ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for noncardiac surgery. Dr. Sonia Anand McMaster University. Overview. Guidelines- reflect evidence synthesis and consensus Evidence as of October 2007 Important Decision points: Urgent vs Elective Surgery
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Dr. Sonia Anand
The Search For High Risk Evaluation and Care for noncardiac surgery
3) cerebrovascular disease
4) high risk surgery (AAA, orthopedic sx)
5) pre-operative insulin tx for diabetes
6) preoperative creatinine for creat > 2 mg/dL
Lee et al
* Not associated with cardiac risk
Moderate recreational golf, dancing, baseball Evaluation and Care for noncardiac surgery
Strenuous sports swimming, basketball
DO light house work i.e. Washing dishes
Climb a flight of stairs
Run a short distances
* Reported risk of cardiac death or nonfatal MI >5%
*Combined morbidity and mortality < 1% even in high risk patients
*** Evaluation and Care for noncardiac surgery
CABGEffect of Prior CABG on Cardiac Risk of Vascular Surgery: The CASS Registry
Eagle et al. Circulation, 1997
510 VA pts, aged 66 years, with stable CAD, scheduled for elective
AAA repair (33%) or infrainguinal bypass (67%), randomized to
Revasc (PCI 59%, CABG 41%) or conservative management.
McFalls, E. CARP Trial;AHA 2004
101 pts with extensive ischemia randomly assigned to pre-op revascularization
or not. Endpoints: all-cause death or MI at 30 days and 1-year follow-up.
2VD in 12 (24%),
3VD in 33 (67%),
Left main in 4 (8%).
Days since surgery
Months since surgery
Poldermans, D. JACC 2007; 49(17): 1763
1.0 Long-Term Outcomes
Survival Free of Death/MI
YearsThe Effect of Percutaneous Revascularization Above Optimal Medical Therapy:COURAGE
2287 Pts w/myocardial ischemia and CAD randomized to PCI with
optimal medical therapy (PCI group) and 1138 to medical therapy alone.
PCI + Medical therapy
Boden, W. NEJM 2007; 356:1503
If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after
If received DES....
Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended
1) beta blockers-if on keep them if not....
2) Statins continue, ? Start -need randomized trials
100 pts randomized 20 mg atorvastatin or placebo for 45 days.
Vascular surgery ~ 30 days after randomization. F/U 6 months
CV death +
Durazzo, AES. JVS 2004:39(5):975
1.00 or planned non cardiac sx that will necessitate d/c of antiplatelet agents is
Time (months)Statins Improve Long-Term Survival After Vascular Surgery
Retrospective review of 446 consecutive infrainguinal bypass surgeries
p < 0.004
Ward, RP. Int J Card 2005; 104(3):264