacological stre%s.~’ Some palienta may benefit from coronary revascularization >y CABG or FICA. Most patients who have documented arteriosclerosis will benefit from phanacolqical agems to lower low density lipoprotein (LDL) cholesterol levels, increaw high denslty lipoprotein (HDL) I;4,. or horh The goal %houltl be 111lower thr LDI. lore1 to IL.*\ than 11%)mddl. (2.6 mmol/dl.).~~‘~ In genctal. the indicatiuns for add~tion~~l ~scrcening or te\:mg &re dependent on individual patient characteristics It is mtp)rtant that tke physician(a) rcspon6hic for the long-term carr of the patient he ~III full mk~rmatic~u about my cartliova~ular iibnornaitti~\ (,r rt\k factor\ Ior (‘Al) ~tlent~ficd durmp lbr pcr~~pcr.~t v’c peritnl.

X 1. Conclusions Successful perioper&r: high-risk cardiac patienta

crzhtdh7

undergoing

and

manigwrcw

noncardtac

surgery

UF

rc-

quirer careful teamwork and communication between surgeon, enesthc4ogi~t, the patient’s primary care phpician, and the c~tttsultant. In general, indicrtions for further cardiac trsting and treatments are the same as in the nonoperative setting. but their timing is dependent on several factors. inch&g the urgency of noncardiac surgery, patient-specific risk factors, and surgery-specific considerations. The use of both noninvasive and invasive preoperative testing should be limited to those circumstances in which the results of s sh tests will clearly affect palient management. Finiilly. for many patients, noncardisc $urgety represents their first chat,ce to rcccive an appropriate assessment of both short- and long-term cardiac risk. Thus, the amsultant best serves the patient by making recom* mendations aimed at Iowcring the immediate perioperative cardiac risk as well as assessing the need for subsequent posttrpcrative risk stratification and interventions directed to modify ammary risk faders.

XII. Cardiac Risk of Noncardiac Surgery: Areas in Need of Further Research Role of prophylactic revascularization in reducing perioperative and long-term MI and death and its costeffectiveness * Costeffectiveness of the various methods of noninvasive testing for reducing cardiac complications l Establishment of efficacy and cost-elfectiveness of variou:, medical therapies for high-risk pdticnts l Estabbshmsnt of optimal guidelines for selected patient suhgro:tps. particularly the elderly and women l Establishment of the efficacy of monitoring patients for myocardial ischemia and infarction, particularly the role of monitoring in affecting treatment decisions and outcomer. l

Appendix 1 Methods The\c guitlelincb arc hvvd on a Mcdlinc scerrch of the English htcraturc from 1075 through IVV4, review of sclccled journals frum I’NS, .mtl the expert opinton\ 01 I? committee members repre.senting variou\ diriplines of cardiovascular care. including general cardiolugy, noninvasive testing, vascular mcdicinc. vascular turgery. ancsthesiology, and arrhrhmia managemet*t. !n addition. draft guidelines were \uhmittcd for critical Y+W and amendment cl phpicians rrpresentmp intcrnid mcdrme. lumily pm&x, nuclear curdloklgy. general uugcry. and anc9lti~:si~~lr~gy ii% well as erecutivc &kern rcpreu!nting the hmeriwl (iNqtv *tl t’ardiology and the hmcrican ltran hwciHIIltl. ‘Thr final tk%umcnt rcprc%nts the eighth iteration over 1X month\. uhxh mcluded six Jr& m ctrmmittce and tw11 additional drafts to incorporate key tinding from external rev&. A large proponiorl of the dala used to derclup thru: guidelines is bared on obuxvatitmal or retrcnpertivc studies or kntwtedge of rumdt+xn:.lt cri c&kwaccular dbr)r&n in the nencwrative utting. While the collective knowledge rurrnunding the identification of high-

JACC Vet. 27. No ( Mrrcb IS. IwfKYIU-48

@AAS. ET Al.. A(‘C/AtlA ‘t-A% EY)ICE

and low-risk paticnts uning perioperntive clinical rind no&a&e evaluation i8 nukantial, very few prospective or randomized studier have been pertormed that establish the value of tests or treatmentx on perioperative outcomes. Therefore. data are presented in a tabular format, and whenever pokble retlect the value of a test or intervention for similar outcomes of a perioperative MI or cardii death. Because the studies were rarely randomized amtmlkd trials definitions of a perioperative event varied, invesdgston were rar$y blinded, and many inherent selection biases existed. the task force haJ chosen no1 IO provide an aggregate synthesis of ~bc data in the form of a point estimate or m&-anal@. On the olhcr hand, prrscntation of lhe origimd Dada pnwidcs substantial supp.a! for thaw recc~mcndalions,

Appedi~

2

staff American

College

of Car&o&v

David J. Feild, Executive Vice Presidcm Grace D. Ronan. A\sklam Dircclor, Special Projects Nclle H. Stewart. Guidelincs/Ducumenl Coordinator, Special Projects David P. Bodycombe, ScD, Director, Research and Information Management Helene B. Goldstein, MLS, Director, Griffith Resource Library Gwen C. Pigman, ML.% A&ant Director. Griffith Resc*nrce Library

American

Heart

Rodman D. Slake, Scientific Ahirs

Association MD, FACC, Senior Vice PrcFident. Office of

References 2. Lubiu 1. fkacon R. The tie in tbc itwdena of hcap%&&onr lor the aged. I967 to lY7Y. HP& Cure Fimmcr~ I&&n. I98?:3z21-40. 3. Fleishcr LA. lbltir C. Cumnl practice in the im2qwaliw c*alualk* of piicnir umlergoinp mqor vascular surgery: a survey of cardiwauuldr nwhcsiuQisa. J Cuniknh/war Vorc Atusth. I993;7:hhMS4. 4. Wells PH. ffipiun IA. 0ptimal management of paGems with iwhcmic heart discw for noncardiac surgery by cvmplementury anenlhcdogist and curdwlogi~t interaction. Am 1981;l0?:1029-1037. 5. Roger VL Ballard IJJ. Hbiiett JW Jr, Dhmundwn PJ, Pue~zPA. Genb BJ. hdlucncc of cwmary ancry disease wn motiii~y and monalny rfter abdominal aortic ancuryxnn~my: a popularron-bwd s:udy. 1971sIYX7. J Am Coil Cardid. 198%14:1?45-1252. 6. Herizer NR. Basic dala aaccming awciated coronary tJww in penphvral vau-ular pillirnts. Inn C’urcSurg. 1%?7;l:f1l&h2O. 7. ifliltky MA. Boineru HE, IfiayinhHham MB, Ire KI.. Mdrk IJB. (‘al16 WM. C&h FR. Pryw DB. A hrwf ~If~adminMcred quc~0wmairc IU deiwminc luncliwnitl cupaciiy (Ibr Duke Activiiy Stilw Indcn). Am I ( irnlrrd. I’wrJ:h5I G4. Y,.(ionh W. Rihrl (3. Rwke IW, fJullard Il. flruluativn and mrnrgmcm of patients with both peripheral vwular rnd cownary ancry diwr JAm t cd/ (brdhl. I99I:II):203.2I4. 9. Jamicwrn WRE. J;lnw MT, Miyagishima R7’. Gcrein AN. Influence of i&cmic heart discwe on csdy and late mortality after surgev for peripheral oulu~~vc vwxdar diwzw. C;rculufimr. I9S2:hysuppl l):l%?-I97. ItI. 1%~ GA. The aluJowk,miajupl~r tclt: :whnique and hensdynamic correI&s. Arm inlem M-d. I9WIoI):4ih-JM. I I. Butman SM, Ewy GA. Swtden JR. Kern KB. Hahn E. BcdGde cardiwaso&r cwminathn in p&ems wlh ‘~yerc chrome hewi failure: importance

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I?. Goldmen L Cal&n DL Nurabaam SR !kanlnvict FS, Km&d D, Murray 8. Burke I& OM$ey TA Gmdl AK Cqden CH. Nolan 1. Cambelk, 8, Sleter EE. Mtddioriel

index of cardiac risk in wnsardirs

surgical pm&m% N t&J J Mad 1977397:84%350. 13. Dajani AS, Bisno AL Clamg W. Durack LW, Freed M. Gerber MA. Kerehmcr AW. Mi HD. Rabimteola S. Sbulmea ST, cl d Prevention of lwmeriel eadccenlhk: recommen&uionr by the Amedces Hem Aem= cish. JAW. I9%264:29192922. 14. Nclaon AH. Reisher LA Rorenbaum Sit. Reladwwbip benwen prtup

emrive anemia and cardiac inoWdt~ la hi&-N

vamcularpatknn In the

intensive care tmn. Cdl Cwe &f. IW%2I:%B*. 15. Ashton CM. Pewncn NJ. Wmy NP. Rtefe Cl. Dunn JR Wu L llww JM. Tlte inciina of periqemtfw mywa&al i&r&n in men totdew irtg noncardiac surgery. Ann Inrem Hnl. IW~l18%4-SlO. 16. tfollenbwg M, Msnguw, DT. Browner WS. LoDdoD MI, Tubau JF. Two IM. Predictorn of prxdopcn~ivc myacort inl ischdmb in pa~iun~ undqwtng noncwdinc surgsy: The Qudy of Pw rprrntivc luhcm~r Rwerrh Omup. JAM4. IW2;2bS%S.209. 17. Hubhard RI, Oihbwr RJ. Lvpcym AC III, Urwncister AR Ckmenta IP. hkntiftcatimt of severe conmay ancy dirase usingimpk cfinicai parent etm. Arch Imrm Md 1992;152:309-312. Ih. L&u: J. Walcls D, Bender H. Chnmpqne P, -de 1. Picard M Cerhm M, Nsttel S, Boucher Y, Heyen F. el al. Preqrcnlivc and lo&t-term csniiac risk iwmmenl: prediiiw veluc cd 23 dinical dcwipion. 7’muftfwifde Yanngsystermsandquantitatiiedipyridanucr imqingin36Uptientr Arm Sq. lW2;216:192 204. 19. Mangana DT. Browner WS. Hofknkrg hf. London MJ, Tubau JF. Tateo IM. &ociarion of pcrioprntivc myacardial irhcmii with cwdiw m&idily and mwta!:ty in men undergning rnmwdii wgety: The Study of Pcriira~rve Is&emit+ Rcswch Group. N w J MnL l99&32.%lf%lI7m8. 2). Michel LA. Jamart J, Bradpii HA, Malt RA. Prediitimt uf ti in noncardiac opcntias after cardiac nptntiow. I 77wwr C&w Su@ l%w.loo:595-N15 !I. F+-k KA. Caky CM. Newell 18. Bnwuer DC, Diltlirtg RC. Straw HW. ‘,umei TE. Bowher CA Combming clinical and lhallium data optimizes prtxq,ww wcsmcnt of evrdw r& before m&r wwdar “urgcry. Awn /nfm Med. I9ll%l I(kR5wt& 2. Dctsky AS, Abrarm HR McLaughlin JR. Druckcr DJ. Sawn 2 m N. Sew JG. Forbath N. Hill&d JR. Prediiing urdiac complicaliom in pafiena undqoingnon-cardiisurgery. J&n /memMcd. 1986;1:211-219. 23 FWC~ ED. fIavis KB, Cvpcnter IA, Ab& S. Fray D. Risk d ~ncnrdii qradan in p&16 with defined coronary d&w: The Ciwonsry ANv Surgery Study (C’ASS) rcgistirtryrxpcricnce. Ann Thwar Siu& 19&41:42%). Cwpcrman M. PRug B, Manm EW Jr. Ewu WE. Cnrd@%ulu ti factao in ptiemr wth fxripbcrtd wculsr diww. .Suwy. Iy7H;Iw:s(J5SW. 2. T~rhrn S, M&ia EA. Taylur WF, Giuliani ER. Myoc*rdii htfarctbm after general ancs~hcsia. JAMA 197?;22lH451-14.54. ‘6. Gunnar RM. Pawam ER, fJourdillon PD. Pitt B, Diwn DW Raprprrt E. Funer V, Reeves TJ. Karp RB. Russclf RO Jr. el d. Cuiclriincs for the e&y management of patients wh act&z myucardial inIarctiw: a report of the &r&an College of Cardiik~/Americ~n Heart Awciation T&r FOW 03" &~smeni of Diiosk mrhlIbcnpulix Cardiowcular Pr@ crdurt3 (SubcommiUx to Devck~ Gui&lines for lhc Early Managcmnt of PaGents with Acute Myuurdial Infarctan). I Am CUU C&of 19‘Mkl6:249-292. 27. Fk~chcr GF. &lady h. Frcxlichur VF. Hartley LH. HuskelI WL Pufloct MI., fkcrciw rtandards a rtramcnl for hcalthean pmfm fn#n the American Hew Awciation: Writing Gwp. Cbrulati. 19%91:580615. X Strcn PA. Tinker JH. Ijrhan S. Mywardial reinfarctti ahn anesthesia

24.

and auqcry. JAMA. 1978:239:~5~257@ b. Rae Tl.. Jaw& KH. EJ-E G AA. Reinfarction fdlouing aneslbsia in parienu with -dial infarction. Aw.Ulu&@ 191(3%499-54%. It). Hezer NR. Falal myocardial infarctti following peripheral vascular opmims: a rmdy d 951 paticntr fol@ed h to I I yeas pc~mpentivrly. (hr r/in Q. 19%?:4w-11. $1. Milhar IJ. Swn PA. Tinker JH. Vlictwa RE. Smith HC. f’futh JR. P~rpcmlivc mycxardral infarction m palienlx with a,mnary arlcry die%

944

EAOLk lil’ AL A(‘(‘!AIIA IASK FOI(I.1

JAC’(’ Vol. 27, Nu. 4 Marsh I% I(nw:Ytll-4N

(3 ‘l?w IilIh repwr uf the Jmnc N”t~u”rl C’omm~ltrc (1” Dewiun. Evvlur~ion urd Twnlmcn: d thgb Hknnl Prenure IJNC’ Vl. Arch lruwn Med. 1991:1!3 IQ.!XJ

55. Saw JG. Fwx P, Sear JW, Johnson LL, Khamhirtta HJ. Triter L Myucardial &hernia in untreatrd hyprrentic pmients: effea of a sin& wll wdl doss 01 P hels-adrerrergic blocking agent. Arresr/wticr(lv. I’hu(;by~4‘&?I! 56 Swnc IG, f-w P. Sear JW. J&w” LL. KhsmhaIIr HI. Tnncr L. Risk of mwwdul whwmtr duunlt ~n.wthrw I” w&d ““d umrcrtrd hyperwnwc p”ticnI%. fh J Anuwh. I’NIX;bl~h75-070. q7 PryvRohrrt~ C. Mchrhc R. locr P. Studvr of itnwlhcw in tclalroo IO hypenrnuun. I: wdrowuular rcy*wcr ~1 ircaccd zr”d untrestrd pa~len~r. BlI 4”urrrll. 1’~7l;J3.1??-117

iwkmm JCwdud IWI;21~7hl-769. .’ - ’ ’ 4h. Tilm Bc. Sherman CT. Asm~lumatr mwcardiil ischemia dunnn wcuIanrow tnunluminzl coronilry~~“gi+&a”d importance of prior-&we infarction and diabetes “x&us. Am J Cnrdiol 199l:hx:735-739.

dual tinf~rcrmn. tiru~“’ Italirno per b Studio dclla Soprawlvenra nell’infarto Mwcardlcw f.anrrt. l9943U3:I I IS-I 122.

SY (‘wchnra RF, fkwtiul DJ, MUII~ RS. DcWwd M, Nhin MS, Evalualion c;f ~wsiol in w”Irdling ir#‘rcer* in heun wle and blood prewre during cndw~kiil inIuh&r” I” palicna undergoing c”r:rtid wlarIcrecIc-+ .hfhnw,qr 19L:hc fr’g-531. NI Mta@wv” 1. Thuhn T. Wcmer 0, Jarhult J. Thonwn D. Hacm&ynamic &ca of prrlreatmni with mrtupr& il hyp’rtemiw patiints undergo&g wacr). t?rJAnw& l9&%:2.51-Wl. hi. SbgoU S, Keal; AS. lxxr penoperativc mywardial irhemia lead to patoperative “ryocwdial infarction? Anurrhesi&. 1985;h2:lll7-1II. “2. &dford RF. Fwrstei” B. Hospital dmiwun blood prrzwe: a prediior for hypertension follot+iy endalracheal iO~Iuhation. Amrh A&g. IYw~Jy:3h7.370. h3. hlJman L Caldxra DL Rirb of gerwd .mestbew mrrdrtective uperatioct tn the hypwtemivc patient. Anesrhmwk~, 1979%285-M. 64. Thompson RC. filwthw” RR. l~nvenrtein E. Perioperativc anesthetic r&k of m”xwhac nrrgry m hypcrtrophic ohrlruc~ive cardfomyopaIhy. Irlx4 l9#;25):241~.2421. hS Heyo VP. Ra]u HS. Wynnc 1. Skpknnm LW, Rafu R, Promm BS. Rspppal P. Mchtr P. Singh 5, R~lo DP, et al. Pcrcutancw b&on valvuk@sty compued w&h open wrgical commis.wotomy for mitral \tcmKhi\. N Engl I Mvd lw1:331:9hl-967. 64 Win PD. Alpn JS (‘opcland J, Dale” JE, Goldman S, Turpie AC%. A”Iithrombwc therapy ii pawnIs wh mechamcnl and &&g&l prcethc~. Ic kart valw. t3l3/. i*l02fslm”ll:445E55s, h7 GrIdmu” 1, Cakiera DL. Southwick FS. Nusbaum SR, Murray R, O’Malley TA. Gorofl AH, Capla” CH, Nolan J. Burke DS, Krogstad D. Carabelfo B, Sister EE. Cardiic risk factors and cumplicariom in “oncardiac surgery. Medicine (Lkhimm). W/857:357-370. MI. O‘Kelly 8. Brw”er WS, Massit B, Tubau J. Ngo L, Mangi” DT. Vemricular arrhythmias in pativntr unJerping rwwrdiac surgery: The Study01 Pwit~ralive lrhemia Rcv”rehGrwp./A%4 IuyZ:zN1:217Z21. 6’) Fithcr FD. Tyrolcr #IA. Relsior+p bcrwcen venwiculitr premature co”Ir~w”$ o” wurine cl~wtrwardiography and suhscqurnt wddw death lrum coronary hedrI d&w ~‘ircul”rirm. lY73;47:712-719. 71) Kennedy HL Whrtkxk Jk Sprague MK Kennedy W. Buckingham TA. GolJherg RI. Lung term follow-up of &ymptnmatic healthy wbjccIs with frequent and complex venlricukr ectopy. N Elrgl J M-d. 19l%:312:193-197. 71. Pawre JO, Yurchak PM, Janis KM, MUI&! JD, Zir LM. The risk of adwccd hePn block m wrgical pabcrtr &1d righi hundlc hrartch Mock md let! axi\ deuwcum. (iwfubrrcm tY7U:J1:h77.t#tl 72 Wehh CiD. tirnm I-A ‘Ilrc tik of mmcrtdmc rurgery I Am &‘I (irdrul IVll.ltb323-x5 73. Lveker RD. V~clltl. B&unc xi II (Brdiovr+ula! rhmrrmahIKs Mlweng turgcq lor I~fr~~+righI shunts: &ewstions in atrial ~ptal defe@s, wnlricubr scfndl Jrfecl* and p;rtenI ducts anerww. Crrwl”rian. i9h9‘~Yus-lutt.

JACC Vol. 27. No. 4 Murh 1% 19wx9NJ4 tkxponne IO cwrcbc in patbacl nfwr tutttl wrgtcal wmninn uf strsk*y of Fallnt. Ci&skvr. 19’&U:671-679 76. lWann 0. Gaba EG, Blunt A. l3aenmcngFt’s syndmnw and prcgnttncy. Hedl Awf‘ w7l;l:431-434. 77. Taylor LM Jr, Pwtcr JM. Bade dam r&cd tu clinical deciskm~making in nbdomhl nortic aneurysms. Ann VW SW. 1987;1:M2-504. 78. Bncker CL Tiir JH, Rnbcrtwn Dfd, vlkktm RE. f+axdid reinfwction f&wing local ancsth? in for ophthalmic surgery. ArrmfJ~ An& I(WOJP:257-262. 79. wnmcr m siliilds SE, chr* co. Mnjm elotbidib Md moflnlily within I rnnnthdwrdndatntysurg:ry andanestlusia.lMU. 1993;2R1437-1441. NJ. Greenburg AC. Saik RP, Prifbam D. lnflucr~~ of age on nwtality trf colun surgery, Am J Sq I’M19 65-70. HI Plecha FR. Bdn VJ, Pkcho FJ, Awlkmc JC. Fvrrell CJ. Hertzcr NH, Mayda J II. Rlwdcw RS. Ihc curly resulir d vwulur xurpry in prlicnh 75 yesn uf rqjc and ukkr: wt annlytin uf 3259 c&es. J Vuw Sug. wtw76y.n4. 82. Guldman L Cardiac risks and curnplicati~ms uf nuncardiic surgery. Ann /nfm Med. 1983;WW.S 13. 83. Pcdcrscn T. Eli&w K. Hcnrikaen E. A pmrpective study of risk fwtnrr and carduqndmonaty armptbtians uwciuted wth ,muctlhcea and urrpry. r&k mdiaton of curdapulmonmy nwbtdity. Arra AnurrfhrrirJ ~&wkJ IY%Jd:l444-155. 114.Murach SC, Schrcfcr HG. Skarvan K Cuslclli I, Scheide&ter D. P&perat& myucardial isshemiu in pulirnb undctguing ekctive hip arthtuplarty during lumhvr regiooal anesthesia. Anrsrhew+y. 1992:7h:SIX-S27. ‘45. tin&d WC. Layvg EL Reilly LM, Rapp JH. Mangano DT. Comparison of cardiac morbidity rates between aortic and infrarnguinal operations: we-year follow-up. Study of Periuperativr lschemid Research Qoup. J V&SCSwg. 1993;IR:6C4-615. X6. LX&n GJ, Cambria RP, Cude~ BS. Lcppu IA. Paul SD, Prwsler DC. Handel RC. Abhat WM, Eagle KA. Ctrmpurativc early und lptc c&x murbidity among patients requiring different wssular surgery pnrudurc~.. J VW- Sq Iu9S;tl:935-944. X7. Hsia DC, Krwhat WM. Moscue LM. Epidemiolo@ of car&xi endarterectumies among Mediiare bneticiaries. J Vnsr Sq. 1992:16%1-20% XII. I i&r ES. Muknks DJ, Sulomcn Nh Buboiz I’A, Whnley FS, Wcnnbcrg JE. Risk of carotid cndurtcrcct~nny in 1he elderly. Am J Ad& Nmhlr. I9%7U:lhl7.162t). I$‘#.PiC4cr DB, Davis JH, Alhikzga T, Bwkwal~rr 1. Butch DW. f’hw CR. Ellnw BR, Vacrk PM. Lord CF. Treatment of abdominal awlif aoeuryvn in an entire stale uver 7 I/2 years Am J Stq. IwUkI39%7-494. 90. Riihardsun ID, Mam KA. Repair of abdominal aorttc ancuryww i+ stutcwlde exp&ncc. Arch .Swx. IWl;l26:614-6lh. 91. Hamum EL Kilbum H Jr. G’Donncll JF. Bernard IIR. Shiclh EP. Lmdw) ML, Yarici A. A lungitudinal analy+s of the relatiumhip between inhu\pilal murt&y in New Yurk State mtd the volume of abdominal enrtic mncur)cim rurgerics perfnrmed. Hdrh .Gv Hrr 1992:~7:517-542. 92. Gillum RF. Pcriphcral arterial ucclt sive Jirrw of the cxtrumitk+ in the United Salts: hurpitalbatiun and mort&ty. Am HWI 1. I9W2iYpl l):l414-141x. Y3. Chain MR. Park Rl:. Lohr KN. Krwy 1. tlrwk RH. DilTwnce~ among ho@& in Mcdkwe patlent nwtah!y. I/eu/fulllr .Qw Ret. IVHU;?-1: l-31. 94. &&son RW II. Weir\ DG, Fields WS. Goldstonc J. Marc WS. Tcmne Jlt. Wright CB. Etlicacy of carotid cndartorcctomy ror asymptomatic carotid wmnisz Tlw Veterans A&in (h~rat~ve Study Gnwp. N C~IE/J Med. I9+3s.8??I-??7.

V7 Pc&rwn T. Kclhrck Il. Murk 0. Cardk+wlrwwy mmpl~atnm~ m huth-rk surercal aatienth: the value uf nrcomxatrw rrdnmwlide cur&~,a-&. Acro &r&lre~iol &wuf. l9%~‘:llt.~l8% Vii. I m)r L Rusvll JC. D&ha 1, Radlurd M. Use ul the multipk upt;lke gad acqubiticm Qn for the preyrerathr aw~~rwnt of cardiac rid. St<* c;)wrrd wnirl. IUKH:ihLL~Zul. W. Pastemad; PF. Impante AM, Bear G. Rilrr TS. Buunwn FG. Benj#nin D. wr 1. Kramer E Wood RP. The \alur of r;aiimuclide anmgit~apb)

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I983:72:~. 101. ParcemackPF. fmparato AM. RiksTS,Bwnann FG,BearG,fsnparellu PJ. Benjamin D, sslgcr J Krarsr E. The value of tbc mdbnwi& nnglo#amto1k~ofpcriopuativcm)oatrdisliafsrrlbe~ patiehts undcrgoi~g lower ert&ni~ rwwuLrLPtiun procedures. C6aduh. 19&%7utuwl2. M 21:11-13.11.17. 102. Ksvnm h Ccqwin, MD, Z&rkrr RB. Ttm mla uf prwpomtive ntdiaw clii ejcc~Il fractinn m direct abdnntiid uwtk &w#ysnt rep&. J Ver sag Iwu3:LI:l28.l36. 103. Fiw WP. Thump*nt BW, Thompa, AR, Ewut C. f&ad RC. Nucknr cnrdinc ejectton fnniun and atrdii index in &dutnitud anrtic w. slqwy. wn3;94:73b739. 104. Host&r MD. Dunn MI. Pcri~~~rative evrduatiun of a pr&ttt witb sbdominal awtic uncurysm. JAMA 1995:261):293. 105. f’uldermws D. Fiitti PM, For&r T. Tlmntwn IR Bwsmn E. ~1 Said EM, du Rnii NA, Rnelwdt JR. van Urk N. Dnbutrminu strec~ cchwrdl~ ugrapby fur wcsmcnt of prbpcralivc cardiac rii m putknb under mcrjor vwukr wrgrry. C6w.&i,rion. I993;X7:ISMI512. IOh. M&he 1’1. Rcidy NC. Abtmtt WM, Fukhinu DM. Bwwtcr DC. Ihe 1

cnl va5cular d&case. b. l9u1:89%&&. 107. Cutler BS, Wheeler HB, Parr&~ IA Card& PA. Ap@ubiYty and interpretatiun ofckctrwardiiraphic strcs tcstiq in ptknlrrilh peripheral wcukr dire. An J .%rq. !981;141:.(01-!Ml6506, 108. Arous EJ, Baum PL Cutkr BS. The ischcmic exercise teat in patients with pcripbcrJ w&-&r disease! impiicatium for m~tnent. A&I w 19s-w t9:7w)-783. 109. Gardii RL Mcftrkk K. Gncnbcrg H, Mulcnre RI. TRc value nf mrdi monitoring during pertphcral erterial wrcs :cating in the surgltal mana$c mcnt of txriuhcral uwubr dtsedr, J C~WUY Swx., r %v~~ :‘%5,L6: 2%.26l.’ . 1IO. van Knowing 1. Lcpantalo M. l’rediiion of prioprutiw cardix armpli. cations by electrocardiographic momtoting during twadmill exercise testing b&rc: peripherztl va.scular w@%y. .%u$rry. I986$9+l0-613. 1I I. Lrppo J. Plaja 1. Gimncl M. Tumub J, Par&m Jk Cutkr BS. Nuninvasive cvalua~bn of crrdiac rrak bcforc clcctivc vascular surgery. J Am Co// (imhd. I987.9:?ou-!76. II?. tfanw P. Pcur M. Bcrkntl 14.Tumipced W. Rtmcr D. Arm nercbc testing fur coronary artery dixiwe in ptientr with peripheral vascular disc. (t C&i& Iy1uI;l I:M74. I1 3. MePhail N. Calvin JE Shariatmadar A, Barber GG. Smhie TK. The UT of prcopcrrtive rxcrcise testing to prcdii cardii cumplicatium dhcr arterial rcwnstruction. J Va.wStq 19K8;7:60.68. 114. tirlirr NH, Fisher ML Ptntnrk OD. Garbur~ H. Rapqmrt A, Kekntcn MH. Moran GW. Gadw T. Pctcn RW. Routine prwpcrrtivc ewciv testing in pa~krur undcrgning majur mmncardi&csurgery. An J C&O!. I96s:s~sIJx. I Ifi. Cierwn MC. liunt JM. Hertzberg VS. Bugbman R. Rouan GW. Ellis K. Prcdiiinn of cardiuc and pulmonary ~wnplicatiunr related to ekctiw sbdominal and nuncardii tbrucic surgery in geriatric patkna. Am J Med. l9w~xx:llll-liJ7. 1Ih. Kopccky SL Gibbons RI. Hullier LH. Preoprative supine excrci% radii &Ii& an&gram predicts ~rinperatiw wdiuwcul& events in rasular suracw. J rim Cull CmM IUHfi.,.;:?%A Ahmci. II-. &in~tr S. Di Pasqualc G. Andrwli A, Luu AM. Carini G. Grazi P. l~lwnrl G. k.t..wclli P. Corhelli i. Pinelli G. Preupcrativc nuninwivc wronary rusk vntificatwn in candidara for carotid ewartercctorn) S&. l994;xx122.20?7.

IIY. &u&x CA Brmtcr DC. f)ariing RC. Ok& RD Straw HW. Drterminarion of cwdii ris by dipyridamok-thallium itraging before peripbcral w.wdar wrgq. N h# J >Med.l98%31?:.38%~%. IX Cutler Bs. l.rppu IA. Dipyridarwk thallium 201 scintigrapb~ lo det~rl mmnary anee dkav irhue ahckminal aurtic surgery. J lis .SW Iux7~YI-ltnl. 121. Fktcbcr JP. Anta) VF. Grucnrwld S Kenhw lZ f$+kun&-thallium

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141. l&t&ii IL, Bmeman TM, fJonw RO, Crmvford MH, Cibhmw RJ, Hall RJ. O’Roake RA. ~iuisi AF. Verani MS. Guidcliiw for din& we of cwdtiae radionoclide imaging: a report of riK American Gdlege d Cardi/ Amcocan Heart Asocirtion Task Force on AmemmentofDtagtvjticamJ llrcrqeubc Cardiiwcular Prwcdures (G>mmiclce on Radiiwlide Imaging). dcvclopcd in cott~lxwrtion with the American Socie~ of Nuclear G~rdiotogy J Am CidJ Chrrhct( IWS:?5:5?i-547, 142. &he C. Piirord lA, Hrrnaoa M. Trmrcur G, Icmpcrcur P, C’urltcr 1. Kulbccw HE. Predktmg ~hcwent mnl hrution ofwonmy artery dincusc in a&tllL mywardial infarctifm by ectkwnrdH~r:~thy during dnbuimmr mlunt~n. Am J Cwdu~. tUX(I;.%;llh7.117:. 141 (Uen IL Circcnc TO. Chlemwlkr 1. Hincnbaum SZ. Wikhlon SD. Kim (5. Dohulaminc dighi ethwardrlgruphy for dcbxwg coronary awry u,+nx./lmJOnJd IWl;67:1311.131& I44 !imwla SCi, Scgm DS. Ryan T. Brown SE.. Dohan /*hi. Williams R. ~mchcrg NS Armstrong WF. Fcrgcnhaum H. Echocwdiiphic dcre&n ol coronury artery disease during dobutamine info& Circdudm IWt;K):tN)5-lht4, 145. M&~Url’t%‘. Seaworth JF. Johns JP. Pup LE. Gmdo+ WH. Comparism of &mrame. dm@amote. and dobutamw in rtres, echoc&liography. Ann Jruem .Mrd. IYVL;llh:Iw.I96. 146. &wick T. Willemart B, D’Hondl AM, Baudhuin T, Wijm W, Detry JM, Melm 1. Selection of the opomat nonexerciSe sties for .hc whation of ischemic regional myocardial dysfunaion and malperfusion: comparison of dolwlaminc and a&no.+ using c&cardiography and WmTc-MlBl ingk photon emiuion compmrd tomography. C’i~&tiun. !W3;H7:3453.54.

Brrw JF Bundler Cl. hrir~nd M. VUUI L. Harrc E. Cirnkl Ci. &m&ma CM Ccrrwl P. k&r t, Vmn P. Dqyrrdrmotc~~h~lhum wmigrzphy and pslcd rrdivmrchdc angiography lo w.cs czrdlac risk bcforc abdomimd UMIK wgety. H Ert$ J
Bly JD. B&n M. Olhmnell TF Jr, Ma&y WC. Udel.. JE, Schmid CH, S&m VG, An aw%smcm of the pcKitive preddive value and cosrffcfrakene\s of dipyridti mywrdral +cint&aphy in pmrne undergo. ingwcuhrwgr) Jlrw.Su~. IW;IY:II?-I?I. C’amp AD. Cirrvin PJ. Hoff 1. Mdnh J. Uyer\ SL, C‘h.owlun BH. Prugxnoc &f ol m~rwcnuu~ dtwidam& thdlhum nv,om~~ m n~tcw wh d~dk.

LI( mth~aw~far wrgcfy .41 J (unltd IWL:6Y:I?Wt.l111>. 11% Sh& L. Miller DD. Kony MA. Hilton ‘I’. Slrlken A. Stockc K. Chmrman UR. Dctermmalon of pcr’qxralive cardiac risk by ademninc t’r;llliull-201 mywrdml rmaging. Am Jfeunl. IUV?:l?4:MI-M. UY. ‘Ilkare 1). Younn LT. Byen SL Shrw Lt. Ldxwiu At. Chairman BH. Miller VD. ~ommparatiu~progmnric value cd clinkal risk imkxn. rnling

147. Ldnr: RT, Swada s(i, !&gar DS, Ryan 1: Latku SD, Williams R, &own SE, Armwxiy WF. Fergenhaum H. Dohmrminc h&w echwardiignphy for awwmem oi cardrac risk hefore nowardiac rurgmy Am J Cadid IWI .6ww77. I#. lrlka Yi. Silwatl~ SC;. Dalwg MC’, Clkrll DE Smvchuk AP, Kovw RI,, Sqw IJS. Hyw T, l~cigcnhaum Il. lhlhuhm~mc wcs~echwardii~aphy ~11 a pmhe~or 01 c;ardii wems wocuwd wnh sonic sorgery. J l’ax Surg. lw2.I5%31-840. 144. EichcI:xrger JP, Schwarr KO. Htack ER, Green RM, O&et K Predictive wluc of tirh&immc cchwodlyraphy just hclore wncardiac vasvlar \ur@ry. ,:,.I J G~JI~/. tW3:72:h0?-607 1.511.Lmg~ 1% Ill. Youkq JR. FrankIm DP. ttmore JR, Gaello JM. Naarf IA. Dobwaminc wcw c&cardiography lor cardrac risk assswm Idore aatic wrmxv. I l&c Surz lW3:18:W5-9t I, ISI. D&ila-Rtin V&‘W;lggoner Ab, S&d GA, Ciellman EM, Schechrman KI3, Perez JE. Dobutamine ures cchocardbgmphy prcdids nurgicat outcome in paiienlr rith an aonic wwysm and pcrtphcral wcutar dirar. J Am Co// (brdird. tWD;ZI:VS7-963. 152. D9ucy EC>.Ciucrder-Krawuymka I!. R&him WL Thallium~zOl SPECT in nmnsry anrry diva.. pcrdcm~ wnh left hondk: branch hlwk. J Mu/ Md. I’IlJ&,n~t479.l&5. 153. Ivnm G. Ciihhmr RJ. BwwwnML. Diagmwicaccurmy ofexercisr: th&om311h!k&aon cmimkm L~~LWIC~ mmrm-~hv in natknts with left ho&k branchb&+x. Am J CidLd 1’&6tt:75h7~. ’ . ’ 154. Rocket1 JF. Wood WC. Moinuddin N, Lovel~z$ V. Parrish 8. tmravemu~ dipyriimole thallium-201 SPECT imagifig in p&ntr with left hundie branch hkrk. C/m hLi/ h&J. Ivllll.l5:UlI-hl7 iS5. CIKEL’IC111 Jr. Ikvmm ~I$ l&han CS. Adcnmmc tkdlium.?ltt 8% wtwwr lo eww thultium.llt LH dclcc~m~ ummary wtcry d&w m (rtwna wi(h kit hondte hrwh +&. 1 An Cid (b&J tWJ;?I:l13?-I\.~. 1% Iliml HO. Scnn M. Nucujt K. Boertncr C‘. Pktder A. tick% DM. Kraymhuchl tlP.‘thallium2tJl winllluaphv m n>mplelc 6~11hmdle branch hhrck. Am J Car&d. IvxJS3:7k(-76Y. 157. Tighe .._.. DA, Hmchinwn HG. Park C’H, Clmng EK. Fiihman DL Rzdchten I>. l%ibc-posrtrvc rwenrhk pcrfuwn dckcl during duhuwminc-!hallium tmrginn in kfi bundk branch h&k. J fiw1 Marl. t9!UJS:tYli%IWl. 15X. Fldxr Lt. Row&mm SH. N&m AH. Bar&h PG, T?w predictive value

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15% Khwin JD. Anxr E Gennrtro M, Wehan C, Jrmtw S. York&h W. Metuno R. Siknt myueardbl h&mm b not prediitivc of myocardial fnfarctkm in pttiphertif v8xtdttr buurgerypdtfmttx. Ann Vpsc SlyF 1993?27-3.2. 160. McPhafl NV, Ruddy ID, Bmber GG. Cok CW, Mar&s Lf, Gtdcnchyn KY. Cardiac risk stratifkatfon using dipyrhhutlok myocardkd perfu&m fmagfng and ambulatory ECG monitorbtg prior 10 vmctdar surgety. EurJ Vmc Smg fW3;7:151-155. 161. R&y KE Gofdman L Crmtgcr MA, Cook EF. Wckbmg MC, Whittcmore AD Selwyn Ap. Cormlatton between prcoper.tk imhemia tmd major cardiac cvcnu after periphcrttl vmculm ~lrgcty. N f?ngf I Mrd. fw((I-,BZI: 12961300. 162. PnhmrrCa PF. Ortnri EA. Rmrmrnn FG, Rikx IS, &parello PJ. titnttpdrt G, P-imir LK, Minuer R. Impttrato AM. Tltc vahte of !dlcnt mywardtal imchmnirtmonitoring in the prcdktbm of pctmpcrtttin myocardial inhrctbn in p&ne undergoing pcriphmrd vawzular surgery. J Vrr.w Sag. IY8Y~lt617-625. 163. Fletshcr LA, Roscnbtmm SH. N&on, Jam D, Wrwken FJT. Zarel BL. Prcopcmrivr dipyridmnok thallium imqfng .und Hohrr monitorinp II> a prcdktor of pcrmperrlivr cmdiac evcnh and long 1erm mttcomc. Anrtrhr~ sidqv. In prc*r. 161. Mvnlhr S. Roircn MF, &rnlrrd 1. ‘fltk1ed KA, Ellir JE. FUM 1. RrDtivc ctfectivenesa of four prcopcrtttivc lmts for prediing rtdvene cardiac outcams aher vmcubu wrrgmy: a meta-analysis. An& An& IvW;‘Iv: 422433. 165. Cambria RP, Brewster DC. Abbott WM. L’ltatien GJ, Megerman JJ. I~MuragJi GM, h4oncure AC. &It M, Eagk K ‘fhr imps&?of selective use of dik-thtdlittm rans and surgical facton on the current morbidity of aortic surgery. I Vatc Siog 1992;15:43-Sf. 166. Rihal CS, Eagk Kk Mike1 MC. Foster ED. Sopko G, Gersb BJ. Surgical therapy for &nary rrtcry diirwe among patientr with combined coronary srtrg and peripMru) vascular dkusc. Cirrulutimkxl.IW5;Yl:4653. 167. C&y CM, Eagk KA, Singer DE. et al. D&vii analysis for prcopxrativc cardiac risk evaluation before vascular sumerv. I I C/m Rm. IYU735:34i!A. Abstract. 168. Flebher LA. Skolnick ED, tlolroyd KJ. lzhnt~no HP. Coronary artery revmctdmiretion before abdominal aortic rncmybm ~rgcry: ;1 dcrbioo rnalytr apprtrxh. Anrsrh An& IW4:W.MI-(rhU. 169. Mason JJ, Owens DK Hanb RA. Cooke JP. Hlrtky MA. fix rok ol coronary angiugqhy ml uwmry rc%uculrru.athm Mrrr notw.trdr.rc vascular surgery. JAMA. IYYk27Jl~lY-iY2S. 170. Diehl JT. C~li RF. Hrrtzcr NR. Bcvcn Eri. Compk tiom of ~bdommal aortk ream~nuction: an analy+r of priopeonivc rbk Ikcto~ in 557 patients. Ann Sua lY~?:IvI:4%56. 171. Crawford EJ, Morris GC Jr, timfcll JF. Lynn WF. Moorhead M. Operative rink to patrenn with previous coronary artcry bypa.% Ann 7kwor Sq 197&&215 221. 172. Rcul GJ Jr. Cc&y DA, Duncan JM. Frwrcr OH. 011 DA. Livc~y JJ. Walker WE, llte ctfect ol coronary byprt.. on the outcome of peripheral wcukr opcrationr in I693 patients. I Vux Stq IwM:~:7~-7YH. 173. Nichzn JL, Pap CP. M;mn C. Schwcsingcr WH. Fountain RL. Grover FL. Risk of major clectivc operation rfter mycrardiitl rcvasrularir.-lion. Am I Sug. Ivuz: l64z423-426. 174. Hertrer NR. Bcven EC. Young JR, G-Ham PJ. Ruschhaupt WF Ill. Cmor R.4 Dewolfe VG. Mrdjovcc LC. Coronary artery disra% in ~ripberal vascular patients: P classification of IIkill coronary anpiogmrm and resllhs of surgical munapmmt. Ann .%rg lwW:lWZ!3-233. 172. tlcrtrcr NH. Young JR. Bc?cn EG. o’llurrr PJ. Grnrr RA, RuuhNmp1 WF. Malj~wec 1.C Lme rcudh ol txmmmv bypahr in patml% wrth pvripnd v~ucub~r LLIK‘ISE.I: f&year survhal auwtding to age and cbnical c;lrdiac stutu~. (%1p Cgrr Q I~53:l.33-I43. I7 t. Coropcan Corirmiry Surgq Sludy Group. tuilgdem rCUllh of pnw7lvc randomwod r&dy of ammary artcry bypar\ surgery in stat& anginr fwlofia. bmrr. IYtt2.?:ll7fllXo. 177. Hear NR. Yonng JR. &vcn LG. G’lram PJ. Gratw RA Rtochhaopt WF. Maljovec LC. he rcwla of arn~nary bypaks in patant\ with peripbcral vascubr diare, II: &r-year uuvir~ according to SCL byportkon. and dmbctex C/m C/III I Med. Iv87;!4:15-23 1711.Guideltmand indicatiom for annary artctj bypa% grart wgely: a repon of the Arnertcan Cotkge of Caofii!Amerimn Heart Awociation T&r

17% Huher KC, Evuns MA. Brcattahan IF. Gtbbom RJ. Holmes DR Jr, owumC of noncmdittc ofwrstions in p&ems wfth eevem coronary artery dbcase sutxemftdty treamd ~rcopcrntivefy with coronary angiopfasty. ilkryo c&l fw. 19!q;67:15-21. 181).Elmore JR. Hafktt JW Jr. Gii RI. Nmmcrt JM, Bavcr IC, Chq W. Gfo+.ki P. Paimkro PC. Mycxnrdmt rcvmadariratfnn before abdmttinal aortk snmtrysmorrhnphy: ctfect of cornnmy m@ptmty. g@w C&n Pm. vwwt37.MI. 1111.Allen JR. fklling IS, Hart& GG. f%rtttlve pmccdum not hwnMng thu hctot rf1rr pcrcutmteuttn tnn&rmlttal umrtthry ongtopfmty. Syr Gynmwf fifwf, IWl:l7j:2ttxttrt. 1x2. (iuidcbnm for ~rcu1mtcotw tramfuminaf ununmy angfopbwty: a repon of the Amcmxn Cotkgc of Cardii/Amcriam Heart Araaiirlion Dwk Force on Axmrtent of Dkagnostk and 3lmnpcmtcC&imm&m b cedurcs (Committee on Pcrcutancmn Tranduminal Conmary Angfm plmty). I Am Cd Gdid. IW3:22Qil3XU54. IK3. Cormt P. D&r hi. Bomacau I). Ftwctmdi 1, E.chsr Ii, Virm P. Prmwnnon of intrattpe?rtfvc myocrtrdfal it&mitt during nomnrdlm surgery with m1rrwcnom nnnrgfyccrtn, Arrm&rodof~ IYh4;6I.IY3-I96. Iffl. Dmhb TM. Stone JG. Coromilm 1, Weitdwrger hf. Levy Do. Prophyfnetfc niaogfyv~rin infusion during noncardff wrgery does not r&c-e perfopc~ntivc khemia. An& An& 19Y3:76:M-713. IItS. Godet G. Cllrist P. Baron JF. Bertrand M. Diquet 8. Stbrtg C Vima P. Preventfort of in1rrtoperathc myocardial ischemia during rmncnrdfac snrget-y with intravmtous diltirccm: a rmnk~mM trial vcmtrn f#ambo. Arrm flwio&. 1!%7:66:241-24% IM. Partemack PF, hpnu AM liaumann FG. Lnub G. Riles IS, Lamparelht PJ.Gnryii~kt*rgusonP.&cLcrG.BearG.The&swdpsmnid baa-blai~&? in patients umkrg&g abdominrl aortic mtmnyrm repab. C~ulmion. lW7;76(suppi 3. pt 2):lll-l.lB-7. IR7. Hayes SN. H&am DR Jr. Niimura RA, R&m GS. Paflivtivc ptntta~ kow aonlc bdlooc rahdopksty before nmwanfii opcntions und fttvb sivc diagmxtr procedurrx. Mo)n Cfin Ar. 19l%ld:753-757. IKH Rahim~volaSH.Cathetrr~~nvvuhruluplirctyulslwticundmitmI~cnmb in ad&$. Cirrubrfo+r. 19ttx7;75#lSspOI. Ii+. Mvrcus fl. Ewy G4 GRomke RA, W&b B. ftkich AC. llw c&t of prqrunty WI the OU~NIJR of mitral und @ortic rcgttrgitati. CiroJofon. lUllC4l 7W4itB. IQII Wslkr ‘TJ, Kav HR. Spiclmnn SR, Km&k SP, Greerspiln AM, Horuwhz LN. ftcductim in sudden death und lotal aMnalihy by ant&rbyth& rkrapy cvalu~ed by ekctn@y+ohrgic drug testing: criteria of&racy in patiena with st&ined ventricular tachyarrhyrhmiu. I Am Cdl C&d I%7:Iti83-)Io. 1%. Sucrdknv CD. Winkle RA, Mason JW. f%gnostic signiikattm of the number of induced vcntrictdar cumpka during vrreemcntofthr apyfor ventricular trwhyarrhythmias. Cirrukrrion. I9ft3P:4Olt4tB. 192. Guidclincr fur imptantsfon of c;mlire pwxmakcn mnd mtlinrrhythmfa ~WILW: 8 rqx~tf of [he Amrkun Cdkgc of Cmdirtof@twr(rmn WC:.* Assoctation Task Force on Awewtnxnl of fXagnm& mtd Tlterrrpmttis Cardiiawoktr Proccdurc+ (Committee on Paccmakcr Implantatkm). JAa (‘d/cardid. IwI:l&l-I3. 193. &rlauk JF. Ahrams JH. Gilmom II. O’Connor SR. Kniiton DR. Cerrn FB. Prqcrdtive optimiration of cardii%-uQr hcmodynami~ @roves outin peripheral vascular surgery: a prcaparjve, mmbmii dittkal tiisl. Ann Swp. 1Wl;?l4:2tN-297, lq4. Uagctt GP. Andcrum FA Jr. Levine MN. S&man EW. Whcekr HB. Prc$cmion of vcno~s thrombocmbol~m. Char IW2;Itt2(juf@ 4J:Jgff 417s. IO. Vetrarte M. The diagn& uml treutmcm of dvvvem Ihnanhra. N&j I Ifor. IW?32%141K1421t. F~torkd csmmcnt, I%. Wlr DN. Sferstcin MD. IMnrp DM. Heit IA Morrcy BF. Venous Ihtonhxntb&m au&ted with hip and knee atthqdasty: mnrent omphylac~ic pm&es and OUI-. .M,, ~/in Ar. Iy12.67+6l-tt7lt. 197. Hcijboer K Cogo A. B&r HR Prandoni P. ten Cam JW. Dctfflfon of deep nio dmmbctis with impoxtance pktmapby and xal-time aumprcsskm tdtraxmography in h&it&red patirnu. Arch &em Ned 1(N?;l52:IuoI-IYtB. MS. Mow KM, Fcdullu PF. Tbc di@nc& of deep vein thromhti h’ F& I Md IYUt:3.~xhuw. Lcttcr.

otdl pm@wab fouowinplnatcardiac rurgey: ‘I-beStudy OpPcfiapwntlur lsbemir Reacurh Group JAM HY2:268:WZW. 21% Ycqet RA, Moncu Gl, F&w& JM. Tiiy+w LM Jr, McC&well Df& Pmtet hf. lrfr olvivsl ahrr pt&urrtiw “pwdial i&raion a~@. catIn& vtwulat suqcty. J VL* Suq I9’M$k59Lc(IIM. 216 harun II. Low&n ID. &try AJ, 5miL RR HI. Knaa GB, W&z Fl, Ryan KnwvalueorpuhnmulyvtefyandecnImrvclKmsmlmi0oria(lnp mldr1lJoblgrbdaniaonic recoMvuetk~~r)r:Pa)mparatkc~d IWO xkckd randmid goup J Var Sq I9’%12~7S4.%?4I. 217. Joyce Wp. Pmvan IL A&i FM, hlcEwan MM, Jeksich $ Jones DP. The &dEcflIdbnemodpamiclnonitoriagill~aort*~:il ptcqatiw Dndcmised study. .EwJ var SK& 199a4%33&6. 21X. Praice yidclincs fat pultnonaty snety c&ewiz&ion: a tcpori by the Amencall sorily of -ogi!llr rank Fm 011Pnlmonafy Ancty Calhcwiration. Atusthetidqp 1W3:7x1B394. 2lU. ImmJchrg G, L&a MH. COIN S Edelman IA, A&w H. Maseed M, Schcchkr D, Asat J. Erel 1. Betlatzky Y. ltnponsna of IoqdaraUoa pmpentiic ST-rqpnea Jcprraaion in cardiac motbidiry &or verulsr wrgay. Luva 1Wx4l:7l5-7lY. ??o Fletsber L?\. Nelson AH, Rwnhaum SH. Paqcnti~ mpurdiil i&a. nw rbolugy of cardiac motbidq ot mtmikstrtion cd underlying discwe? I(linnA~~~h IW5:797-IUZ. ??I. Mathew JP, Flcishcr LA. Rinchwse JA. Sevatino fB. Sinaata R$ N&on AH, Ptoktqr EK. Rwnbaum SH. ST \egtnem deptcsiw during labor and drliicty. Anestk&/qv. IW2:77:b35-641. 222. Btrshw MI. Millrr CF. Parker SD, Walman AT, Rqcts MC. changes in T-waw mwphdogy f&wing anc&sia and .wtgay: a common teatveryrwm phciumenun. Am he-. 19&;64:3%.402. 223. Adam\ JE Ill, Siiatd GA. Allen BT. Brihvell M. Lenke LG. Davilt,. Roman VG. Bodot GS, Lademon JH. Jade AS. Di of perioperathz myocatdii infarction with measurement of catdii buponin 1. N En$ J Md. l!H4$0~670-674. 224. Charkon ME. MacKenzie CR. Aka IL Gold JP, F&lough G Jr, Shires GT. Swvrillamx for postoperative myaatdiil infwction after mxward& Llvcralium.. Sun Gvnecd oh$ie1. 1u88:16~7:4uc414. dinnti anlic “Urysnammy. i ib*Rec vie ,4&i. 1991;5:42s& Notdtrhuug JE. Malignanl arrhythmia in relation lo ~tum polasium in JCUIL mywatdul inf;ltcticm. Am J Cwdtrrl I9llS:56:2lID-23D, ?17. H~dliliild JW. Tbwtde ~rcutmcnl of syslcmk hypcttcnskm: cfkcts cm *eturn magncwtn and vcnlricular cclopic activity. Am J CtttiioJ. IvxV;W:22G-25G. 22X. Wang KC. S&let PG. Schultz JR. Hypokalemia and aneslhaic implicawm Anrwh Ant& IW77: 123&12fdl. ?!O Summaty ol the vamd tcpw ~1 tbc National Clwkeaetol Wucatinn pn-r w (NCtP) Enperi Prncl un Dewion. Evaluation. andTreatment of 1 igi Blood (bokwtol in Adulh (Adult Ttcatmcnc Panel II). JAMA IW.I,?w.~~‘5-.3@3.

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