ACC-AHA Preoperative Cardiac Risk Assessment

Aka: ACC-AHA Preoperative Cardiac Risk Assessment, American Heart Association Perioperative Risk Assessment before Non-Cardiac Surgery, American College of Cardiology Perioperative Risk Assessment before Non-Cardiac Surgery

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II. Background

  1. Preferred over the ACP Preoperative Cardiac Risk Assessment

III. 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 (Stress Imaging)
    1. Consider in patients with functional capacity <4 METS or unknown capacity
      1. Unable to do Light housework (dusting, washing dishes)
      2. Unable to Climb a flight of stairs
      3. Unable to walk on level ground at 15 minutes per mile (4 miles/hour)
    2. 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 vascular disease (Coronary Artery Disease, Peripheral Vascular Disease)
        2. Compensated Heart Failure or prior history of Congestive Heart Failure
        3. Diabetes Mellitus
        4. Chronic Kidney Disease (esp. Serum Creatinine >2)
        5. Cerebrovascular Disease
        6. Poor functional capacity (<4 METS capacity)
    3. Active cardiac conditions (Cardiology Consultation recommended)
      1. Unstable coronary syndrome
        1. Unstable Angina
        2. Myocardial Infarction in the last month
      2. Decompensated Heart Failure
        1. NYHA Class 4 Heart Failure
        2. New onset Congestive Heart Failure
      3. Significant Arrhythmia
        1. Second Degree Atrioventricular Block (esp. Mobitz II)
        2. Third degree AV Block
        3. Symptomatic ventricular Arrhythmia
        4. Supraventricular Tachycardia
        5. Atrial Fibrillation with uncontrolled Heart Rate
        6. Symptomatic Bradycardia
        7. Ventricular Tachycardia (new)
      4. Severe valvular heart disease
        1. Severe Aortic Stenosis (symptoms, mean pressure gradient >40 mm or valve area <1cm)
        2. Symptomatic Mitral Stenosis (increasing Dyspnea, Presyncope or secondary Heart Failure)
    4. Major patient risk factors
      1. Indication: Three or more risk factors (listed above) 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
          2. Most patients in this group will not have a perioperative cardiovascular event
          3. Beattie (2006) Anesth Analg 102(1): 8-16 [PubMed]
    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

IV. Reference

  1. Fleisher (2007) Circulation 116: e418-e500 [PubMed]
  2. Eagle (2002) Circulation 105:1257-67 [PubMed]
  3. Poldermans (2006) J Am Coll Cardiol 48(5): 964-9 [PubMed]

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