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Journal of Nuclear Cardiology

, Volume 24, Issue 1, pp 165–170 | Cite as

Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery and the 2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular assessment and management

  • Alejandro Velasco
  • Eliana Reyes
  • Fadi G. Hage
Comparison of 2014 ACCAHA vs. ESC guidelines Editorial
Two sets of clinical practice guidelines (Table 1) were published in 2014 related to the cardiovascular assessment of patients undergoing noncardiac surgery: one endorsed by the American College of Cardiology and the American Heart Association (2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery),1 and the other by the European Society of Cardiology and the European Society of Anaesthesiology (2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular Assessment and Management).2 We have previously summarized the ACC/AHA guidelines in the Journal focusing on the recommendations pertaining to noninvasive imaging and coronary revascularization.3 Since many of our readers are not familiar with both sets of guidelines, we will present here the recommendations from both documents side-by-side (Tables 2, 3, 4, 5, 6, 7). The Class (I, IIa, IIb, III) and the level of evidence (A, B, C) are shown next to each recommendation. We also include a flowchart comparing the stepwise approach of both guidelines toward the evaluation of patients undergoing noncardiac surgery (Figure 1). Our summary will be followed by 2 editorials: The first by Kristensen 4 summarizes the ESC/ESA guidelines focusing on the changes that have been introduced compared to previous versions of these guidelines. The editorial raises awareness to situations where imaging, angiography, and revascularization are and are not indicated in this setting. The second editorial by Port 5 reflects on the similarities and the differences between the 2 sets of guidelines and the implications of these to clinical care. It highlights situations whereby imaging may be indicated by one set of guidelines but not the other. We hope that this new series initiated by the Journal will provide an important service to the imaging community by highlighting the similarities and the differences between the American and the European guidelines and providing a perspective that may not be apparent from reading one set of guidelines.
Table 1

Comparison of ACC/AHA and ESC/ESA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery

Characteristic

ACC/AHA

ESC/ESA

Year of publication

2014

2014

Length of document in pages

61

49

References

490

279

Recommendations

69

120

Recommendations relevant to imaging

16

19

Class of recommendations

 Class I

15

50

 Class IIa

17

30

 Class IIb

21

26

 Class III

16

14

Level of evidence (LOE)

 LOE A

3

9

 LOE B

38

44

 LOE C

28

67

Table 2

Recommendations regarding perioperative ECG

Indication

AHA/ACC

EHS/ESA

Class

LOE

Class

LOE

Patients with risk factors undergoing intermediate- or high-risk surgery

  

I

C

Patients with known CAD, significant arrhythmia, peripheral arterial disease, cerebrovascular disease or other cardiac structural abnormalities, except those undergoing low-risk surgery

IIa

B

  

Patients with risk factors undergoing low-risk surgery

  

IIb

C

Patients with no risk factors, age >65 years undergoing intermediate-risk surgery

  

IIb

C

Asymptomatic patients without known CAD except those undergoing low-risk surgery

IIb

B

  

Patients with no risk factors scheduled for low-risk surgery

  

III

B

Asymptomatic patients undergoing low-risk surgery

III

B

  

CAD, coronary artery disease

Table 3

Recommendations regarding perioperative assessment of left ventricular (LV) function

Indication

AHA/ACC

EHS/ESA

Class

LOE

Class

LOE

Patients with dyspnea of unknown origin

IIa

C

  

Heart failure patients with worsening dyspnea or change in clinical status

IIa

C

  

Reassessment of LV function in stable patients with known LV dysfunction without an assessment within a year

IIb

C

  

Patients undergoing high-risk surgery

  

IIb

C

Routine preoperative evaluation of LV function

III

B

  

Routine assessment prior to low- or intermediate-risk surgery

  

III

C

Table 4

Recommendations regarding stress testing for myocardial ischemia

Recommendation

AHA/ACC

EHS/ESA

Class

LOE

Class

LOE

For patients with >2 risk factors* and poor functional capacity (<4 METs) undergoing high-risk surgery imaging stress test is recommended

  

I

C

For patients with elevated risk** and excellent functional capacity (>10 METS), it is reasonable to forgo further exercise testing with cardiac imaging and proceed with surgery

IIa

B

  

For patients with elevated risk** and poor functional capacity (<4 METs), it is reasonable to undergo pharmacologic stress testing, if it will change management

IIa

B

  

For patients with elevated risk** and unknown functional capacity, it is reasonable to perform exercise testing to assess functional capacity, if it will change management

IIb

B

  

For patients with elevated risk** and moderate-to-good functional capacity (METS 4-10), it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery

IIb

B

  

For patients with elevated risk** and poor functional capacity (<4 METs) it may be reasonable to perform exercise testing with cardiac imaging, if it will change management

IIb

C

  

For patients with 1–2 risk factors and poor functional capacity (<4 METs) undergoing intermediate- or high-risk surgery, imaging stress test may be considered

  

IIb

C

Routine stress testing is not useful for low-risk surgery

III

B

III

C

*Clinical risk factors include CAD (angina and/or prior myocardial infarction), heart failure, stroke or transient ischemic attack, renal insufficiency (serum creatinine >2mg/dl or creatinine clearance <60ml/min/1.73 m2), and diabetes requiring insulin therapy

** Defined as >1%. Estimation of risk based on the Revised Cardiac Risk Index score or the American College of Surgeons NSQIP risk calculator

Table 5

Recommendations regarding coronary angiography

Recommendation

AHA/ACC

EHS/ESA

Class

LOE

Class

LOE

Indications for preoperative angiography and revascularization are similar to those in the the nonsurgical setting

  

I

C

STEMI in the setting of nonurgent noncardiac surgery

  

I

A

NSTEMI in setting of nonurgent noncardiac surgery

  

I

B

Patients with proven ischemia and unstabilized chest pain* on optimal medical therapy, undergoing nonurgent noncardiac surgery

  

I

C

Stable cardiac patients undergoing nonurgent carotid endarterectomy

  

IIb

B

Routine coronary angiography is not recommended

III

C

  

Stable patients undergoing low-risk surgery

  

III

C

* Canadian Cardiovascular Society Class III–IV

STEMI, ST elevation myocardial infarction; NSTEMI, Non-ST elevation myocardial infarction

Table 6

Recommendations regarding elective coronary revascularization prior to noncardiac surgery

Indication

AHA/ACC

EHS/ESA

Class

LOE

Class

LOE

Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to clinical practice guidelines

I

C

I

B

Late revascularization after successful noncardiac surgery should be considered in accordance to clinical practice guidelines

  

I

C

Prophylactic revascularization before high-risk surgery may be considered, depending on the extent of the stress–induced perfusion defect

  

IIb

B

Routine revascularization before low- and intermediate-risk surgeries in patients with known CAD is not recommended

  

III

B

Routine revascularization is not recommended before noncardiac surgery exclusively to reduce perioperative events

III

B

  
Table 7

Surgical risk estimate of 30-day cardiovascular risk of myocardial infarction and cardiovascular death according to ESC/ESA guidelines

Low-risk surgery (<1%)

Intermediate-risk surgery (1–5%)

High-risk surgery (>5%)

Superficial surgery

Intraperitoneal

Pulmonary or liver transplant

Breast

Carotid, Symptomatic

Total cystectomy

Dental

Intrathoracic minor

Aortic and major vascular surgery

Endocrine: Thyroid

Peripheral arterial angioplasty

Duodeno-pancreatic surgery

Reconstructive

Endovascular aneurysm repair

Liver-resection bile duct surgery

Eye

Head and neck surgery

Esophagectomy

Carotid, symptomatic

Major orthopedic, neurological, gynecologic or urological procedure

Repair of perforated bowel

Minor gynecologic

Renal transplant

Adrenal Resection

Minor orthopedic

 

Pneumonectomy

Minor urologic

  
Figure 1

Comparison of stepwise approach based on AHA/ACC and ESC/ESA guidelines. * Unstable angina, acute hart failure, significant cardiac arrhythmia, symptomatic valvular heart disease, myocaridal infarction within the past 30 days and residual myocardial ischemia. **See Table 6. § Estimation of risk based on the Revised Cardiac Risk Index score or the American College of Surgeons NSQIP risk calculator. ¶ According to the Revised Cardiac Risk Index Score

References

  1. 1.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215–45.CrossRefPubMedGoogle Scholar
  2. 2.
    Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, Hert SD, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35:2383–431.CrossRefPubMedGoogle Scholar
  3. 3.
    Chatterjee A, Hage FG. Guidelines in review: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Nucl Cardiol. 2015;22:158–61.CrossRefPubMedGoogle Scholar
  4. 4.
    Kristensen SD. 2014 ESC/ESA Guidelines on Non-cardiac surgery: Cardiovascular Assessment and Management. Are the differences clinically relevant? The European Perspective. J Nucl Cardiol 2016; In press.Google Scholar
  5. 5.
    Port S. 2014 ESC/ESA Guidelines on Non-cardiac surgery: Cardiovascular Assessment and Management. Are the differences clinically relevant? The American Perspective. J Nucl Cardiol; In Press.Google Scholar

Copyright information

© American Society of Nuclear Cardiology 2016

Authors and Affiliations

  • Alejandro Velasco
    • 1
  • Eliana Reyes
    • 2
  • Fadi G. Hage
    • 1
    • 3
  1. 1.Division of Cardiovascular Disease, Department of MedicineThe University of Alabama at BirminghamBirminghamUSA
  2. 2.Royal Brompton and Harefield HospitalsLondonUnited Kingdom
  3. 3.Section of Cardiology, Birmingham Veterans Affairs Medical CenterBirminghamUSA

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