ACC-AHA Preoperative Cardiac Risk Assessment

1. See Also
   1. ACP Preoperative Cardiac Risk Assessment
   2. Preoperative Cardiovascular Evaluation
   3. Eagle's Cardiac Risk Assessment
2. Background
   1. Preferred over the ACP Preoperative Cardiac Risk Assessment
3. Protocol
   1. Step 1: Evaluate urgency of noncardiac surgery
      1. Emergency requires surgery regardless of risk
      2. Manage Cardiac Risk Factors postoperatively
   2. Step 2: Noninvasive cardiac testing not required
      1. No acute cardiovascular disease and able to perform 4 METS of Exercise without symptoms
         1. See Metabolic Equivalents (METS)
         2. Able to climb one flight of stairs holding a bag of groceries
         3. Able to walk on level ground at 4 miles per hour (1 mile in 15 minutes)
         4. Able to perform light housework (e.g. dusting or washing dishes)
      2. Coronary revascularization in past 5 years (does not apply to last 6 months)
         1. Must be stable and no recurrent symptoms or signs
         2. Evaluation IS indicated if revascularization was in the last 6 months
         3. Discussion with the patient's cardiologist is recommended
      3. Coronary evaluation in last 2 years
         1. Evaluation must have been favorable and adequate
         2. No new symptoms or signs since evaluation
   3. Step 3: Indications for noninvasive cardiac testing
      1. Evaluation based on patient risk factors
         1. See Eagle's Cardiac Risk Assessment (typically used for ACC-AHA Guideline)
         2. See Detsky's Modified Cardiac Risk Index
         3. See Lee's Revised Cardiac Risk Index
         4. Risk factors include
            1. Ischemic Heart Disease
            2. Compensated Heart Failure or prior history of Heart Failure
            3. Diabetes Mellitus
            4. Renal Insufficiency
            5. Cerebrovascular Disease
      2. Active cardiac conditions
         1. Unstable coronary syndrome
         2. Decompensated Heart Failure
         3. Significant arrhythmia
         4. Severe valvular heart disease
      3. Consider in patients with functional capacity <4 METS or unknown capacity
      4. Major patient risk factors
         1. Indication: Three or more risk factors and cardiovascular surgery
         2. Cardiac evaluation needed in all cases
      5. Intermediate Risk: Indications for cardiac evaluation
         1. See High Risk Surgery
         2. Indication: Vascular Surgery or Intermediate Risk Surgery and at least 1 risk factor
         3. Most challenging group to determine whether cardiac testing is needed prior to surgery
            1. Optimizing medical therapy without additional testing may be indicated in this group as well
            2. Positive Predictive Value for stress testing predicting adverse cardiovascular event is only 20-40%
               1. Despite even an abnormal stress test, most patients in this group will not have a perioperative cardiovascular event
               2. Beattie (2006) Anesth Analg 102(1): 8-16
      6. Minor risk: Indications for no cardiac evaluation
         1. Evaluate on individual basis
         2. No symptoms at functional capacity >4 METS activity requires no evaluation
4. Reference
   1. (2007) ACC-AHA Guidelines
   2. Eagle (2002) Circulation 105:1257-67