1. Evaluation of the Cardiac Patient Before Non-Cardiac Surgery
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Department of Anesthesiology
Département d’anésthesiologie

2. Disclosure of competing interests
No financial CI
No professional CI
Member CCS Guidelines Panel

3. Objectives
Using the 2014 ACC/AHA Guidelines as a framework, the learner will:
Identify patients at risk for major adverse cardiac events following surgery
Propose a rational approach to preoperative investigation
Select therapies proven to reduce risk of major adverse cardiac events
Contrast ACC/AHA and ESC/ESA guidance

4. Where to find this stuff
2014 ACC/AHA Guideline on perioperative …
J Am Coll Cardiol 2014;64(22):e77–137
Circulation 2014;30(24):e
2014 ESC/ESA Guidelines on non-cardiac surgery …
Eur Heart J 2014;35(35):
Eur J Anaesthesiol 2014;31(10): ($)

5. T1. Class and Level
Applying Classification of Recommendations and Level of Evidence
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

6. 2014 ACC/AHA New Sections Valvular Heart Disease
ECHO within a year for mod-severe disease or change (IC)
Consider valve repair/replacement (IC)
Implantable Electric Devices
Have an individualized plan! (IC)
Pulmonary vascular disease
Continue meds (IC)
Use a validated risk tool (IIaB)

7. 2007/2009 ACC/AHA Guidelines
Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical conditions. †See Class III recommendations in Section Noninvasive Stress Testing. ‡See Table 3 for estimated MET level equivalent. §Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management. ∥Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperative beta blockade (see Table 12) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent.
Lee A. Fleisher et al. Circulation. 2007;116:e418-e500
Copyright © American Heart Association, Inc. All rights reserved.

8. 2014 ACC-AHA Guidelines
Stepwise approach to perioperative cardiac assessment for CAD. Colors correspond to the Classes of Recommendations in Table 1. Step 1: In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment (see Section 2.1 for more information on CAD). (For patients with symptomatic HF, VHD, or arrhythmias, see Sections 2.2, 2.4, and 2.5 for information on evaluation and management.) Step 2: If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs.18,20Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator ( or incorporate the RCRI131 with an estimation of surgical risk. For example, a patient undergoing very low-risk surgery (eg, ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE, whereas a patient undergoing major vascular surgery with few risk factors would have an elevated risk of MACE (Section 3). Step 4: If the patient has a low risk of MACE (<1%), then no further testing is needed, and the patient may proceed to surgery (Section 3). Step 5: If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI.133 If the patient has moderate, good, or excellent functional capacity (≥4 METs), then proceed to surgery without further evaluation (Section 4.1). Step 6: If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (eg, decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT (Section 5.3). Step 7: If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CPG, clinical practice guideline; DASI, Duke Activity Status Index; GDMT, guideline-directed medical therapy; HF, heart failure; MACE, major adverse cardiac event; MET, metabolic equivalent; NB, No Benefit; NSQIP, National Surgical Quality Improvement Program; PCI, percutaneous coronary intervention; RCRI, Revised Cardiac Risk Index; STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; and VHD, valvular heart disease.
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

9. 2014 ACC-AHA Guidelines
Step 1: In patients scheduled for surgery with risk factors for or known CAD, determine the urgency of surgery. If an emergency, then determine the clinical risk factors that may influence perioperative management and proceed to surgery with appropriate monitoring and management strategies based on the clinical assessment (see Section 2.1 for more information on CAD). (For patients with symptomatic HF, VHD, or arrhythmias, see Sections 2.2, 2.4, and 2.5 for information on evaluation and management.) Step 2: If the surgery is urgent or elective, determine if the patient has an ACS. If yes, then refer patient for cardiology evaluation and management according to GDMT according to the UA/NSTEMI and STEMI CPGs.
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

10. 2014 ACC-AHA Guidelines
Step 3: If the patient has risk factors for stable CAD, then estimate the perioperative risk of MACE on the basis of the combined clinical/surgical risk. This estimate can use the American College of Surgeons NSQIP risk calculator ( or incorporate the RCRI131 with an estimation of surgical risk. For example, a patient undergoing very low-risk surgery (eg, ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE, whereas a patient undergoing major vascular surgery with few risk factors would have an elevated risk of MACE (Section 3). Step 4: If the patient has a low risk of MACE (<1%), then no further testing is needed, and the patient may proceed to surgery (Section 3). Step 5: If the patient is at elevated risk of MACE, then determine functional capacity with an objective measure or scale such as the DASI.133 If the patient has moderate, good, or excellent functional capacity (≥4 METs), then proceed to surgery without further evaluation (Section 4.1).
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

11. When I say risk, you say ....? 2007 ACC/AHA two-step risk evaluation
Surgical risk (low, intermed, vasc)
“Clinical risk factors”
2014 ESC/ESA two-step method
2014 ACC/AHA indicates “combined clinical surgical risk”
Low risk <1% MACE
Elevated risk >1% MACE

12. Are risk models the same?
Characteristic
RCRI
ASC-NSQIP
Derived
N = 2,900
N = 1,414,000
Validated
N = 1,400
Unclear
Data collected
Prospective
Retrospective
Variables 6 22
MACE outcomes
Five
Two
Biomarkers
Routine
Clinical indication
Procedures
Mixed, 48h stay
All NSQIP
Lee TH. Circulation 1999;100:
Bilimoria KY. J Am Coll Surg 2013;217: 833e842.

13. An example 70 male Colectomy for CA colon STEMI 5 years ago,
RCA BMS placed
Angina-free, active (8 METS)
DM2, oral meds
Otherwise well

14. Revised Cardiac Risk Index
Risk Factor 
High risk surgery
History of CAD
History of CHF
History of stroke
Diabetes mellitus
Cr > 177
Risk Factors
Events (%)
95% CI
0.4
0.05 – 1.5 1
0.9
0.3 – 2.1 2
6.6
3.9 – 10.3 3
11.0
5.8 – 18.4
Lee TH. Circulation 1999;100:

15. ACS-NSQIP Risk Predictor

16. ACS Surgical Risk Calculator

17. ACS Surgical Risk Calculator

18. 2014 ACC-AHA Guidelines
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

19. 2014 ACC-AHA Guidelines
Step 6: If the patient has poor (<4 METs) or unknown functional capacity, then the clinician should consult with the patient and perioperative team to determine whether further testing will impact patient decision making (eg, decision to perform original surgery or willingness to undergo CABG or PCI, depending on the results of the test) or perioperative care. If yes, then pharmacological stress testing is appropriate. In those patients with unknown functional capacity, exercise stress testing may be reasonable to perform. If the stress test is abnormal, consider coronary angiography and revascularization depending on the extent of the abnormal test. The patient can then proceed to surgery with GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation. If the test is normal, proceed to surgery according to GDMT (Section 5.3). Step 7: If testing will not impact decision making or care, then proceed to surgery according to GDMT or consider alternative strategies, such as noninvasive treatment of the indication for surgery (eg, radiation therapy for cancer) or palliation.
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

20. T5. Supplemental Investigations
12 Lead
LVEF
Fancy
Summary of Recommendations for Supplemental Preoperative Evaluation
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

21. CPG - Revascularization
Left main
3 Vessel
2 Vessel + badness
Left Main CAD Revascularization Recommendations From the 2011 CABG and PCI CPGs
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

22. T6. Perioperative Therapy
Revascularization
B-blockers
Other Stuff
Antiplatelet
Summary of Recommendations for Perioperative Therapy
CIED
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

23. Beta-blockers are a mess
ACC/AHA
ESC/ESA
Continue IB
Intermediate-high risk tests
IIbC
Known IHD ischemia
IIbB
≥3 Risk Factors
≥2 Risk Factors or ASA ≥3
Don’t start without titrating
IIIB
Atenolol or bisoprolol

24. DECREASEing the effect
Outcome
All Trials
RR (95%CI)
DECREASE
OTHERS
Non-fatal MI
484/11,963 (4.0%)
0.66
(0.57 to 0.85)
0.22
(0.03 to 1.45)
0.72
(0.59 to 0.86)
Stroke
68/11,611 (0.6%)
1.79
(1.09 to 2.95)
1.86
(1.09 to 3.16)
1.33
(0.30 to 5.93)
Mortality
324/11,963 (2.7%)
0.96
(0.62 to 1.47)
0.42
(0.15 to 1.22)
1.30
(1.03 to 1.63)
Wijeysundera DN. Circulation. 2014; 130:

25. T7. Anesthetic management
RA v GA
NTG
TEE
Summary of Recommendations for Anesthetic Consideration and Intraoperative Management
PAC
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

26. Antiplatelet Rx and PCI
Algorithm for antiplatelet management in patients with PCI and noncardiac surgery. Colors correspond to the Classes of Recommendations in Table 1. *Assuming patient is currently on DAPT. ASA indicates aspirin; ASAP, as soon as possible; BMS, bare-metal stent; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; and PCI, percutaneous coronary intervention.
Lee A. Fleisher et al. Circulation. 2014;130:e278-e333
Copyright © American Heart Association, Inc. All rights reserved.

27. New DAPT recommendations
Levine GN. Circulation 2016: doi /CIR

28. Summary Combined medical-surgical risk
Surgery w MACE < 1% needs NOTHING
Functional capacity remains key assessment
Beta-blockers in evolution
Anti-platelet agents in evolution
ASA reconsidered after POISE 2
Wait following newer stents down to 6 mo.
No longer just about CAD