What are the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for managing cardiac patients undergoing non-cardiac surgeries?

ACC/AHA Guidelines for Cardiac Patients Undergoing Non-Cardiac Surgeries

The ACC/AHA guidelines recommend a stepwise approach to perioperative cardiac assessment, focusing on identifying patients at elevated risk while avoiding unnecessary testing in low-risk scenarios. 1

Step-by-Step Approach to Perioperative Cardiac Assessment

Step 1: Determine Surgery Urgency

• For emergency surgery, proceed with appropriate monitoring and management based on clinical assessment 1
• For urgent or elective surgery, continue with systematic evaluation 1

Step 2: Identify Active Cardiac Conditions

• Screen for unstable coronary syndromes (unstable/severe angina, recent MI) 1
• Assess for decompensated heart failure (NYHA class IV, worsening or new-onset HF) 1
• Identify significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation) 1
• Evaluate for severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) 1
• If active cardiac conditions exist, evaluate and treat per ACC/AHA guidelines before proceeding with surgery 1

Step 3: Estimate Perioperative Risk

• Calculate risk based on combined clinical and surgical factors 1
• Use tools like American College of Surgeons NSQIP risk calculator (http://www.riskcalculator.facs.org) or Revised Cardiac Risk Index (RCRI) 1
• Consider surgical risk - very low-risk procedures (ophthalmologic) have low MACE risk even with multiple risk factors, while major vascular surgery carries elevated risk even with few risk factors 1

Step 4: Determine Need for Further Testing

• For low-risk MACE (<1%), proceed to surgery without further testing 1
• For elevated risk, assess functional capacity 1

Step 5: Evaluate Functional Capacity

• If functional capacity is moderate to excellent (≥4 METs), proceed to surgery without further evaluation 1
• Consider using Duke Activity Status Index (DASI) for objective measurement 1

Step 6: Consider Further Testing for Poor Functional Capacity

• For patients with poor (<4 METs) or unknown functional capacity, determine if testing will impact decision-making 1
• If yes, pharmacological stress testing is appropriate 1
• Exercise stress testing may be reasonable for those with unknown functional capacity 1
• If stress test is abnormal, consider coronary angiography and revascularization based on results 1

Supplemental Preoperative Evaluation Recommendations

12-Lead ECG

• Reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease (except for low-risk surgery) 1
• May be considered for asymptomatic patients undergoing non-low-risk surgery 1
• Not useful for asymptomatic patients undergoing low-risk procedures 1

Assessment of Left Ventricular Function

• Reasonable for patients with dyspnea of unknown origin 1
• Reasonable for patients with heart failure with worsening dyspnea or changed clinical status 1
• Reassessment may be considered in clinically stable patients with previously documented cardiomyopathy 1
• Routine preoperative evaluation not recommended 1

Exercise Stress Testing

• Reasonable to forgo testing in patients with elevated risk but excellent functional capacity 1
• May be reasonable for patients with elevated risk and unknown functional capacity if it will change management 1
• May be reasonable to forgo testing in patients with elevated risk and moderate to good functional capacity 1
• Not useful for low-risk noncardiac surgery 1

Pharmacological Stress Testing

• Reasonable for patients at elevated risk with poor functional capacity if results will change management 1
• Not useful for low-risk noncardiac surgery 1

Perioperative Monitoring Recommendations

ST-Segment Monitoring

• Useful for monitoring patients with known CAD or those undergoing vascular surgery 1
• May be considered in patients with multiple risk factors for CAD undergoing noncardiac surgery 1

Troponin Monitoring

• Recommended in patients with ECG changes or chest pain typical of acute coronary syndrome 1
• Not well established in clinically stable patients who have undergone vascular and intermediate-risk surgery 1
• Not recommended in asymptomatic stable patients who have undergone low-risk surgery 1

Common Pitfalls and Caveats

• Overuse of preoperative testing in low-risk patients can lead to unnecessary delays, costs, and potential harm 2, 3
• Underestimation of cardiac risk in high-risk patients may result in preventable perioperative cardiac events 3, 4
• Poor implementation of guidelines across specialties despite awareness of their existence 5
• Failure to recognize that timing of surgery after percutaneous coronary intervention depends on stent type and antiplatelet regimen 3
• Lack of recognition that coronary revascularization before noncardiac surgery has not been shown to reduce morbidity and mortality in most cases 3, 4

The 2014 ACC/AHA guidelines represent the most recent comprehensive update, with the 2024 guidelines now superseding them but maintaining the core stepwise approach to perioperative cardiac assessment 1.