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Guidelines for Assessing and Managing the Perioperative Risk from Coronary Artery Disease Associated with Major Noncardiac Surgery
- American College of Physicians* *This paper, written by Valerie A. Palda, MD, MSc, and Allan S. Detsky, MD, PhD, was developed for the Health and Public Policy Committee by the Clinical Efficacy Assessment Subcommittee: George E. Thibault, MD, Chair; John R. Feussner, MD, Co-Chair; Anne-Marie J. Audet, MD; Gottlieb C. Freisinger Jr., MD; Daniel L. Kent, MD; Keith I. Marton, MD; Valerie Anne Palda, MD; John J. Whyte, MD: and Preston L. Winters, MD. This paper was approved by the Board of Regents on 25 October 1996. Requests for Reprints: Valerie A. Palda, MD. 4-151, St. Michael's Hospital, 30 Bond Street, Toronto. Ontario M5B 1W8. Canada. Current Author Addresses: Dr. Palda: 4-151, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper, “Perioperative Assessment and Management of Risk from Coronary Artery Disease,” which is part II of this guideline (see pages 313-328).
The recommendations in this guideline concentrate on summarizing the evidence supporting the clinical evaluation (history, physical examination, and electrocardiography) and noninvasive evaluation of the patient [1.1, 1.2]. Studies on clinical and noninvasive testing were considered to be of “strong,” “fair,” or “weak” evidence [2.6]. If a recommendation has no weighting for strength of evidence, no studies were found that related to that clinical decision point. Perioperative risk estimates refer to the reported incidence of perioperative myocardial infarction and cardiac death [2.4]. The literature on noninvasive risk stratification has focused on patients undergoing vascular surgery. These patients have a higher risk for perioperative cardiac events and may not be representative of most patients (>90%) undergoing major noncardiac surgery [1.3]. We make separate recommendations for patients having vascular and nonvascular surgery, according to the quality of evidence available for each. For management issues, evidence is still lacking. In these situations, the clinician must use available evidence from the nonoperative setting combined with clinical judgment and patient preferences [5].
Clinical Assessment
When assessing a patient's risk for major cardiac events during or after a noncardiac operation, the clinician uses clinical evaluation to determine the risk for fatal and nonfatal cardiac events and may refine the risk assessment for intermediate-risk patients through noninvasive testing.
In patients who have previously had angiography results indicating mild coronary artery disease or successful coronary revascularization and have no new clinical symptoms of concern, the risk for perioperative cardiac events is probably similar to that in patients without coronary artery disease (weak evidence) [3.1]. If new or worrisome coronary symptoms develop, the patient's risk status …
This 100-word excerpt has been provided in the absence of an abstract.
