What are the American College of Cardiology (ACC) guidelines for ordering cardiac testing prior to non-cardiac surgery?

From the Guidelines

The American College of Cardiology (ACC) recommends preoperative cardiac testing before non-cardiac surgery only for patients with active cardiac conditions, such as unstable coronary syndromes, decompensated heart failure, or severe arrhythmias, as outlined in Table 2 of the ACC/AHA 2007 guidelines 1.

Key Considerations

• The decision to order cardiac testing should be based on the presence of active cardiac conditions, the patient's functional capacity, and the type of surgery being performed.
• Patients with poor functional capacity (less than 4 METs) who are undergoing high-risk surgeries, such as vascular or major thoracic surgery, may benefit from cardiac testing if it will change management 1.
• The preferred testing modalities include stress echocardiography, nuclear myocardial perfusion imaging, or coronary CT angiography, and should be chosen based on patient-specific factors.
• Testing should only be performed if the results would change management, such as leading to coronary revascularization, medication adjustments, or changes in surgical approach.

Risk Stratification

• The ACC/AHA 2007 guidelines provide a framework for determining which patients are candidates for cardiac testing, taking into account the urgency of the surgery, the presence of active cardiac conditions, and the patient's functional capacity.
• The guidelines emphasize the importance of risk stratification using tools like the Revised Cardiac Risk Index, rather than blanket testing, to balance the need to identify patients who would benefit from preoperative cardiac optimization against the risks of overtesting and treatment delays.

Clinical Application

• Clinicians should consider the patient's overall clinical profile, including their medical history, current symptoms, and functional capacity, when deciding whether to order cardiac testing.
• The results of cardiac testing should be used to inform management decisions, such as the need for coronary revascularization or adjustments to medical therapy, rather than simply to delay surgery.
• By following the ACC/AHA 2007 guidelines and using a selective approach to cardiac testing, clinicians can optimize preoperative care for patients undergoing non-cardiac surgery and reduce the risk of perioperative cardiac complications 1.

From the Research

Cardiac Testing Prior to Non-Cardiac Surgery

The American College of Cardiology (ACC) guidelines provide recommendations on when to order cardiac testing prior to non-cardiac surgery. The decision to order cardiac testing is based on the patient's risk factors, functional status, and the type of surgery being performed.

• The Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP) scores can be used to estimate perioperative risk for major cardiac adverse events 2.
• Patients with unstable cardiac conditions or recent coronary revascularization may require further evaluation and management before undergoing non-cardiac surgery 2.
• The use of stress echocardiography can help identify high-risk features and guide clinical decision-making in patients with valvular heart disease 3, 4.
• Stress testing modalities, such as stress echocardiography, can accurately delineate reversible myocardial ischemia, but their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone 5.

Indications for Cardiac Testing

Cardiac testing may be indicated in patients with:

• High-risk surgery (e.g., vascular, thoracic, or major abdominal surgery) 2.
• History of coronary artery disease, heart failure, or cerebrovascular disease 2.
• Unstable cardiac conditions, such as unstable angina or acute myocardial infarction 2.
• Recent coronary revascularization (e.g., percutaneous coronary intervention or coronary artery bypass grafting) 2.
• Valvular heart disease, particularly if symptoms are discordant with the severity of valve disease 3, 4.

Type of Cardiac Testing

The type of cardiac testing ordered depends on the patient's individual risk factors and clinical presentation. Options include:

• Stress echocardiography 3, 4.
• Myocardial stress testing (e.g., treadmill or bicycle exercise testing) 5.
• Pharmacological stress testing (e.g., dobutamine stress echocardiography) 4.
• Invasive cardiac testing (e.g., coronary angiography) may be considered in select patients with high-risk features or unstable cardiac conditions 2.