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Canadian Journal of Cardiology

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery

Published:October 04, 2016DOI:https://doi.org/10.1016/j.cjca.2016.09.008

      Abstract

      The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.

      Résumé

      Le comité des lignes directrices de la Société canadienne de cardiologie et les principaux leaders d'opinion canadiens ont estimé qu'il y avait un besoin pour des lignes directrices à jour utilisant le système d'évaluation des données probantes GRADE (Grading of Recommendations Assessment, Development, and Evaluation) pour l’évaluation des patients qui subissent une intervention chirurgicale non cardiaque. Les principales recommandations sont les suivantes : 1) la mesure des peptides natriurétiques de type B (BNP) ou le fragment N-terminal du propeptide natriurétique de type B (NT-proBNP) avant l’intervention chirurgicale pour améliorer l’estimation du risque cardiaque périopératoire chez les patients qui ont 65 ans ou plus, ou qui sont âgés de 45 à 64 ans et qui ont une maladie cardiovasculaire importante, ou qui ont un score RCRI (Revised Cardiac Risk Index) ≥ 1 ; 2) contre la réalisation de l’échocardiographie de repos préopératoire, l’angiographie cardiaque par tomodensitométrie, l’épreuve à l’effort ou l’épreuve d’effort cardiorespiratoire, ou l’échocardiographie de stress pharmacologique ou l’imagerie isotopique pour améliorer l’estimation du risque cardiaque périopératoire ; 3) contre l’introduction ou la continuation de l’acide acétylsalicylique pour prévenir les événements cardiaques périopératoires, excepté chez les patients ayant subi l’implantation récente d’une endoprothèse coronarienne ou qui subiront une endartériectomie carotididienne ; 4) contre l’introduction des α2-agonistes ou des β-bloqueurs dans les 24 heures qui précèdent l’intervention chirurgicale ; 5) la suspension des inhibiteurs de l’enzyme de conversion de l’angiotensine et des antagonistes des récepteurs de l’angiotensine II 24 heures avant l’intervention chirurgicale ; 6) la facilitation de l’abandon du tabac avant l’intervention chirurgicale ; 7) la mesure quotidienne de la troponine de 48 à 72 heures après l’intervention chirurgicale chez les patients qui avaient une mesure élevée des NT-proBNP/BNP avant l’intervention chirurgicale ou s’il n’y avait eu aucune mesure des NT-proBNP/BNP avant l’intervention chirurgicale, chez ceux qui ont un score RCRI ≥ 1, ou qui sont âgés de 45 à 64 ans et qui ont une maladie cardiovasculaire importante, ou qui sont âgés de 65 ans ou plus ; 8) l’introduction du traitement par acide acétylsalicylique et statines chez les patients qui souffrent de dommages myocardiques et d’infarctus après l’intervention chirurgicale.
      Worldwide 1 in every 30-40 adults has major noncardiac surgery (ie, defined in this report as surgery requiring overnight hospital admission) annually,
      • Weiser T.G.
      • Regenbogen S.E.
      • Thompson K.D.
      • et al.
      An estimation of the global volume of surgery: a modelling strategy based on available data.
      and > 10 million of the > 200,000,000 patients having surgery will suffer a major cardiac complication (ie, cardiac death, myocardial infarction/injury, cardiac arrest) in the first 30 days after surgery.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      Moreover, the number of patients who undergo surgery is increasing, as is their mean age and number of cardiac risk factors.
      • Siddiqui N.F.
      • Coca S.G.
      • Devereaux P.J.
      • et al.
      Secular trends in acute dialysis after elective major surgery–1995 to 2009.
      Major perioperative cardiac complications are important because they account for at least a third of perioperative deaths,
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      result in substantial morbidity,
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      prolong hospitalization,
      • van Waes J.A.
      • Nathoe H.M.
      • de Graaff J.C.
      • et al.
      Myocardial injury after noncardiac surgery and its association with short-term mortality.
      increase cost,
      • Udeh B.L.
      • Dalton J.E.
      • Hata J.S.
      • Udeh C.I.
      • Sessler D.I.
      Economic trends from 2003 to 2010 for perioperative myocardial infarction: a retrospective, cohort study.
      and affect intermediate and long-term prognosis.
      • Levy M.
      • Heels-Ansdell D.
      • Hiralal R.
      • et al.
      Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis.
      Although previous perioperative cardiac risk guidelines exist,
      • Fleisher L.A.
      • Fleischmann K.E.
      • Auerbach A.D.
      • et al.
      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.
      • Kristensen S.D.
      • Knuuti J.
      • Saraste A.
      • 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).
      members of the Canadian Cardiovascular Society (CCS) Guidelines Committee and several Canadian opinion leaders believed there was a need for up-to-date cardiac guidelines for patients who undergo noncardiac surgery using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for guidelines.
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      These individuals believed that this process could result in some recommendations divergent from previous perioperative guidelines. The CCS Guidelines Committee appointed co-chairs, a primary panel, and a secondary panel to develop these guidelines. Beyond CCS members, these panels also included a variety of medical specialists who belong to the Canadian Anesthesiologists' Society, Canadian Association of General Surgeons, Canadian Association of Thoracic Surgeons, Canadian Orthopaedic Association, Canadian Society of Internal Medicine, and Canadian Society for Vascular Surgery; members are listed in Appendix 1.

      Guidelines Development

      The primary panel established the scope of the guidelines (ie, 4 themes: preoperative cardiac risk assessment, perioperative cardiac risk modification, monitoring for perioperative cardiac events, and management of perioperative cardiac complications), identified topics and working groups, searched the literature, developed the summary of findings and GRADE quality assessment tables, voted on the recommendations, and wrote the guidelines. The secondary panel reviewed the guidelines manuscript and made suggested edits and comments, which the primary panel addressed. Next the guidelines were sent to the CCS Guidelines Committee; they also provided suggested edits and comments that the primary panel addressed before finally submitting the guidelines to the CCS Council.
      Because of uncertainty regarding the reliability of data that were published by Dr Don Poldermans,

      Erasmus MC, Follow-up Investigation Committee. Report on the 2012 follow-up investigation of possible breaches of academic integrity. September 30, 2012.

      the committee decided to exclude studies for which he was the first or senior author. If a study by Dr Poldermans was included in a meta-analysis, the panel only included the meta-analysis in a summary of findings table if his study had results that were consistent with the results from the other studies.
      During an in-person meeting and several conference calls, the primary panel reviewed the summary of findings and GRADE quality assessment tables for each topic. Before discussing any topic all panel members had to declare if they had any financial or intellectual conflicts of interest. If a panel member had a conflict of interest, they were allowed to participate in the discussion but were not allowed to vote on the recommendation. Supplemental Table S1 shows details of all declared conflicts of interest and individual voting results.
      The panel used the GRADE recommendation rating system, and recommendations were graded as a strong or conditional recommendation on the basis of high, moderate, low, or very low quality of evidence.
      • Guyatt G.H.
      • Cook D.J.
      • Jaeschke R.
      • Pauker S.G.
      • Schunemann H.J.
      Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
      Supplemental Table S2 shows, for each GRADE recommendation, the corresponding balance of benefits vs the risks and burdens, the methodological quality of the supporting evidence, and the implications.
      • Guyatt G.H.
      • Cook D.J.
      • Jaeschke R.
      • Pauker S.G.
      • Schunemann H.J.
      Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
      Each recommendation required at least two-thirds of the nonconflicted primary panel members to agree during a vote on a GRADE of recommendation rating. If this was not achieved, the primary panel re-evaluated the evidence and another vote was taken, until consensus was achieved. If a panel member still disagreed with the consensus, they were provided the opportunity to discuss their dissension in the text of the guidelines. If two-thirds of the panel members believed the evidence was too weak to support a recommendation, then no recommendation was made. If two-thirds of the panel members believed that a recommendation was indicated only on the basis of values and preferences for a topic with no direct research evidence (eg, communicating to patients their perioperative cardiac risk), then a good practice statement was made.
      • Guyatt G.H.
      • Schunemann H.J.
      • Djulbegovic B.
      • Akl E.A.
      Guideline panels should not GRADE good practice statements.

      Preoperative Cardiac Risk Assessment

      Accurate preoperative cardiac risk estimation can serve several functions. Valid estimates of the risks and benefits of surgery can facilitate informed decision-making about the appropriateness of surgery. Accurate cardiac risk estimation can also guide management decisions (eg, consideration of endovascular vs open surgical approach) and inform decisions around monitoring (eg, troponin measurements) after surgery.

      Which Patients Should Undergo Cardiac Risk Assessment Before Noncardiac Surgery?

      Our recommendations only pertain to patients (1) 45 years of age and older or (2) patients 18-44 years of age with known significant cardiovascular disease (ie, coronary artery disease, cerebral vascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or a severe obstructive intracardiac abnormality, such as aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy), because these patients have, or are at risk of having, an underlying cardiac substrate that puts them at risk of a perioperative cardiac complication.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      • Lee T.H.
      • Marcantonio E.R.
      • Mangione C.M.
      • et al.
      Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
      • Sabate S.
      • Mases A.
      • Guilera N.
      • et al.
      Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.
      • Gupta P.K.
      • Gupta H.
      • Sundaram A.
      • et al.
      Development and validation of a risk calculator for prediction of cardiac risk after surgery.
      • Agarwal S.
      • Rajamanickam A.
      • Bajaj N.S.
      • et al.
      Impact of aortic stenosis on postoperative outcomes after noncardiac surgeries.
      Moreover, our recommendations apply to noncardiac surgeries that require at least an overnight stay in the hospital after surgery, because of the availability of evidence and these surgeries are most likely to produce sufficient cardiac stressors to put these patients at risk of a cardiac complication.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      • Lee T.H.
      • Marcantonio E.R.
      • Mangione C.M.
      • et al.
      Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
      Figure 1 provides an overview of our approach to preoperative cardiac risk assessment and perioperative cardiac monitoring. We divided surgeries into 3 categories on the basis of the timing of surgery (ie, emergency, urgent/semiurgent, and elective), and these categories influenced our recommendations regarding preoperative cardiac risk assessment.
      Figure thumbnail gr1
      Figure 1Preoperative risk assessment and postoperative monitoring flow diagram. BNP, brain natriuretic peptide; ECG, electrocardiogram; NT-proBNP, N-terminal pro-brain natriuretic peptide; PACU, postanesthesia care unit; PHTN, pulmonary hypertension; RCRI, Revised Cardiac Risk Index. Significant cardiovascular disease includes known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy). Timing of surgery refers to emergency surgery (eg, severe trauma, ruptured aortic aneurysm), urgent surgery (eg, hip fracture, bowel obstruction), semiurgent surgery (eg, cancer with potential to metastasize), or elective surgery (eg, knee arthroplasty). £ If physical examination suggests there is an unknown severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy) or severe PHTN, then obtain an echocardiogram before surgery to inform the anesthesiologist, surgeon, and medical team of the type and degree of disease. If the history suggests the patient has an unstable cardiac condition (eg, unstable angina) then discussion with the patient and surgical/medical team is required to decide whether to delay, cancel, or proceed with surgery. § RCRI score (each worth 1 point): history of coronary artery disease, cerebrovascular disease, congestive heart failure, preoperative insulin use, preoperative creatinine > 177 μmol/L, and high-risk surgery (ie, intraperitoneal, intrathoracic, or suprainguinal vascular surgery). ∗∗ Shared-care management refers to a multidisciplinary approach to inpatient postoperative care; this includes the surgeon and a medical specialist (eg, internist, cardiologist, gerontologist), who will help with perioperative monitoring and management of cardiovascular complications.
      Regarding whether physicians should undertake a preoperative cardiac risk assessment, our recommendations represent good practice statements. We believe that providing patients with the opportunity to engage in shared decision-making for major health care decisions—including the decision about undergoing elective surgery—irrespective of its effect on other patient-important outcomes, is of value in itself. Providing an accurate risk assessment is a prerequisite for shared decision-making in the perioperative setting. Among patients who undergo elective surgery, patients who are 45 years of age or older or 18-44 years of age with known significant cardiovascular disease have the most to gain from preoperative cardiac risk evaluation—in other elective surgery patients the risk assessment will result in a sufficiently low risk that it is very unlikely to influence decisions regarding surgery.
      If a patient requires emergency surgery (ie, an acute life- or limb-threatening condition), we believe the vast majority of patients' values and preferences will favour the benefits of surgery over the risks; therefore, surgery should not be delayed unnecessarily. We believe most patients' values and preferences will favour the benefits of urgent surgery (eg, surgery for an acute bowel obstruction or hip fracture) or semiurgent surgery (ie, surgery for a cancer that has the potential to metastasize) over the risks, unless there is an unstable cardiovascular condition (eg, unstable angina, acute stroke), severe obstructive intracardiac abnormality, or severe pulmonary hypertension. If this is the case, this information might influence the decision around delaying, cancelling, or proceeding with surgery, and the choice of the surgical and anaesthetic techniques.
      • 1.
        In patients who require emergency surgery, we recommend against delaying surgery for a preoperative cardiac risk assessment.
      • 2.
        In patients who require urgent or semiurgent surgery, we recommend undertaking preoperative cardiac risk assessment only if the patients' history or physical examination suggests there is a potential undiagnosed severe obstructive intracardiac abnormality, severe pulmonary hypertension, or an unstable cardiovascular condition.
      • 3.
        In patients who undergo elective noncardiac surgery who are 45 years of age or older or 18-44 years of age with known significant cardiovascular disease, we recommend they undergo preoperative cardiac risk assessment.
      Practical tip. Preoperative cardiac risk assessments should be undertaken by a physician or surgeon with substantial knowledge in this area (eg, a thorough understanding of these perioperative guidelines) and who is proficient in cardiac clinical evaluation.

      Risk communication

      There is an ethical requirement to accurately apprise patients about the benefits and risks of surgery.
      • 4.
        We recommend communicating to patients their perioperative cardiac risk.
      Supplemental Tables S3 and S4 show the summary of findings and the GRADE quality assessment for communicating perioperative cardiac risk, respectively. A survey of 104 general internists who performed an average of 17 preoperative consults a month showed marked variability in definitions of low, moderate, and high risk.
      • Taher T.
      • Khan N.A.
      • Devereaux P.J.
      • et al.
      Assessment and reporting of perioperative cardiac risk by Canadian general internists: art or science?.
      With these results, there is substantial risk of misunderstanding between individuals when they hear subjective terms of risk. A systematic review of high-quality randomized controlled trials (RCTs) in surgical and nonsurgical settings showed that patients have a more accurate perception of risk if probabilistic information is presented as numbers like event rates (natural frequencies), rather than words (ie, subjective terms like low, moderate, or high chance), probabilities, or summarized as effect measures such as relative risk (RR) reduction.
      • Trevena L.J.
      • Davey H.M.
      • Barratt A.
      • Butow P.
      • Caldwell P.
      A systematic review on communicating with patients about evidence.
      • 5.
        We recommend explicit communication of perioperative cardiac risk on the basis of the expected event rate among 100 patients or the range of risk consistent with the 95% confidence interval (CI) of the risk estimate (Strong Recommendation; Moderate-Quality Evidence).
      Practical tip. An example of communicating perioperative cardiac risk quantitatively follows. “Ms Smith, if we had 100 patients with the same underlying conditions that you have who were to undergo the same type of surgery as you, we would expect 8 to 12 of these patients to suffer a heart attack, cardiac arrest, or die within the first 30 days after surgery. This also means we would expect 88 to 92 of these patients to go through surgery without one of these complications.”

      Methods of preoperative cardiac risk assessment

      Researchers have evaluated 3 methods of estimating perioperative cardiac risk (ie, clinical risk indices, cardiac biomarkers, and noninvasive cardiac testing) that can provide the required data for risk communication in addition to routine clinical evaluation.

      Clinical risk indices

      Supplemental Tables S5 and S6 show the summary of findings and GRADE quality assessment for 3 clinical risk indices, respectively. These risk indices include the most validated clinical risk index (known as the Revised Cardiac Risk Index [RCRI]),
      • Lee T.H.
      • Marcantonio E.R.
      • Mangione C.M.
      • et al.
      Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
      and 2 risk indices that were recently developed using data from the National Surgical Quality Improvement Program (NSQIP).
      • Gupta P.K.
      • Gupta H.
      • Sundaram A.
      • et al.
      Development and validation of a risk calculator for prediction of cardiac risk after surgery.
      • Bilimoria K.Y.
      • Liu Y.
      • Paruch J.L.
      • et al.
      Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons.
      Although some risk factors (eg, severe aortic stenosis) have important perioperative prognostic implications, a risk factor might not show up in a risk index because few or no patients in the original study had the relevant risk factor or it was not assessed.
      The RCRI includes 6 factors, each worth 1 point (ie, history of ischemic heart disease, cerebrovascular disease, congestive heart failure, preoperative insulin use, preoperative creatinine > 177 μmol/L, and high-risk surgery; Table 1).
      • Lee T.H.
      • Marcantonio E.R.
      • Mangione C.M.
      • et al.
      Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
      In a systematic review that included 792,740 patients from 24 studies, the RCRI showed moderate discrimination to predict major perioperative cardiac complications.
      • Ford M.K.
      • Beattie W.S.
      • Wijeysundera D.N.
      Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index.
      Table 1Computation of Revised Cardiac Risk Index score
      VariablePoints
      History of ischemic heart disease
      Defined as a history of myocardial infarction, positive exercise test, current complaint of ischemic chest pain or nitrate use, or ECG with pathological Q waves; patients with previous coronary bypass surgery or angioplasty meet criteria if they have such findings after their procedure.
      1
      History of congestive heart failure
      Defined as a history of heart failure, pulmonary edema, or paroxysmal nocturnal dyspnea; an S3 gallop or bilateral rales on physical examination; or a chest radiograph showing pulmonary vascular resistance.
      1
      History of cerebrovascular disease
      Defined as a stroke or transient ischemic attack.
      1
      Use of insulin therapy for diabetes1
      Preoperative serum creatinine > 177 μmol/L (> 2.0 mg/dL)1
      High-risk surgery
      Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery.
      1
      ECG, electrocardiogram.
      Defined as a history of myocardial infarction, positive exercise test, current complaint of ischemic chest pain or nitrate use, or ECG with pathological Q waves; patients with previous coronary bypass surgery or angioplasty meet criteria if they have such findings after their procedure.
      Defined as a history of heart failure, pulmonary edema, or paroxysmal nocturnal dyspnea; an S3 gallop or bilateral rales on physical examination; or a chest radiograph showing pulmonary vascular resistance.
      Defined as a stroke or transient ischemic attack.
      § Defined as intraperitoneal, intrathoracic, or suprainguinal vascular surgery.
      Table 2 and Supplemental Table S7 show the pooled risk estimates of external validation studies of the RCRI that were published in the past 15 years, systematically monitored perioperative troponin measurements, and reported event rates for the various RCRI scores. The results showed risk estimates for myocardial infarction, cardiac arrest, or death of 3.9% (95% CI, 2.8%-5.4%) for an RCRI score of 0, 6.0% (95% CI, 4.9%-7.4%) for an RCRI score of 1, 10.1% (95% CI, 8.1%-12.6%) for an RCRI score of 2, and 15.0% (95% CI, 11.1%-20.0%) for an RCRI score ≥ 3.
      • Devereaux P.J.
      • Bradley D.
      • Chan M.T.
      • et al.
      An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study.
      • Sheth T.
      • Chan M.
      • Butler C.
      • et al.
      Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study.
      • Ausset S.
      • Auroy Y.
      • Lambert E.
      • et al.
      Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome.
      • Cuthbertson B.H.
      • Amiri A.R.
      • Croal B.L.
      • et al.
      Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non-cardiac surgery.
      • Rajagopalan S.
      • Croal B.L.
      • Bachoo P.
      • et al.
      N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery.
      These values are higher than the risk estimates on the basis of the original data that were used to derive the RCRI.
      • Lee T.H.
      • Marcantonio E.R.
      • Mangione C.M.
      • et al.
      Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
      • Devereaux P.J.
      • Goldman L.
      • Cook D.J.
      • et al.
      Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk.
      The likely explanation for these differences is that the original RCRI study monitored creatine kinase muscle and brain isoenzyme and excluded emergency surgery patients, whereas the external validation studies monitored troponin measurements that are much more sensitive than creatine kinase muscle and brain isoenzyme, and some studies included emergency surgery patients.
      Table 2Total RCRI score and corresponding risk of myocardial infarction, cardiac arrest, or death at 30 days after noncardiac surgery
      On the basis of high-quality external validation studies.
      Total RCRI pointsRisk estimate, %95% CI for the risk estimate
      03.92.8%-5.4%
      16.04.9%-7.4%
      210.18.1%-12.6%
      ≥315.011.1%-20.0%
      CI, confidence interval; RCRI, Revised Cardiac Risk Index.
      On the basis of high-quality external validation studies.
      The NSQIP Myocardial Infarction and Cardiac Arrest (MICA) risk index and the American College of Surgeons (ACS) NSQIP risk index have both been developed using large data sets.
      • Gupta P.K.
      • Gupta H.
      • Sundaram A.
      • et al.
      Development and validation of a risk calculator for prediction of cardiac risk after surgery.
      • Bilimoria K.Y.
      • Liu Y.
      • Paruch J.L.
      • et al.
      Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons.
      In these studies, these risk indices showed superior discrimination compared with the RCRI; however, it is highly probable that the NSQIP MICA and the ACS NSQIP risk indices underestimated cardiac risk, because patients did not undergo systematic measurements of perioperative troponin levels in these studies. Without cardiac biomarker screening more than half of all perioperative myocardial infarctions go undetected.
      • Devereaux P.J.
      • Xavier D.
      • Pogue J.
      • et al.
      Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
      This likely explains the low number of perioperative myocardial infarctions in these studies that developed the NSQIP MICA and the ACS NSQIP risk indices.
      • Gupta P.K.
      • Gupta H.
      • Sundaram A.
      • et al.
      Development and validation of a risk calculator for prediction of cardiac risk after surgery.
      • Bilimoria K.Y.
      • Liu Y.
      • Paruch J.L.
      • et al.
      Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons.
      Moreover, the NSQIP MICA and the ACS NSQIP risk indices have not undergone external validation in a study that has systematically monitored troponin measurements after noncardiac surgery. For these reasons the panel favoured the RCRI for cardiac risk prediction.
      • 6.
        When evaluating cardiac risk, we suggest clinicians use the RCRI over the other available clinical risk prediction scores (Conditional Recommendation; Low-Quality Evidence).

      Self-reported functional capacity

      Some groups have recommended assessing patients' self-reported functional capacity to determine their metabolic equivalents (METs), to guide perioperative cardiac risk assessment.
      • Fleisher L.A.
      • Fleischmann K.E.
      • Auerbach A.D.
      • 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.
      There are, however, limited data to inform this issue.
      In 1999, Reilly et al. evaluated 600 consecutive patients who underwent major noncardiac surgery and showed that after adjustment for age, patient self-reported functional capacity (METs) did not predict perioperative cardiovascular complications (adjusted odds ratio [aOR], 1.81; 95% CI, 0.94-3.46).
      • Reilly D.F.
      • McNeely M.J.
      • Doerner D.
      • et al.
      Self-reported exercise tolerance and the risk of serious perioperative complications.
      Similarly, Wiklund et al. determined METs in 5939 patients who underwent noncardiac surgery and showed after adjustment for age that patients' METs were not independently predictive of major perioperative cardiac complications.
      • Wiklund R.A.
      • Stein H.D.
      • Rosenbaum S.H.
      Activities of daily living and cardiovascular complications following elective, noncardiac surgery.
      Moreover, the data raised concerns about observer bias in the estimation of patients' METs.
      Because of the limitations of the evidence, the primary panel unanimously decided not to make a recommendation on how to use patient self-reported functional capacity to estimate perioperative cardiac risk. A large prospective cohort study (scheduled to report in 2017) that is evaluating the prognostic capabilities of a physicians' assessment of patients' METs vs other measures (eg, cardiopulmonary testing) will provide more insight into the value of estimating a patients' METs.
      • Wijeysundera D.N.
      • Pearse R.M.
      • Shulman M.A.
      • et al.
      Measurement of Exercise Tolerance before Surgery (METS) study: a protocol for an international multicentre prospective cohort study of cardiopulmonary exercise testing prior to major non-cardiac surgery.

      Cardiac biomarkers

      Brain natriuretic peptides (BNPs) and N-terminal fragment of proBNP (NT-proBNP) are released from the myocardium in response to various stimuli such as myocardial stretch and ischemia.
      • Struthers A.
      • Lang C.
      The potential to improve primary prevention in the future by using BNP/N-BNP as an indicator of silent ‘pancardiac’ target organ damage: BNP/N-BNP could become for the heart what microalbuminuria is for the kidney.
      • Luchner A.
      • Stevens T.L.
      • Borgeson D.D.
      • et al.
      Differential atrial and ventricular expression of myocardial BNP during evolution of heart failure.
      • Clerico A.
      • Giannoni A.
      • Vittorini S.
      • Passino C.
      Thirty years of the heart as an endocrine organ: physiological role and clinical utility of cardiac natriuretic hormones.
      Several prospective observational studies have evaluated the prognostic capabilities of NT-proBNP and BNP to predict major cardiovascular events after noncardiac surgery. Supplemental Tables S8 and S9 show the summary of findings and GRADE quality assessment for the prognostic capabilities of NT-proBNP and BNP, respectively.
      An individual patient data meta-analysis included 2179 patients from 18 studies and showed that a preoperative NT-proBNP/BNP measurement was independently associated with the primary outcome (ie, death or nonfatal myocardial infarction) at 30 days after noncardiac surgery (aOR, 3.40; 95% CI, 2.57-4.47; P < 0.001).
      • Rodseth R.N.
      • Biccard B.M.
      • Le Manach Y.
      • et al.
      The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.
      Importantly, a preoperative NT-proBNP/BNP measurement before noncardiac surgery improved risk prediction among patients who did and did not suffer the primary outcome. Values ≥ 300 ng/L for NT-proBNP and ≥ 92 mg/L for BNP were identified as significant thresholds associated with an increased risk of the primary outcome. According to these thresholds, 7.6% of patients had an elevated NT-proBNP/BNP measurement before noncardiac surgery. Death or nonfatal myocardial infarction within 30 days after surgery occurred in 4.9% of patients with preoperative NT-proBNP/BNP values below these thresholds compared with 21.8% of patients with NT-proBNP/BNP values at or above these thresholds (Table 3). These findings were consistent with results from previous meta-analyses.
      • Rodseth R.N.
      • Biccard B.M.
      • Le Manach Y.
      • et al.
      The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.
      • Karthikeyan G.
      • Moncur R.A.
      • Levine O.
      • et al.
      Is a pre-operative brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of noncardiac surgery? A systematic review and meta-analysis of observational studies.
      • Ryding A.D.
      • Kumar S.
      • Worthington A.M.
      • Burgess D.
      Prognostic value of brain natriuretic peptide in noncardiac surgery: a meta-analysis.
      • Rodseth R.N.
      • Padayachee L.
      • Biccard B.M.
      A meta-analysis of the utility of pre-operative brain natriuretic peptide in predicting early and intermediate-term mortality and major adverse cardiac events in vascular surgical patients.
      • Young Y.R.
      • Sheu B.F.
      • Li W.C.
      • et al.
      Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications; a systemic review and meta-analysis.
      • 7.
        We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have an RCRI score ≥ 1 (Strong Recommendation; Moderate-Quality Evidence).
      • Values and preferences. Cost and accessibility were considered important determinants of biomarker selection. Considering cost, we restricted testing to patient groups that had a baseline clinical risk estimate > 5%. Data from the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study showed that patients 65 years of age or older or 45-64 years of age with known cardiovascular disease have a baseline risk > 5% for cardiovascular death or nonfatal myocardial infarction at 30 days after surgery, whereas patients without these characteristics have a ≤ 2.0% 30-day event rate.
        • Botto F.
        • Alonso-Coello P.
        • Chan M.T.
        • et al.
        Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
        Compared with cardiac imaging and noninvasive cardiac stress testing, NT-proBNP/BNP biomarkers are inexpensive and avoid the need for return visits.
      Table 3Risk of death or myocardial infarction at 30 days after noncardiac surgery, based upon a patient's preoperative NT-proBNP or BNP result
      Test resultRisk estimate, %95% CI for the risk estimate
      NT-proBNP < 300 ng/L or BNP < 92 mg/L4.93.9%-6.1%
      NT-proBNP value ≥ 300 ng/L or BNP ≥ 92 mg/L21.819.0%-24.8%
      BNP, brain natriuretic peptide; CI, confidence interval; NT-proBNP, N-terminal pro-brain natriuretic peptide.
      Practical tip. Hospitals that do not analyze NT-proBNP/BNP in their core laboratory can obtain an instrument to allow clinicians to obtain NT-proBNP as a point of care test in the preoperative setting, offering biomarker information within minutes.

      Resting echocardiography

      Supplemental Tables S10 and S11 show the summary of findings and GRADE quality assessment for the prognostic capabilities of preoperative resting echocardiography, respectively. Two small studies of 339 and 570 patients suggested that a low ejection fraction was a borderline significant independent predictor of major cardiovascular complications within 30 days after noncardiac surgery.
      • Halm E.A.
      • Browner W.S.
      • Tubau J.F.
      • Tateo I.M.
      • Mangano D.T.
      Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group.
      • Rohde L.E.
      • Polanczyk C.A.
      • Goldman L.
      • et al.
      Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery.
      The largest study (N = 1923) to assess the prognostic capabilities of preoperative echocardiographic parameters suggested that several parameters (eg, left ventricular ejection fraction < 50%) were independent predictors of major perioperative cardiovascular complications; however, a preoperative NT-proBNP measurement was a much stronger independent predictor.
      • Park S.J.
      • Choi J.H.
      • Cho S.J.
      • et al.
      Comparison of transthoracic echocardiography with N-terminal pro-brain natriuretic peptide as a tool for risk stratification of patients undergoing major noncardiac surgery.
      The prognostic capabilities of an RCRI threshold ≥ 2 increased with the addition of an NT-proBNP threshold of ≥ 301 ng/L (ie, an RR of 1.4; 95% CI, 1.0-1.8 went to an RR of 3.7; 95% CI, 2.7-5.0; P < 0.001); however, use of echocardiographic parameters in addition did not result in a further increase in the RR.
      Because of these data and our recommendation to measure a preoperative NT-proBNP or BNP in patients who undergo noncardiac surgery who are 65 years of age or older, or 45-64 years of age with known cardiovascular disease, the current evidence does not support the use of routine preoperative echocardiography for risk assessment in patients who undergo noncardiac surgery.
      • 8.
        We recommend against performing preoperative resting echocardiography to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
      Practical tip. Although we recommend against routinely obtaining echocardiography before noncardiac surgery to enhance perioperative cardiac risk estimation, if a patient requires urgent/semiurgent or elective surgery and their clinical examination suggests the patient has an undiagnosed severe obstructive intracardiac abnormality (eg, aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy) or severe pulmonary hypertension, then urgent echocardiography should be obtained before surgery to inform the anesthesiologist, surgeon, and medical team of the type and degree of disease. Moreover, if a physician's clinical assessment suggests a patient might have an undiagnosed cardiomyopathy then echocardiography should be performed to facilitate optimization of long-term cardiac health. Physicians should consider the urgency of the surgery when deciding whether echocardiography is obtained before or after surgery.

      Coronary computed tomographic angiography

      Supplemental Tables S12 and S13 show the summary of findings and GRADE quality assessment for preoperative coronary computed tomographic angiography (CCTA), respectively. Of the preoperative CCTA studies the VISION CCTA study was the highest-quality study.
      • Sheth T.
      • Chan M.
      • Butler C.
      • et al.
      Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study.
      This was a prospective cohort study conducted at 12 centres in 8 countries that evaluated the prognostic capabilities of preoperative CCTA to enhance perioperative risk prediction beyond clinical data in 955 patients. The CCTA results were blinded unless significant left main disease was identified, and patients had daily troponin measurements for 3 days after surgery.
      • Sheth T.
      • Chan M.
      • Butler C.
      • et al.
      Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study.
      The primary outcome of cardiovascular death and nonfatal myocardial infarction occurred in 74 patients (7.7%) within 30 days of surgery.
      The study showed, compared with the RCRI alone, that preoperative CCTA findings improved risk estimation (ie, extensive obstructive disease had an adjusted hazard ratio [aHR], 3.76; 95% CI, 1.12-12.62) among patients who suffered the primary outcome, but also overestimated risk among patients who did not suffer the primary outcome. Although CCTA findings can appropriately improve risk estimation among patients who will suffer the primary outcome, CCTA findings are more than 5 times as likely to lead to an inappropriate overestimation of risk among patients who will not suffer a perioperative cardiovascular death or myocardial infarction. The overall absolute net reclassification in a sample of 1000 patients is that CCTA will result in an inappropriate estimate of risk in 81 patients (on the basis of risk categories of < 5%, 5%-15%, and > 15% for the primary outcome).
      • Sheth T.
      • Chan M.
      • Butler C.
      • et al.
      Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study.
      Overestimating risk can have negative consequences. For example, many patients who have a positive preoperative cardiac stress test have their surgery delayed while they are sent for coronary angiography with a plan for coronary revascularization, which might provide no benefit.
      • Beattie W.S.
      • Abdelnaem E.
      • Wijeysundera D.N.
      • Buckley D.N.
      A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging.
      • Etchells E.
      • Meade M.
      • Tomlinson G.
      • Cook D.
      Semiquantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a meta-analysis.
      Overestimating cardiac risk might also result in delays and cancellations of beneficial surgery or inappropriate use of postoperative high-intensity beds, precluding access for patients at greater risk.
      • 9.
        We recommend against performing preoperative CCTA to enhance perioperative cardiac risk estimation (Strong Recommendation; Moderate-Quality Evidence).

      Exercise stress testing and cardiopulmonary exercise testing

      Supplemental Tables S14 and S15 show the summary of findings and GRADE quality assessment for preoperative exercise stress testing, respectively. Only a few studies have addressed the preoperative value of exercise stress testing to enhance risk prediction of postoperative cardiovascular complications, and the overall number of patients and events were small.
      • Kaaja R.
      • Sell H.
      • Erkola O.
      • Harjula A.
      Predictive value of manual ECG-monitored exercise test before abdominal aortic or peripheral vascular surgery.
      • McPhail N.
      • Calvin J.E.
      • Shariatmadar A.
      • Barber G.G.
      • Scobie T.K.
      The use of preoperative exercise testing to predict cardiac complications after arterial reconstruction.
      • Carliner N.H.
      • Fisher M.L.
      • Plotnick G.D.
      • et al.
      Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
      • Sgura F.A.
      • Kopecky S.L.
      • Grill J.P.
      • Gibbons R.J.
      Supine exercise capacity identifies patients at low risk for perioperative cardiovascular events and predicts long-term survival.
      Results did not show an association between electrocardiogram (ECG) changes during exercise and postoperative outcome.
      • McPhail N.
      • Calvin J.E.
      • Shariatmadar A.
      • Barber G.G.
      • Scobie T.K.
      The use of preoperative exercise testing to predict cardiac complications after arterial reconstruction.
      • Carliner N.H.
      • Fisher M.L.
      • Plotnick G.D.
      • et al.
      Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
      • Sgura F.A.
      • Kopecky S.L.
      • Grill J.P.
      • Gibbons R.J.
      Supine exercise capacity identifies patients at low risk for perioperative cardiovascular events and predicts long-term survival.
      Two studies showed that low performance capacity was associated with a higher incidence of postoperative cardiovascular events, but neither study performed a risk-adjusted analysis.
      • Kaaja R.
      • Sell H.
      • Erkola O.
      • Harjula A.
      Predictive value of manual ECG-monitored exercise test before abdominal aortic or peripheral vascular surgery.
      • Sgura F.A.
      • Kopecky S.L.
      • Grill J.P.
      • Gibbons R.J.
      Supine exercise capacity identifies patients at low risk for perioperative cardiovascular events and predicts long-term survival.
      Supplemental Tables S16 and S17 show the summary of findings and GRADE quality assessment for preoperative cardiopulmonary exercise testing (CPET), respectively. Few studies have assessed the prognostic capabilities of CPET to independently predict 30-day cardiac outcomes. The largest prospective cohort study included 1725 patients who underwent elective major abdominal or thoracic surgery and showed CPET was a weak independent predictor of long-term postoperative mortality.
      • Colson M.
      • Baglin J.
      • Bolsin S.
      • Grocott M.P.
      Cardiopulmonary exercise testing predicts 5 yr survival after major surgery.
      Other studies showed similar results,
      • Grant S.W.
      • Hickey G.L.
      • Wisely N.A.
      • et al.
      Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repairdagger.
      • Lai C.W.
      • Minto G.
      • Challand C.P.
      • et al.
      Patients’ inability to perform a preoperative cardiopulmonary exercise test or demonstrate an anaerobic threshold is associated with inferior outcomes after major colorectal surgery.
      • Hartley R.A.
      • Pichel A.C.
      • Grant S.W.
      • et al.
      Preoperative cardiopulmonary exercise testing and risk of early mortality following abdominal aortic aneurysm repair.
      • Carlisle J.
      • Swart M.
      Mid-term survival after abdominal aortic aneurysm surgery predicted by cardiopulmonary exercise testing.
      with various strength of the association between CPET and mortality, but none determined if CPET performance allowed for improved risk reclassification in addition to clinical evaluation. The value of preoperative exercise testing or CPET to enhance perioperative cardiac risk reclassification in addition to clinical evaluation alone remains unclear, is inconvenient for patients, and costs significantly more than NT-proBNP or BNP measurement.
      • 10.
        We recommend against performing preoperative exercise stress testing to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
      • 11.
        We recommend against performing preoperative CPET to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).

      Pharmacological stress echocardiography and radionuclide imaging

      Supplemental Tables S18 and S19 show the summary of findings and GRADE quality assessment for pharmacological stress echocardiography and radionuclide imaging, respectively. Several observational studies have evaluated the predictive value of pharmacological stress echocardiography and radionuclide imaging in patients who undergo noncardiac surgery.
      • Beattie W.S.
      • Abdelnaem E.
      • Wijeysundera D.N.
      • Buckley D.N.
      A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging.
      All studies had relatively small sample sizes with a limited number of events. Only a few were prospective studies, and few reported risk-adjusted associations. No study adequately assessed the incremental value of these stress tests to well-established perioperative cardiac risk factors (eg, RCRI).
      • 12.
        We recommend against performing preoperative pharmacological stress echocardiography to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
      • 13.
        We recommend against performing preoperative pharmacological stress radionuclide imaging to enhance perioperative cardiac risk estimation (Strong Recommendation; Moderate-Quality Evidence).
      • Values and preferences. The panel believed that the cost and potential delays associated with these stress tests should be taken into account because of the absence of evidence of an overall absolute net improvement in risk reclassification.

      Perioperative Cardiac Risk Modification

      Table 4 shows the recommended management of interventions that target perioperative cardiac risk.
      Table 4Management of interventions targeting the prevention of perioperative cardiac events
      This applies to patients age 45 years of age or older or 18-44 years of age with known significant cardiovascular disease (ie, history of coronary artery disease, cerebral vascular disease, peripheral vascular disease, congestive heart failure, or a severe obstructive intracardiac abnormality [eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy]) undergoing noncardiac surgery requiring hospital admission.
      InterventionManagement
      Management of medications taken chronically and smoking before noncardiac surgery
       ASAWithhold at least 3 days before surgery
      Except in patients with a recent coronary artery stent and patients undergoing carotid endarterectomy.
      and restart ASA when the risk of bleeding related to surgery has passed (ie, 8-10 days after major noncardiac surgery)
       β-BlockerContinue the β-blocker during the perioperative period; however, if a patient's systolic blood pressure is low before surgery, physicians should consider decreasing or holding the dose of the β-blocker before surgery
       ACEI/ARBWithhold ACEI/ARB 24 hours before noncardiac surgery and restart ACEI/ARB on day 2 after surgery, if the patient is hemodynamically stable
       StatinContinue the statin during the perioperative period
       SmokingDiscuss and facilitate smoking cessation (eg, nicotine replacement therapy), ideally starting ≥ 4 weeks before surgery
      Initiation of new medications and coronary revascularization before noncardiac surgery
       ASADo not initiate ASA for the prevention of perioperative cardiac events
       β-BlockerDo not initiate a β-blocker within 24 hours before noncardiac surgery
       α2-AgonistDo not initiate an α2-agonist for the prevention of perioperative cardiovascular events
       Calcium channel blockerDo not initiate a calcium channel blocker for the prevention of perioperative cardiovascular events
       Coronary revascularizationDo not undertake preoperative prophylactic coronary revascularization for patients with stable coronary artery disease
      ACEI/ARB, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker; ASA, acetylsalicylic acid.
      This applies to patients age 45 years of age or older or 18-44 years of age with known significant cardiovascular disease (ie, history of coronary artery disease, cerebral vascular disease, peripheral vascular disease, congestive heart failure, or a severe obstructive intracardiac abnormality [eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy]) undergoing noncardiac surgery requiring hospital admission.
      Except in patients with a recent coronary artery stent and patients undergoing carotid endarterectomy.

      Perioperative use of acetylsalicylic acid

      Supplemental Tables S20 and S21 show the summary of findings and GRADE quality assessment for perioperative initiation and continuation of acetylsalicylic acid (ASA), respectively. The Pulmonary Embolism Prevention (PEP) trial showed that ASA prevents venous thromboembolism (HR, 0.64; 95% CI, 0.50-0.81) in patients who undergo hip fracture surgery.
      Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.
      In PEP, ASA was associated with an increased risk of myocardial infarction (HR, 1.33; 95% CI, 1.00-1.78); however, there was no systematic monitoring of cardiac biomarkers after surgery, and there were only 184 myocardial infarctions.
      The Perioperative Ischemic Evaluation-2 (POISE-2) trial was a large RCT of 10,010 patients who underwent a wide spectrum of in-hospital noncardiac surgeries.
      • Devereaux P.J.
      • Mrkobrada M.
      • Sessler D.I.
      • et al.
      Aspirin in patients undergoing noncardiac surgery.
      Patients who underwent a carotid endarterectomy, had received a bare-metal stent in the 6 weeks before surgery, or had received a drug-eluting stent in the 12 months before surgery were excluded from the trial. Patients had systematic monitoring of cardiac biomarkers or enzymes for the first 3 days after surgery. POISE-2 showed no effect of ASA on myocardial infarction and cardiac or all-cause mortality. POISE-2, similar to PEP, showed perioperative ASA increased the risk of major bleeding. POISE-2 included 5628 patients who were not previously taking ASA and 4382 patients who were taking ASA chronically but had stopped taking it a minimum of 3 days (median of 7 days) before surgery. The results were consistent in these 2 groups of patients. In POISE-2 the risk of bleeding related to surgery had passed 8-10 days after surgery.
      • 14.
        We recommend against initiation of ASA for the prevention of perioperative cardiac events (Strong Recommendation; High-Quality Evidence).
      • 15.
        We recommend against the continuation of ASA to prevent perioperative cardiac events, except in patients with a recent coronary artery stent and patients who undergo carotid endarterectomy (Strong Recommendation; High-Quality Evidence).
      Practical tip. The timeline to define “recent” coronary stent varies on the basis of the type of stent but usually refers to 6 weeks for bare-metal stent and between 3 and 12 months for drug-eluting stent, depending on the stent generation. Physicians should discontinue ASA at least 3 days before noncardiac surgery to reduce the risk of major bleeding.
      • Devereaux P.J.
      POISE-2 Investigators. Rationale and design of the PeriOperative ISchemic Evaluation-2 (POISE-2) trial: an international 2 x 2 factorial randomized controlled trial of acetyl-salicylic acid vs. placebo and clonidine vs. placebo in patients undergoing noncardiac surgery.
      In patients with an indication for chronic ASA, it is important to restart ASA when the risk of bleeding related to surgery has passed (ie, 8-10 days after major noncardiac surgery).
      • Devereaux P.J.
      • Mrkobrada M.
      • Sessler D.I.
      • et al.
      Aspirin in patients undergoing noncardiac surgery.
      Perioperative ASA continuation might be reasonable for some surgical interventions to prevent local thrombosis (eg, free flap, acute limb ischemia). When a patient suffers a myocardial injury or thrombotic event after surgery in the absence of bleeding, there might be a net value to restarting ASA sooner after surgery than 8-10 days.

      β-Blockade initiation before noncardiac surgery

      Supplemental Tables S22 and S23 show the summary of findings and GRADE quality assessment for perioperative β-blocker initiation, respectively. A recent meta-analysis that included data from > 10,000 patients in 14 trials showed that perioperative β-blockers initiated within 24 hours of noncardiac surgery reduced the risk of nonfatal myocardial infarction but increased the risk of death, nonfatal stroke, hypotension, and bradycardia.
      • Wijeysundera D.N.
      • Duncan D.
      • Nkonde-Price C.
      • et al.
      Perioperative beta blockade in noncardiac surgery: a systematic review for the 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.
      This meta-analysis included data from the POISE trial, which randomized 8351 patients with, or at risk of, coronary artery disease to receive extended-release metoprolol or placebo starting 2-4 hours before induction of anesthesia and continued for 30 days.
      • Devereaux P.J.
      • Yang H.
      • Yusuf S.
      • et al.
      Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.
      The meta-analysis showed that the increased risk of death and stroke was qualitatively unchanged without the POISE data.
      Some authors have advocated for the initiation and titration of β-blockade starting weeks before surgery
      • Fleisher L.A.
      • Poldermans D.
      Perioperative beta blockade: where do we go from here?.
      ; however, most patients are seen in preoperative clinics within days to weeks before surgery, making β-blocker dose titration challenging. Moreover, whatever β-blocker dose a patient tolerates before surgery does not necessarily inform a safe perioperative dose because hypotension is common after surgery.
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      Although some authorities advocate beginning β-blockers more than 24 hours before noncardiac surgery, there are no reliable data to support this practice.
      • 16.
        We recommend against β-blocker initiation within 24 hours before noncardiac surgery (Strong Recommendation; High-Quality Evidence).

      β-Blocker continuation during the perioperative period

      Supplemental Tables S24 and S25 show the summary of findings and GRADE quality assessment for perioperative β-blocker continuation, respectively. No RCT informs the risks and benefits of continuing vs holding perioperative β-blockade during the perioperative period in patients chronically taking a β-blocker. Although there are inconsistent results, one large observational study suggested in risk-adjusted analyses that continuing chronic β-blocker usage decreases perioperative mortality, whereas perioperative withholding of a β-blocker in patients taking a β-blocker chronically increased mortality.
      • Wallace A.W.
      • Au S.
      • Cason B.A.
      Association of the pattern of use of perioperative beta-blockade and postoperative mortality.
      Although POISE evaluated the initiation of a β-blocker in the perioperative setting, the POISE data suggest that hypotension was the likely mechanism regarding how β-blockers increase the risk of mortality and stroke in the perioperative setting.
      • Devereaux P.J.
      • Yang H.
      • Yusuf S.
      • et al.
      Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.
      • 17.
        Among patients taking a β-blocker chronically, we suggest to continue the β-blocker during the perioperative period (Conditional Recommendation; Low-Quality Evidence).
      Practical tip. If a patient's systolic blood pressure is low before surgery, physicians should consider decreasing or holding the dose of the β-blocker before surgery.

      α2-Agonist initiation before noncardiac surgery

      Supplemental Tables S26 and S27 show the summary of findings and GRADE quality assessment for perioperative initiation of an α2-agonist, respectively. Researchers have evaluated the potential of α2-agonists as an alternative means to control the perioperative stress response, which is a major determinant of perioperative cardiac complications. A meta-analysis of small trials suggested α2-agonists might prevent perioperative cardiovascular complications
      • Wijeysundera D.N.
      • Bender J.S.
      • Beattie W.S.
      Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery.
      ; however, a large international trial of 10,010 patients that randomized patients to clonidine or placebo showed that clonidine had no effect on myocardial infarction or death.
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      Moreover, clonidine increased the risk of clinically important hypotension and bradycardia and nonfatal cardiac arrest.
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      • 18.
        We recommend against preoperative initiation of an α2-agonist for the prevention of perioperative cardiovascular events (Strong Recommendation; High-Quality Evidence).

      Calcium channel blocker initiation before noncardiac surgery

      Supplemental Tables S28 and S29 show the summary of findings and GRADE quality assessment for perioperative initiation of a calcium channel blocker, respectively. A meta-analysis of several small trials suggested perioperative calcium channel blockers might prevent death or nonfatal myocardial infarction; however, there were only 5 myocardial infarctions and 17 deaths across all the trials, and the meta-analysis suggested implausible large treatment effects.
      • Wijeysundera D.N.
      • Beattie W.S.
      Calcium channel blockers for reducing cardiac morbidity after noncardiac surgery: a meta-analysis.
      Moreover, the panel was concerned that these small trials with few events do not provide sufficient confidence to exclude potentially important adverse effects.
      • 19.
        We suggest against the initiation of calcium channel blockers for the prevention of perioperative cardiovascular events (Conditional Recommendation; Low-Quality Evidence).

      Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker continuation in the perioperative period

      Supplemental Tables S30 and S31 show the summary of findings and GRADE quality assessment for the perioperative withholding of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), respectively. Three RCTs (total N = 188 patients) have looked at the effect of preoperative continuing vs withholding an ACEI or ARB around the time of noncardiac surgery.
      • Coriat P.
      • Richer C.
      • Douraki T.
      • et al.
      Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction.
      • Bertrand M.
      • Godet G.
      • Meersschaert K.
      • et al.
      Should the angiotensin II antagonists be discontinued before surgery?.
      • Schirmer U.
      • Schurmann W.
      Preoperative administration of angiotensin-converting enzyme inhibitors [in German].
      All 3 trials showed that preoperative continuation of an ACEI/ARB was associated with an increased risk of intraoperative hypotension (pooled RR 2.53; 95% CI, 1.08-5.93). Only one trial reported on cardiovascular complications, but the number of events was too small to draw any conclusions.
      • Bertrand M.
      • Godet G.
      • Meersschaert K.
      • et al.
      Should the angiotensin II antagonists be discontinued before surgery?.
      In other perioperative studies, clinically important hypotension has been independently associated with an increased risk of death, myocardial infarction, and stroke.
      • Devereaux P.J.
      • Yang H.
      • Yusuf S.
      • et al.
      Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      The highest risk for clinically important hypotension after noncardiac surgery is the day after surgery.
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      • 20.
        We recommend withholding ACEI/ARB starting 24 hours before noncardiac surgery in patients treated chronically with an ACEI/ARB (Strong Recommendation; Low-Quality Evidence).
      • Values and preferences. Weight was accorded to the absence of demonstrated benefit and the substantial increase in the risk of intraoperative hypotension associated with perioperative continuation of ACEI/ARB therapy.
      Practical tip. Because the risk of hypotension is greatest within 24 hours of surgery, physicians should consider restarting ACEI/ARB on day 2 after surgery in patients receiving chronic ACEI/ARB therapy, if the patient is hemodynamically stable.

      Statin initiation before noncardiac surgery

      Supplemental Tables S32 and S33 show the summary of findings and GRADE quality assessment for statin initiation before noncardiac surgery, respectively. Sanders et al. reported a systematic review and meta-analysis of 3 trials (total of 178 patients) that evaluated the cardiovascular effect of initiating a statin in patients who undergo vascular surgery.
      • Sanders R.D.
      • Nicholson A.
      • Lewis S.R.
      • Smith A.F.
      • Alderson P.
      Perioperative statin therapy for improving outcomes during and after noncardiac vascular surgery.
      There were very few events and perioperative administration of a statin had no effect on all-cause mortality (17 outcomes), cardiac mortality (2 outcomes), and nonfatal myocardial infarction (12 outcomes).
      • Sanders R.D.
      • Nicholson A.
      • Lewis S.R.
      • Smith A.F.
      • Alderson P.
      Perioperative statin therapy for improving outcomes during and after noncardiac vascular surgery.
      Panel members believed that the evidence was too weak to support a recommendation.

      Statin continuation in the noncardiac surgery setting

      Supplemental Tables S34 and S35 show the summary of findings and GRADE quality assessment for statin continuation in the noncardiac surgery setting, respectively. A single RCT included 550 patients who were admitted for an urgent/emergent surgery and had been taking chronic statin therapy.
      • Xia J.
      • Qu Y.
      • Yin C.
      • Xu D.
      Preoperative rosuvastatin protects patients with coronary artery disease undergoing noncardiac surgery.
      Patients were randomized to receive rosuvastatin 20 mg or placebo 2 hours before surgery. At 30 days 10 patients (3.6%) in the rosuvastatin group and 22 patients (8.0%) in the placebo group suffered a myocardial infarction (P = 0.03).
      • 21.
        We recommend continuing statin therapy perioperatively in patients who are receiving chronic statin therapy (Strong Recommendation; Moderate-Quality Evidence).

      Coronary artery revascularization before noncardiac surgery

      Supplemental Tables S36 and S37 show the summary of findings and GRADE quality assessment for coronary artery revascularization before noncardiac surgery, respectively. One trial randomized 216 patients to undergo coronary angiography followed by coronary revascularization, if applicable, followed by carotid endarterectomy, and 210 patients to undergo carotid endarterectomy without undergoing coronary angiography.
      • Illuminati G.
      • Ricco J.B.
      • Greco C.
      • et al.
      Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial.
      Among the 216 patients assigned to coronary angiography before carotid endarterectomy, 68 (31%) had significant coronary artery disease on angiography. Sixty-six of these patients underwent percutaneous coronary intervention (PCI), and then while still taking ASA and clopidogrel underwent carotid endarterectomy a mean of 4 days later; 2 patients underwent coronary artery bypass grafting surgery and carotid endarterectomy during one anesthetic period.
      Although this trial suggests short- and long-term benefits from a strategy of coronary angiography followed by coronary revascularization—when relevant—before carotid endarterectomy, limitations of the trial include few events, unrealistically large treatment effects, and fixed block sizes that might have compromised concealment of randomization.
      • Illuminati G.
      • Ricco J.B.
      • Greco C.
      • et al.
      Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial.
      • Illuminati G.
      • Schneider F.
      • Greco C.
      • et al.
      Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease.
      Moreover, it is difficult to know how to translate these results to the broader population of patients who undergo noncardiac surgery, especially because of the very short timelines from coronary revascularization to noncardiac surgery and that all of the PCI patients underwent noncardiac surgery while receiving dual antiplatelet therapy.
      The trial that is more broadly applicable to patients who undergo noncardiac surgery is the Coronary Artery Revascularization Prophylaxis (CARP) trial.
      • McFalls E.O.
      • Ward H.B.
      • Moritz T.E.
      • et al.
      Coronary-artery revascularization before elective major vascular surgery.
      This trial randomized 510 patients with known significant coronary artery disease to preoperative coronary revascularization vs no coronary revascularization before vascular surgery. At a median of 2.7 years after randomization, mortality was 22% in the coronary revascularization group and 23% in the no-revascularization group (RR, 0.98; 95% CI, 0.70-1.37; P = 0.92). Vascular surgery was undertaken a median of 48 days after coronary artery bypass grafting surgery and 41 days after PCI. The CARP trial excluded patients with left main coronary artery disease.
      • 22.
        For patients with stable coronary artery disease who undergo noncardiac surgery, we recommend against preoperative prophylactic coronary revascularization (Strong Recommendation; Low-Quality Evidence).
      • Values and preferences. In the absence of clearly demonstrated benefit, the potential for surgical delays, increase in costs, and risk of bleeding with dual antiplatelet therapy supported a strong recommendation against prophylactic preoperative coronary revascularization.
      Practical tip. In patients with CCS class III-IV or unstable angina, obtaining coronary revascularization before noncardiac surgery seems prudent; however, an individual risk-benefit assessment is required in patients who require urgent/semiurgent noncardiac surgery. Patients who receive PCI and a coronary stent should ideally have their noncardiac surgery delayed until the risks of stopping dual antiplatelet therapy are outweighed by the risks associated with delaying noncardiac surgery.
      • Hawn M.T.
      • Graham L.A.
      • Richman J.S.
      • et al.
      Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents.
      • Wijeysundera D.N.
      • Wijeysundera H.C.
      • Yun L.
      • et al.
      Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study.

      Smoking cessation before noncardiac surgery

      Supplemental Tables S38 and S39 show the summary of findings and GRADE quality assessment for preoperative smoking cessation interventions, respectively. A meta-analysis of 4 trials that included 653 patients reported no effect of a preoperative smoking cessation intervention compared with standard care on major perioperative cardiovascular complications (RR, 0.58; 95% CI, 0.17-1.96); however, there were only 16 events.
      A meta-analysis of 9 trials that included 1251 patients showed that preoperative smoking cessation interventions increase smoking cessation at the time of surgery, and the more intensive interventions increased smoking cessation at 12 month follow-up (RR, 2.96; 95% CI, 1.57-5.55).
      • Thomsen T.
      • Villebro N.
      • Moller A.M.
      Interventions for preoperative smoking cessation.
      The more intensive interventions started smoking cessation measures 4 weeks before surgery, and the treatments included smoking cessation counselling and nicotine replacement therapy. The studies were at high risk of bias with high heterogeneity; however, because of the importance of smoking cessation on long-term cardiac outcomes, the panel found the perioperative smoking cessation data compelling.
      • 23.
        We recommend discussing and facilitating smoking cessation before noncardiac surgery (Strong Recommendation; Low-Quality Evidence).
      • Values and preferences. Because even brief counselling on smoking cessation during preoperative evaluation might positively affect smoking cessation, the panel members believe it is important to take advantage of this opportunity to optimize long-term cardiac risk.

      Monitoring for Perioperative Cardiac Events

      Troponin monitoring

      Supplemental Tables S40 and S41 show the summary of findings and GRADE quality assessment for postoperative troponin monitoring, respectively. Most myocardial infarctions occur within 48 hours of noncardiac surgery when patients are receiving analgesic medications that can mask ischemic symptoms.
      • Devereaux P.J.
      • Xavier D.
      • Pogue J.
      • et al.
      Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
      This provides an explanation as to why 65% of patients who suffer a perioperative myocardial infarction do not experience ischemic symptoms, and without perioperative troponin monitoring these myocardial infarctions would go undetected. Asymptomatic myocardial infarctions are associated with an increased risk of 30-day mortality (aOR, 4.00; 95% CI, 2.65-6.06) similar to symptomatic myocardial infarctions (aOR, 4.76; 95% CI, 2.68-8.43).
      • Devereaux P.J.
      • Xavier D.
      • Pogue J.
      • et al.
      Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
      Moreover, asymptomatic perioperative troponin elevation at levels adjudicated as myocardial injuries due to ischemia—that do not fulfil the universal definition of myocardial infarction—are also associated with an increased risk of 30-day mortality (aHR, 3.30; 95% CI, 2.26–4.81).
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      The largest prospective international cohort study (VISION; N = 15,133) showed that the detection of an elevated troponin T level in the postoperative period was the strongest predictor of 30-day mortality.
      • Devereaux P.J.
      • Chan M.T.
      • Alonso-Coello P.
      • et al.
      Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.
      The prognostic importance of an elevated troponin measurement after surgery was supported by a previous meta-analysis of 14 studies that enrolled 3318 patients.
      • Levy M.
      • Heels-Ansdell D.
      • Hiralal R.
      • et al.
      Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis.
      The meta-analysis showed that an elevated troponin level was an independent predictor of all-cause mortality (OR, 6.7; 95% CI, 4.1-10.9) at 1 year after surgery.
      • Levy M.
      • Heels-Ansdell D.
      • Hiralal R.
      • et al.
      Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis.
      Myocardial injury after noncardiac surgery (MINS) was defined as a peak fourth-generation troponin T ≥ 0.03 ng/mL believed to be due to myocardial ischemia.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      MINS was observed in 8% of patients in the VISION study and was associated with a marked increase in 30-day mortality (9.8% vs 1.1%), and had the largest population attributable risk of all the complications after surgery.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      Most of these MINS patients (84%) remained asymptomatic and were only detected through the routine surveillance of postoperative troponin levels.
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      The strong association between an elevated troponin level detected during routine postoperative surveillance and 30-day mortality was confirmed in 2 large cohort studies.
      • van Waes J.A.
      • Nathoe H.M.
      • de Graaff J.C.
      • et al.
      Myocardial injury after noncardiac surgery and its association with short-term mortality.
      • Beattie W.S.
      • Karkouti K.
      • Tait G.
      • et al.
      Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients.
      Moreover, a recent analysis suggests that perioperative troponin surveillance is cost-effective.
      • Torborg A.
      • Ryan L.
      • Kantor G.
      • Biccard B.M.
      The pharmacoeconomics of routine postoperative troponin surveillance to prevent and treat myocardial infarction after non-cardiac surgery.
      Because most patients who suffer a postoperative myocardial infarction or MINS are asymptomatic, routine troponin monitoring can detect patients who are at markedly increased risk of death within 30 days of surgery. Although the optimal management of patients with MINS remains an area of ongoing investigation, we believe that these individuals can benefit from intensification of medical management and close monitoring during their postoperative recovery.
      • 24.
        We recommend obtaining daily troponin measurements for 48-72 hours after noncardiac surgery in patients with a baseline risk > 5% for cardiovascular death or nonfatal myocardial infarction at 30 days after surgery (ie, patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older) (Strong Recommendation; Moderate-Quality Evidence).

      Postoperative ECG

      Supplemental Tables S42 and S43 show the summary of findings and GRADE quality assessment for obtaining a postoperative 12-lead ECG. The association between the occurrence of ischemic changes on a postoperative ECG and the occurrence of adverse cardiac events has been shown in several studies.
      • Mangano D.T.
      • Browner W.S.
      • Hollenberg M.
      • et al.
      Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group.
      • Landesberg G.
      • Luria M.H.
      • Cotev S.
      • et al.
      Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery.
      The largest prospective study to address the prognostic value of a postoperative ECG showed that new ischemic findings were an independent predictor of subsequent major cardiac events (aOR, 2.20; 95% CI, 1.1-3.7; P = 0.009).
      • Rinfret S.
      • Goldman L.
      • Polanczyk C.A.
      • Cook E.F.
      • Lee T.H.
      Value of immediate postoperative electrocardiogram to update risk stratification after major noncardiac surgery.
      Another small study in vascular patients noted that 88% of patients who had ischemic findings on any postoperative ECG had changes detected on the immediate postoperative ECG (15 minutes after surgery); the concordance between ischemia on an ECG and elevation of troponin T level was 85%.
      • Bottiger B.W.
      • Motsch J.
      • Teschendorf P.
      • et al.
      Postoperative 12-lead ECG predicts peri-operative myocardial ischaemia associated with myocardial cell damage.
      The frequent onset of myocardial ischemia during the early postoperative period (< 60 minutes) was also seen in a study using continuous 12-lead ECG recordings after surgery.
      • Landesberg G.
      • Mosseri M.
      • Zahger D.
      • et al.
      Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia.
      • 25.
        We suggest performing a postoperative ECG in the postanesthetic care unit in patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older (Conditional Recommendation; Low-Quality Evidence).

      Postoperative telemetry

      Supplemental Tables S44 and S45 show the summary of findings and GRADE quality assessment for postoperative telemetry, respectively. Studies using telemetry after surgery to detect silent ischemia have generally defined ischemia as ≥ 1 mm of horizontal or downsloping ST depression or ≥ 2 mm ST-elevation for ≥ 60 seconds,
      • Mangano D.T.
      • Browner W.S.
      • Hollenberg M.
      • et al.
      Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group.
      • Landesberg G.
      • Luria M.H.
      • Cotev S.
      • et al.
      Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery.
      • Raby K.E.
      • Barry J.
      • Creager M.A.
      • et al.
      Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery.
      with longer durations of ischemia being more predictive of adverse outcomes after surgery.
      • Landesberg G.
      • Luria M.H.
      • Cotev S.
      • et al.
      Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery.
      • Landesberg G.
      • Mosseri M.
      • Zahger D.
      • et al.
      Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia.
      • Landesberg G.
      • Shatz V.
      • Akopnik I.
      • et al.
      Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery.
      Investigators have identified ischemia after surgery as a predictor of major cardiac events in patients with, or at high risk of, coronary artery disease
      • Botto F.
      • Alonso-Coello P.
      • Chan M.T.
      • et al.
      Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
      • Levy M.
      • Heels-Ansdell D.
      • Hiralal R.
      • et al.
      Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis.
      and in patients who undergo vascular surgery.
      • Raby K.E.
      • Barry J.
      • Creager M.A.
      • et al.
      Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery.
      Because we recommend monitoring troponin in at-risk patients after surgery, the additional benefits of postoperative telemetry monitoring have not been established, and postoperative telemetry is associated with substantial resources and costs, panel members believed that the evidence was too weak to support a recommendation regarding postoperative telemetry monitoring.

      Pulmonary artery catheter monitoring

      Supplemental Tables S46 and S47 show the summary of findings and GRADE quality assessment for routine pulmonary artery catheter monitoring (PACM) in patients who undergo noncardiac surgery, respectively. Eight RCTs have evaluated the effect of routine PACM in patients who undergo noncardiac surgery. Trials varied in terms of whether or not hemodynamic targets and directed therapies were mandated.
      The largest trial included 1994 patients older than the age of 60 years who underwent a high-risk noncardiac surgery. There was no difference in mortality or morbidity, but there was an increase in pulmonary embolism in patients randomized to PACM.
      • Sandham J.D.
      • Hull R.D.
      • Brant R.F.
      • et al.
      A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.
      All studies were included in a meta-analysis of PACM use, along with an additional 5 studies (2384 patients) that enrolled intensive care unit patients or those with acute heart failure. Overall, the meta-analysis did not support any association between PACM use and improved outcomes.
      • Shah M.R.
      • Hasselblad V.
      • Stevenson L.W.
      • et al.
      Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials.
      • 26.
        We recommend against the use of pulmonary artery catheters in patients who undergo noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).

      Postoperative shared-care management

      Supplemental Tables S48 and S49 show the summary of findings and GRADE quality assessment for shared-care management of patients who undergo noncardiac surgery, respectively. Surgeons are commonly busy in operating rooms, which limits their ability to rapidly respond to medical complications on surgical floors. For example, among the 5001 patients given placebo in the POISE-2 trial, the median duration of clinically important hypotension during surgery was 15 minutes, whereas on the first postoperative day it was 150 minutes (P < 0.001).
      • Devereaux P.J.
      • Sessler D.I.
      • Leslie K.
      • et al.
      Clonidine in patients undergoing noncardiac surgery.
      These data suggest a need for pathways to facilitate more rapid management of cardiovascular compromise on surgical floors.
      Shared-care models, between surgeons and medical specialists (eg, anesthesiologist, cardiologist, geriatrician, internist) who are readily available to help with perioperative management of cardiovascular complications, have the potential to improve outcomes. A meta-analysis showed a mortality advantage in patients who had surgery for a hip fracture who were comanaged by surgeons and geriatricians compared with surgeons alone.
      • Grigoryan K.V.
      • Javedan H.
      • Rudolph J.L.
      Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis.
      • 27.
        We suggest shared-care management of patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older (Conditional Recommendation; Low-Quality Evidence).

      Management of Postoperative Events

      ASA and statin in patients who suffer MINS

      Supplemental Tables S50 and S51 show the summary of findings and GRADE quality assessment for ASA and statin in patients who suffer MINS. One prospective cohort study and one retrospective case-control study with propensity score-matching have investigated the question of initiation of ASA and statin therapy in patients who had suffered a myocardial injury or myocardial infarction after noncardiac surgery.
      • Devereaux P.J.
      • Xavier D.
      • Pogue J.
      • et al.
      Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
      • Foucrier A.
      • Rodseth R.
      • Aissaoui M.
      • et al.
      The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery.
      In the prospective cohort study, among the 415 patients who suffered a myocardial infarction after noncardiac surgery, patients who had started receiving ASA and statin had a significant reduction in 30-day mortality (aOR, 0.54; 95% CI, 0.29-0.99, and aOR, 0.26; 95% CI, 0.13-0.54, respectively).
      • Devereaux P.J.
      • Xavier D.
      • Pogue J.
      • et al.
      Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
      The retrospective case controlled study by Foucrier et al.
      • Foucrier A.
      • Rodseth R.
      • Aissaoui M.
      • et al.
      The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery.
      comprised a total of 66 patients who suffered a myocardial injury after major vascular surgery. The primary outcome was the occurrence of a major cardiac event (myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization) at 1 year. Cardiovascular medication intensification referred to the introduction of at least 1 of 4 cardiovascular medications (ie, antiplatelet, statin, β-blocker, and ACEI). Patients with no modification of their cardiovascular treatment had an HR of 1.77 (95% CI, 1.13-2.42; P = 0.004) for the primary outcome compared with a matched control group. In contrast, patients who received intensification of cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome compared with the matched control group.
      • 28.
        We recommend the initiation of long-term ASA in patients who suffer a myocardial injury or myocardial infarction after noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).
      • 29.
        We recommend the initiation of long-term statin therapy in patients who suffer myocardial injury or myocardial infarction after noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).
      • Values and preferences. Although these data are limited to risk-adjusted observational data, the panel believed that the current available data support the use of ASA and a statin in patients who suffer a myocardial injury or myocardial infarction after noncardiac surgery. Panel members also considered the overwhelming evidence of the beneficial effects of ASA and statin after cardiac events in the nonsurgical setting.
      Practical tip. Although our recommendations focus on ASA and statin therapy in patients who suffer a myocardial injury or myocardial infarction after noncardiac surgery, these patients should be followed-up by a medical specialist to monitor their status and optimize medications and undertake prognostic tests on the basis of their expert clinical judgement.

      Conclusions and Future Research

      Throughout the past 2 decades, large clinical trials and prospective observational studies have advanced our understanding of predicting, modifying the risk of, monitoring for, and managing perioperative cardiac complications. Despite these advances, cardiac complications after noncardiac surgery remain a substantial public health problem. There is a need for more large international studies to evaluate promising lines of investigation. Examples include the use of remote, automated, continuous, noninvasive, hemodynamic, and ischemic monitors with alert systems on surgical floors, the prevention or minimization of perioperative bleeding, and management strategies for treating MINS. The evaluation of such lines of investigation holds the potential to substantially improve the safety of noncardiac surgery for the > 200 million adults who annually undergo these procedures.

      Funding Sources

      Funding to support a face-to-face meeting of the primary panel was supported through a McMaster University Scholar Award received by Dr Devereaux.

      Supplementary Material

      Appendix

      Appendix 1Members of guidelines’ panels
      Primary Panel Members
      Co-chairs: Drs P.J. Devereaux, Joel Parlow
      Members: Drs Amal Bessissow, Gregory Bryson, Emmanuelle Duceppe, Michelle Graham, Kristin Lyons, Paul MacDonald, Michael McMullen Daniel I. Sessler, Sadeesh Srinathan, Kim Styles, Vikas Tandon
      Secondary Panel Members
      Drs Rebecca Auer, Mohit Bhandari, Davy Cheng, Peter Choi, Benjamin Chow, Gilles Dagenais, Josée Fafard, Gordon Guyatt, John Harlock, David Hornstein, Michael Jacka, Andrea Kurz, Luc Lanthier, Yannick LeManach, Finlay McAlister, Edward McFalls, Michael McGillion, Marko Mrkobrada, Ameen Patel, Tej Sheth, Maria Tiboni, Duminda Wijeysundera

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      Linked Article

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        Canadian Journal of CardiologyVol. 33Issue 12
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          In the January issue, there were some minor errors in the article “Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery” by Duceppe et al. Can J Cardiol 33;2017:17-32.
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      • Frailty, the Elderly, and the Guidelines on Perioperative Cardiac Risk Assessment and Management in Noncardiac Surgery
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          Whitney et al.1 correctly point out the growing evidence that frailty is a predictor of a variety of complications after surgery and that high-quality evidence for the optimal management of this population has been lacking in the cardiovascular literature. The Canadian Cardiovascular Society (CCS) Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery is a focused document examining preoperative risk assessment, perioperative risk modification, postoperative monitoring for events, and management of cardiac events (the authors of this article participated on the primary panel of the CCS Guidelines on Perioperative Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery and authored the guidelines document).
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