American College of Cardiology American Heart Association
American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving a favourable clinical outcome
Margherita Cinello a,Gaetano Nucifora a,Massimo Bertolissi b,Luigi P.Badano a, Claudio Fresco a,Nevio Gonano c and Paolo M.Fioretti a
Objectives The American College of Cardiology(ACC)and the American Heart Association(AHA)provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery.Even if previously validated as safe and effective in risk
strati?cation,there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines.We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic.
Methods One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation(from September2004to May 2005)were enrolled in the study and compared with a historical group of166patients operated from April2002to September2002.Preoperative resources utilization (cardiologic consultations,non-invasive diagnostic tests, coronary angiograms,coronary revascularizations)and clinical events[all-cause death,acute myocardial infarction (AMI)and acute myocardial ischaemia]occurring within 30days after surgical procedure were compared.
Results Guidelines implementation reduced preoperative cardiologic consultations by21%(P<0.001)and preoperative non-invasive diagnostic testing by11%
(P U0.01),and increased utilization of preoperative b-blockers by13%(P U0.01).Preoperative coronary angiograms(2%versus4%)and coronary revascularizations(3%versus2%)and all-cause death (1%versus2%),AMI(2%versus1%)and acute myocardial ischaemia(4%versus2%)during follow-up were similar in both groups.
Conclusions Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization,improved medical treatment and preserved a low rate of perioperative cardiac complications.J Cardiovasc Med8:882–888Q2007 Italian Federation of Cardiology.
Journal of Cardiovascular Medicine2007,8:882–888
Keywords:ACC/AHA guidelines,anaesthesiologist-led preoperative clinic, cardiac risk strati?cation,outcome,resource utilization,vascular surgery
a Cardiology Unit,Cardiopulmonary Science Department,
b Department of Anaesthesiology and Intensive Care and
c Vascular Surgery Unit,Surgical Science Department,Azienda Ospedaliero-Universitaria di Udine,Udine,Italy Correspondence an
d requests for reprints to Gaetano Nucifora,S.O.C.di Cardiologia,Azienda Ospedaliero-Universitaria di Udine,P.l
e S.Maria della Misericordia15,33100Udine,Italy
Tel:+39432552441;fax:+39432482353;e-mail:gnucifora@cardionet.it Received4August2006Revised17October2006
Accepted18October2006
Introduction
Cardiac events are responsible for30–60%of periopera-tive complications and are the cause of postoperative mortality following noncardiac surgery in more than 50%of patients[1–3].Patients undergoing noncardiac vascular surgery are in the highest-risk group.The American College of Cardiology(ACC)and the Ameri-can Heart Association(AHA)provided perioperative evaluation and management guidelines as evidence-based framework for assessing cardiac risk in a variety of patients and surgical situations including vascular surgery[4,5].Previous studies have tested and validated the ACC/AHA guidelines as being safe and effective in stratifying cardiac risk within a variety of vascular and other noncardiac surgical patient populations[6–11]. Nevertheless,there is still a gap between clinical practice and the recommendations of the ACC/AHA guidelines with respect to cardiac investigation of patients scheduled for vascular surgery[12–15].
According to these considerations,we conducted a study to assess the effects on perioperative clinical outcome and resource utilization of an ACC/AHA guidelines-based strategy for risk-strati?cation of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic.The results
Original
article
1558-2027?2007Italian Federation of Cardiology
were compared with our prior experience of not imple-menting the ACC/AHA guidelines.Our hypothesis was that the application of these guidelines in preoperative evaluations could limit resource utilization with preser-vation of perioperative outcomes.
Methods
The study has been preceded by a multidisciplinary consensus between vascular surgeons,anaesthesiologists and cardiologists of the Azienda Ospedaliero-Universitaria di Udine,Udine,Italy,to strictly implement the ACC/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery [5]in the routine risk assessment performed before all elective vascular surgery procedures.
Patients and study intervention
From September 2004to May 2005,164consecutive patients who were scheduled for elective vascular surgery underwent routine preoperative assessment in a dedicated anaesthesiologist-led preoperative outpatient clinic.All patients received a complete evaluation consisting of medical history,physical examination,electrocardiogram,blood cell count and chemistry,chest roentgenogram,colour and duplex Doppler ultrasonography of the carotid arteries and any further testing deemed necessary by the attending anaesthesiologist,such as spirometry and airway reversibility studies,pulse oximetry and arterial blood gas analysis.During assessment,anaesthesiologists placed particular emphasis on the detection of clinical predictors of increased cardiovascular risk,and ascertaining patients ’functional capacity,as outlined by the ACC/AHA guidelines.According to the algorithm proposed in the ACC/AHA guidelines,a decision was taken as to whether the patient could bene ?t from referral to a cardiologist for medical management and risk factor modi ?cation,non-invasive stress testing or coronary angiography.The attending anaesthesiologist subsequently reviewed the results of additional tests or interventions performed as well as specialist opinions.A decision was then made regarding the feasibility of planned procedure.If the potential bene ?ts of surgery were felt to outweigh the estimated risks,the patient was listed for surgery.A ?ow-chart of the study is depicted in Fig.1.Details regarding ACC/AHA guidelines-based decision-making algorithm implemented in the study are reported in the Appendix.
To establish baseline clinical practice prior to guideline implementation,we retrospectively studied,by chart review,clinical features,preoperative assessment,preoperative treatment and outcomes in 166consecutive patients who were seen in the preoperative clinic before scheduled elective vascular surgery between April 2002and September 2002.No speci ?c protocols for assess-ment of preoperative cardiovascular evaluation before noncardiac surgery were applied in that period.
Data collection
Demographic characteristics,risk factors for coronary artery disease,a history of ischemic heart disease,current presence of symptoms or signs of heart disease,type of vascular surgery and risk of surgical procedure as de ?ned by the ACC/AHA guidelines,preoperative use of b -blocker therapy,preoperative cardiologic consultation and use of preoperative non-invasive diagnostic test,preoperative cardiac catheterization and preoperative percutaneous or surgical coronary revascularization were collected in all patients.A history of ischaemic heart disease was de ?ned as the presence of previous acute myocardial infarction (AMI),typical angina and percutaneous or surgical coronary revascularization.Effective implementation of the ACC/AHA guidelines in the study group was assessed evaluating the adherence to the ACC/AHA guidelines-based decision-making algorithm (see Appendix).
Deaths for all causes,cardiac deaths,AMI and episodes of acute myocardial ischaemia within 30days after surgical procedure were also recorded.Cardiac death was de ?ned as death from intractable dysrhythmia,cardiogenic shock or AMI;all other postoperative deaths were considered noncardiac.Perioperative AMI was de ?ned as occurring of suggestive symptoms and/or electrocardiographic ischemic changes in association with an elevation of diagnostic serum cardiac biomarkers.Perioperative myocardial ischemia was diagnosed according to the presence of suggestive symptoms and/or electrocardio-graphic ischemic changes.
Study end-points and statistical analysis
The main study end-points were the assessment of preoperative resource utilization (i.e.cardiologic
Implementation of the ACC/AHA guidelines for perioperative cardiac risk assessment Cinello et al .883
Fig.
1
REFERRAL FROM SURGICAL CLINIC T O
ANAESTHESIOLOGIST CLINIC
RISK STRA TIFICA TION ACCORDING T O ACC/AHA GUIDELINES
Referral for cardiological assessment MEDICAL CONDITION OPTIMIZED AND DECISION ON SURGICAL INTERVENTION
SURGERY W HEN APPROPRIA TE
AUDIT OF OUTCOME DA T A
Flow-chart of the study.For details regarding ACC/AHA guidelines-based decision-making algorithm,see Appendix.
consultations,use of preoperative non-invasive cardiac testing,use of preoperative cardiac catheterization and use of percutaneous or surgical preoperative coronary revascularization),adverse cardiac events occurring within30days after surgical procedure(cardiac death, AMI,acute myocardial ischemia)and30-day all-cause deaths.
For continuous variables,data were summarized using mean value as a measure of location,and standard deviation as a measure of shape.Percentages were calculated when appropriate.The control and study groups were compared using the chi-square test for discrete variables,Student’s t-test for normally distrib-uted continuous variables,and the Mann–Whitney U-test for non-normally distributed continuous variables.P<0.05was considered statistically signi?-
cant.All analyses were performed using SPSS statistical software for Windows,release13.0(SPSS Inc.,Chicago, Illinois,USA).
Results
Baseline demographic and clinical characteristics are shown in Table1.No signi?cant differences were seen between the two groups with respect to age,gender distribution,almost all risk factors for coronary artery disease,history of ischemic heart disease,and current presence of angina or congestive heart failure.Patients in the intervention group were more likely to be active smokers(43%versus29%;P?0.009).
The two groups had undergone similar types of sched-uled vascular surgery and the evaluated risk of surgical procedure also was similar.
Table2shows preoperative testing and management for both groups.Guidelines implementation achieved a signi?cant reduction in the utilization of preoperative cardiologic consultations(34%to13%;P<0.001) and preoperative non-invasive diagnostic testing (18%to7%;P?0.01).The preoperative utilization of b-adrenergic blocker treatment increased signi?cantly (19%to32%;P?0.01).
ACC/AHA guidelines were strictly implemented in156 (95%)patients of the study group.
Adverse cardiac events occurring within30days after surgical procedure are shown in Table3.Overall rates of perioperative cardiac complications were similar and infrequent in both groups.Almost all perioperative cardiac complications occurred among patients who were referred for high-risk surgical procedures(Table4).
884Journal of Cardiovascular Medicine2007,Vol8No11 Table1Baseline demographic and clinical characteristics
Study group (n?164)Control group
(n?166)P
Age(years)71?874?8NS Male sex126(77%)118(71%)NS Hypertension125(76%)111(67%)NS Diabetes62(38%)42(25%)NS Dyslipidemia62(38%)42(25%)NS Smoking70(43%)48(29%)0.009 History of IHD65(40%)75(45%)NS Current angina12(7%)7(4%)NS Current CHF8(5%)1(1%)NS Type of surgery
Aortic(abdominal)56(34%)36(22%)NS Carotid68(42%)83(50%)
Peripheral vascular40(24%)47(28%)
Risk of surgical procedure
Intermediate77(47%)86(52%)NS High87(53%)80(48%)
Variables are presented as mean?SD or number(percentages in parentheses). IHD,Ischemic heart disease;CHF,congestive heart failure.Table2Preoperative testing and management
Study group
(n?164)
Control group
(n?166)P Preoperative b-blocker53(32%)32(19%)0.01 Cardiologic consultations22(13%)56(34%)<0.001 Non-invasive diagnostic testing,
total
11(7%)30(18%)0.01
2-D rest echocardiography2(1%)13(8%)
Exercise ECG stress test2(1%)9(6%) Pharmacological stress
myocardial scintigraphy
1(1%)4(2%)
Pharmacological stress
echocardiography
6(4%)4(2%)
Coronary angiography3(2%)6(4%)NS PCI2(3%)1(1%)NS CABG01(1%)NS
Variables are presented as number(percentages in parentheses).PCI,Percuta-neous coronary intervention;CABG,coronary artery bypass grafting.
Table3Adverse cardiac events occurring within30days after surgical procedure
Study group
(n?164)
Control group
(n?166)P Cardiac death00NS AMI7(4%)3(2%)NS Acute myocardial ischaemia3(2%)1(1%)NS Cardiac death,AMI or acute
myocardial ischaemia
10(6%)4(3%)NS All-cause death2(1%)3(2%)NS
Variables are presented as number(percentages in parentheses).AMI,Acute myocardial infarction.
Table4Adverse cardiac events occurring within30days after surgical procedure according to the risk of surgical procedure
Intermediate risk
(n?163)
High risk
(n?167)P Cardiac death00NS AMI0(%)10(6%)0.004 Acute myocardial ischaemia1(1%)3(2%)NS Cardiac death,AMI or acute
myocardial ischaemia
1(1%)13(8%)0.003 All-cause death2(1%)3(2%)NS
Variables are presented as number(percentages in parentheses).AMI,Acute myocardial infarction.
Discussion
The present study demonstrates that implementation of the ACC/AHA guidelines for cardiac assessment prior to noncardiac surgery[5]in the routine risk assessment performed before elective vascular surgery procedures reduces preoperative cardiologic consultations and non-invasive cardiac diagnostic testing and increases the use of b-blockers therapy, preserving very low cardiac complications rates.This effect was achieved after a multidisciplinary consensus between vascular surgeons,anaesthesiologists and cardiologists to incorporate guidelines-based decision making algorithms into the preoperative evaluation routinely performed in a consultant anaesthesiologist-led preoperative clinic.
The prevalence of coronary artery disease in patients undergoing noncardiac vascular surgery and the haemo-dynamic stress often associated with vascular surgery accounts for the increased risk of perioperative myocardial ischemic events observed in previous studies [1–3].Our study population has multiple risk factors for coronary artery disease and a previous history of ischemic heart disease in a large proportion;furthermore,approxi-mately one-half of the patients had scheduled high-risk surgical procedures(i.e.aortic and peripheral vascular surgery).Therefore,these patients constitute a group at potential risk for perioperative cardiac complications. Perioperative assessment for prevention of cardiac com-plications is thus an important task of the anaesthesiologist. An approach based on routine cardiac work-up prior to vascular surgery was shown to be time-consuming, expensive and not completely safe and so cannot be recommended[16,17].These?ndings created a require-ment for guidance in the preoperative risk-strati?cation of such patients.A number of risk indices based on a set of clinical risk factors have been therefore developed to estimate the risk of perioperative cardiac complications [18–22]and the ACC and the AHA have developed clinical guidelines for preoperative cardiac risk strati?ca-tion on the basis of expert opinion and the best available evidence[4,5].Previous studies have tested and validated the ACC/AHA guidelines as being safe and effective in stratifying cardiac risk within a variety of vascular and other noncardiac surgical patient populations[6–11].Our study con?rms these data,although it is not suf?ciently powered to detect modest changes in outcomes. Nevertheless,these guidelines are rarely strictly imple-mented[12–15,23–30].Effective implementation of guidelines is not simple;physicians do not always agree with clinical practice guidelines and guideline recommen-dations often do not include all possible clinical scenarios. Thus,these guidelines could be not fully incorporated in clinical practice.Despite these baseline dif?culties,a strict implementation of the ACC/AHA guidelines has been achieved in the majority of patients undergoing elective vascular surgery procedures in our study.
Previous studies have shown that disagreement between clinical practice and the ACC/AHA guidelines primarily occurs with regard to b-blocker therapy implementation, requests of preoperative cardiologic consultations and performance of non-invasive diagnostic testing[12–15, 23–30].
Adequately powered,blinded randomized controlled trials on b-blocker therapy in patients undergoing noncardiac surgery are still lacking[31],but many previous studies have reported a positive association between b-blocker use and a reduction of perioperative cardiovascular mortality and morbidity in patients undergoing noncardiac surgery, irrespective of whether patients were scheduled for high or intermediate-risk surgery[23,32].Furthermore,ACC/ AHA guidelines categorized the use of b-blockers in patients undergoing vascular surgery at high cardiac risk with ischemia detected during preoperative testing as a class I recommendation,and they gave a class IIa recom-mendation to use perioperative b-blocker therapy in patients undergoing vascular surgery with documented coronary artery disease or multiple clinical risk factors [5,25].The mechanisms by which b-blockers exert their perioperative cardioprotective effect are multifactorial. b-blockers decrease the exaggerated sympathetic response during the perioperative period,which is associated with an increased myocardial oxygen demand,heart rate and myocardial contractility[33,34].Furthermore,b-blockers reduce shear stress across atheromatous plaques,thereby decreasing theincidence of plaque rupture and consequent acute coronary thrombosis and reduce the incidence of dysrhythmias[35,36].However,the preoperative use of b-blockers in suitable patients with no contraindications is still too low in the routine clinical practice[24,26].The concerns of anaesthesiologists regarding the applicability of trial data to a particular patient,about prescribing oral medications to patients without scheduled follow-up and about adverse drug effects could explain their reluctance to prescribe b-blockers[24,26].Moreover,concerns still persist that b-blockers could aggravate symptoms of peripheral arterial disease[37];although b-blockers were considered to be relatively contraindicated in patients with peripheral arterial disease,it is now well known that b-blockers(especially b1selective b-blockers and b-blockers with b1-blocking properties)do not adversely affect walking capacity,symptoms of intermittent claudi-cation,and peripheral skin microcirculation[37,38].
Our study suggests that speci?c interventions direct to improve implementation of ACC/AHA guidelines should be performed because they may increase the proportion of patients who receive preoperative b-blockade; however,32%of patients receiving b-blockers in the study group is still suboptimal,despite the scheduled
Implementation of the ACC/AHA guidelines for perioperative cardiac risk assessment Cinello et al.885
intermediate or high-risk surgical procedure;efforts are needed to further improve preoperative prophylactic b-blockade,as a consequence of its bene?cial effects and the recently documented failure of invasive measures to prevent perioperative adverse cardiac events[23, 32,39].
Substantial challenges to the effective implementation of ACC/AHA guidelines also remain regarding performance of preoperative cardiologic consultations and preopera-tive non-invasive diagnostic tests to assess cardiac risk before noncardiac surgery.
Cardiologic consultations are frequently overused because they do not result in alterations in perioperative testing or management.This small yield stems from frequently non-speci?c consult requests;as a result, the consultant often makes broadly inclusive,general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not in?uence the patient’s outcome but pro-longs the hospital stay[27–29].Moreover,practitioners frequently recommend more non-invasive tests than those outlined in the ACC/AHA guidelines[13].Routine use of rest-echocardiography and non-invasive stress tests cannot be recommended because the positive predictive value of these diagnostic modalities is extremely low among this group of patients[40–42].This is particularly true among patients who are at clinical low risk(i.e.those without any identi?ed clinical markers for cardiac com-plications)[12].In this patient group,the guidelines algorithms argue for conservative application of expens-ive tests and treatment;by contrast,stress tests are useful among patients with intermediate or high clinical risk, especially if referred to high-risk surgical procedures [40,43].
Some authors have recently suggested that ACC/AHA guidelines have little or no impact on cardiovascular care because their implementation does not modify the frequency of perioperative cardiac complications[15]. The development of ACC/AHA guidelines in patients seen a decade or more ago,when perioperative care, anaesthesia techniques,endovascular and open surgical interventions,and operative mortality were quite different from their current status,could explain this ?nding[44].However,similarly to other previous studies[12,45,46],our study shows the bene?ts of the ACC/AHA guidelines.Their institution-wide intro-duction has important economic drawbacks,reducing the number and improving the yield of resource utilization(in particular,cardiologic consultations and non-invasive cardiac diagnostic testing).Ulti-mately,these effects allow delivery of high-quality, cost-effective care that is so important to the safe risk-assessment and delivery of noncardiac surgery in the new millennium.This study has some limitations that should be acknowledged;?rst,it involves a single institution’s evaluation of guidelines implementation.Second,it is not randomized but used a historical group as control, retrospectively selected by chart review,the limitations of which are well known.Third,it is a low sample size study with reduced statistical power to identify differences in clinical outcome between the two groups.
In summary,perioperative risk strati?cation of patients being considered for noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic is improved when ACC/AHA guidelines-based tools are implemented. Preoperative resource utilization is reduced and this effect is achievable in the context of maintaining an exceedingly low rate of serious cardiac complications.Although a cost analysis was not performed,the potential cost savings are strongly suggestive.
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888Journal of Cardiovascular Medicine 2007,Vol 8No 11
Evaluation of clinical predictors of increased perioperative cardiovascular risk (AMI,heart failure,death)Major
Unstable coronary syndromes
Acute (within 7days)or recent (between 7–30days)myocardial infraction Unstable or severe angina (Canadian class III or IV)Decompensated heart failure Dysrhythmias
High-grade atrioventricular block
Symptomatic ventricular dysrhythmias in the presence of underlying heart disease Supraventricular dysrhythmias with uncontrolled ventricular rate Severe valvular disease Intermediate
Mild angina pectoris (Canadian class I or II)
Previous myocardial infraction by history or pathologic Q waves Compensated or prior heart failure
Diabetes mellitus (particularly insulin-dependent)Renal insuf ?ciency Minor
Advanced age
Abnormal electrocardiogram (left ventricular hypertrophy,left bundle-branch block,ST-T abnormalities)Rhythm other than sinus (e.g.atrial ?brillation)
Low functional capacity (e.g.inability to climb one ?ight of stairs with a bag of groceries)History of stroke
Uncontrolled systemic hypertension
Cardiac risk strati?cation for noncardiac surgical procedures (combined incidence of cardiac death and nonfatal myocardial infarction)High (reported cardiac risk often greater than 5%)
Emergent major operations,particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgery
Anticipated prolonged surgical procedures associated with large ?uid shifts and/or blood loss Intermediate (reported cardiac risk generally less than 5%) Carotid endarterectomy Head and neck surgery
Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery
Low (reported cardiac risk generally less than 1%) Endoscopic procedures Super ?cial procedure Cataract surgery Breast surgery
Estimated energy requirements for various activities METs
1:Personal care
2:Walk indoors around the house
3:Walk a block or two on level ground at 3.2–4.8km/h
4:Light work around the house (e.g.dusting or washing dishes)5:Climb a ?ight of stairs or walk up a hill 6:Walk on level ground at 6.4km/h 7:Run a short distance
8:Heavy work around the house (e.g.scrubbing ?oors,lifting)
9:Heavy work outdoors (e.g.caving,digging,moving heavy furniture)
10:Moderate recreational activities (e.g.golf,bowling,dancing,doubles tennis,football)
>10:Participate in strenuous sports (e.g.swimming,singles tennis,football,basketball,or skiing)Stepwise algorithm
Major clinical predictors:referral for cardiological assessment and non-invasive/invasive diagnostic testing
Intermediate clinical predictors,METs 4:referral for cardiological assessment and non-invasive/invasive diagnostic testing
Intermediate clinical predictors,METs 5,high-risk surgical procedure:referral for cardiological assessment and non-invasive/invasive diagnostic testing
Intermediate clinical predictors,METs !5,low or intermediate risk surgical procedure:surgical procedure Intermediate clinical predictors,low risk surgical procedure:surgical procedure
Minor or no clinical predictors,METs 4,high-risk surgical procedure:referral for cardiological assessment and non-invasive/invasive diagnostic testing; Minor or no clinical predictors,METs 4,low or intermediate risk surgical procedure:surgical procedure; Minor or no clinical predictors,METs !5:surgical procedure;
Surgical revascularization in the past 5years or percutaneous coronary intervention from 6months to 5years previously,or non-invasive or invasive coronary evaluation within 2years,with favourable ?ndings;asymptomatic,METs !5,low or intermediate risk surgical procedure:surgical procedure; Surgical revascularization in the past 5years or percutaneous coronary intervention from 6months to 5years previously,or non-invasive or invasive coronary evaluation within 2years,with favourable ?ndings,symptomatic METs 4,or METs !5with high-risk surgical procedure:referral for cardiological assessment and non-invasive/invasive diagnostic testing.AMI,Acute myocardial infarction;MET,metabolic equivalent.
Appendix
Approach to preoperative cardiac assessment according to the American College of Cardiology/American Heart Association guidelines [5]