REVIEW

CURRENT
OPINION Update on perioperative care of the cardiac patient
for noncardiac surgery
Kamrouz Ghadimi a,b and Annemarie Thompson a,b

Purpose of review
The current review will address key topics and recommendations of the recent 2014 update of the
American College of Cardiology and American Heart Association clinical practice guideline for the
perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery.
Recent findings
The completely rewritten guideline provides a stepwise approach for the identification and management of
patients at highest risk for major adverse cardiac events and discusses new or updated recommendations.
For example, b-blockers should be continued perioperatively but treatment should not be initiated within
24 h of noncardiac surgery. Angiotensin-converting enzyme inhibitors should be continued, but if held, may
be restarted as soon as feasible. Routine aspirin therapy is not recommended without previous coronary
stent implantation or risk assessment for myocardial ischemia. Elective noncardiac surgery should not be
performed within 30 days of bare metal stent or 12 months of drug-eluting stent implantation because of in-
stent thrombosis as well as bleeding risk from dual antiplatelet therapy during surgery. Noncardiac surgery
may be considered, however, in patients on antiplatelet agents 180 days after drug-eluting stent placement
if risk of surgical delay exceeds risk of stent thrombosis from cessation of antiplatelet therapy.
Summary
In conclusion, this review will discuss the important topics from the 2014 American College of Cardiology/
American Heart Association guideline in order to provide the perioperative physician with the most recent
evidence necessary to minimize major adverse cardiac events in patients undergoing noncardiac surgery.
Keywords
cardiovascular disease, dual antiplatelet therapy, major adverse cardiac event, noncardiac surgery,
perioperative care

INTRODUCTION the likelihood that the recommendations are well

&& &&

The American College of Cardiology (ACC) and
American Heart Association (AHA) clinical practice
guideline on perioperative cardiovascular evalu-
ation and management of patients undergoing non-
cardiac surgery has been recently rewritten and
&& &&
published [1 ,2 ]. The 2014 rewrite of the guideline
incorporated the best available evidence, including
formalized systematic reviews by an Evidence
Review Committee in order to evaluate, classify,
and stratify data pertaining to the improvement
of perioperative care in the patient with cardiovas-
cular disease undergoing noncardiac surgery. The
guideline provides an organized framework of
generalized perioperative management by applying
scientific evidence to clinical practice. Each recom-
mendation is assigned a class and level of evidence
(LoE) determined by the guideline writing commit-
tee to provide information to the clinician regarding
supported by the evidence (Table 1) [1 ,2 ].
PERIOPERATIVE CARDIAC ASSESSMENT:
STEPWISE, ALGORITHMIC APPROACH
The 2014 ACC/AHA Perioperative Guideline pro-
posed a stepwise approach to perioperative cardiac
assessment, incorporating both the physicians role
in managing risk and providing informed consent
a
Division of Cardiothoracic Anesthesiology and bCritical Care Medicine,
Department of Anesthesiology, Duke University School of Medicine,
Durham, North Carolina, USA
Correspondence to Annemarie Thompson, MD, Department of Anes-
thesiology, Duke University Hospital, 2301 Erwin Road, HAFS 5684B,
Durham, NC 27710, USA. E-mail: annemarie.thompson@duke.edu
Curr Opin Anesthesiol 2015, 28:342348
DOI:10.1097/ACO.0000000000000193

www.co-anesthesiology.com Volume 28
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June 2015

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 Update on perioperative care of the cardiac patient for noncardiac surgery Ghadimi and Thompson
KEY POINTS

The 2014 ACC/AHA guideline discusses new or
updated recommendations in a stepwise approach to
the care of the patient with cardiovascular disease
presenting for noncardiac surgery.

The applicability of the various recommendations within
this guideline document is determined by the patients
risk for the development of MACE.

A clear understanding of antiplatelet therapy and the
temporal relationship between percutaneous coronary
interventions and scheduled surgery are important in
determining timing of and perioperative management
during noncardiac surgery.
and the patients perspective in weighing risk,
benefit, and alternatives to invasive testing or pre-
ventive therapies. This rationale serves to highlight
the importance of patient-centered care while
Table 1. Applying classification of recommendation and level of evidence
Level A
Estimate of certainty (precision) of treatment effect
Multiple populalions
evalualed*
Data derived from multiple
randomized clinlcal trials
or meta-analyses
Level B
Limited populalions
evalualed*
Data derived from a
single randomized trial
or nonrandomized studies
Level C
Very limited populalions
evalualed*
Only consensus opinion
of experts, case studies,
or standard of care
Suggested phrases for
writing recommendations
&& &&
Data from [1 ,2 ].
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Size of t re a t ment ef f ect
Class I
Benefit > > > Risk
Procedure/treatment
should be performed/
administered

Recommendation that
procedure or treatment
is useful/effective

Sufficient evidence from
multiple randomized trials
or meta-analyses

Recommendation that
procedure or treatment
is useful/effective

Evidence from single
randomized trial or
nonrandomized studies

Recommendation that
procedure or treatment
is useful/effective

Only expert opinion, case
Only diverging expert
studies, or standard of care opinion, case studies,
or standard of care
should
is recommended
is indicated
is useful/effective/beneficial
minimizing risk for each intervention. The algorith-
mic flow chart begins with determination of surgical
urgency, followed by assessment of the presence
or absence of a preoperative acute coronary event,
and concludes with a perioperative risk calculation
for major adverse cardiac events (MACE) (Fig. 1)
&& &&
[1 ,2 ]. If the patient is at low risk for MACE, then
no further testing is needed and the patient may
proceed to surgery without further evaluation. If the
patient is at high risk for MACE, then the functional
capacity of the patient is determined objectively. If a
patient at high risk for MACE has at least 4 metabolic
equivalents as determined by objective testing, no
further evaluation is required (Table 2) [3]. For high-
risk patients who exert less than 4 metabolic equiv-
alents without symptoms or have an indeterminate
functional capacity, the perioperative clinician
should consult with the perioperative team in order
to determine whether further testing will impact the
decision to undergo the current surgery or delay
surgery for cardiac evaluation (e.g., pharmacologic
Class IIa Class IIb Class III
Benefit > > Risk Benefit Risk Risk Benefit
Additional studies with Additional studies with broad Procedure/treatment should
focused objectives needed objectives needed; additional not be performed/adminis-
It is reasonable to per- registry data would be helpful tered since it is not help-
form procedure/administer ful and may be harmful
Procedure/treatment
treatment may be considered

Recommendation in favor
Recommendation's
Recommendation that
of treatment or procedure usefulness/efficacy less procedure or treatment is
being useful/effective well established not useful/effective and

Some conflicting evidence
Greater conflicting may be harmful
from multiple randomized evidence from multiple
Sufficient evidence from
trials or meta-analyses randomized trials or multiple randomized trials
meta-analyses or meta-analyses

Recommendation in favor
Recommendation's
Recommendation that
of treatment or procedure usefulness/efficacy less procedure or treatment is
being useful/effective well established not useful/effective and

Some conflicting
Greater conflicting may be harmful
evidence from single evidence from single
Evidence from single
randomized trial or randomized trial or randomized trial or
nonrandomized studies nonrandomized studies
nonrandomized studies

Recommendation in favor
Recommendation's
Recommendation that
of treatment or procedure usefulness/efficacy less procedure or treatment is
being useful/effective well established not useful/effective and

Only diverging expert may be harmful
opinion, case studies,
Only expert opinion, case
or standard of care studies, or standard of care
is reasonable may/might be considered is not recommended
can be useful/effective/beneficial may/might be reasonable is not indicated
is probably recommended usefulness/effectiveness is should not
or indicated unknown/unclear/uncertain is not useful/effective/beneficial
or not well established may be harmful
www.co-anesthesiology.com 343
Anesthesia and medical disease

Patient scheduled fat surgery with *See sections 2.2, 2.4, and 2.5
known of risk factors for CAD* for recommendations for patients
(step 1) with symptomatic HF, VHD, or
arrhythmias.

See UA/NSTEMI and STEMI

CPGs (table 2).

Emergency Yes Clinical risk stratification

and proceed to surgery

No

ACS Yes Evaluate and treat

(step 2) according to GDMT

No

Estimated perioperative risk of MACE

basad on combined clinical surgical risk
No further
(step 3)
testing
(class lla)
Excellent
(>10 METs)

Low risk (<1%) Elevated risk Moderate or greater Proceed to

(step 4) (step 5) (4 METs) functional surgery
capacity
Moderate/good
(410 METs)

No further
No further No or testing
testing unknown (class llb)
(class III:NB)

Proceed to Poor OR unknown

surgery functional capacity
(<4 METs): Pharmacologic
Will further testing impact Yes stress testing
decision-making OR (class lla)
perioperative care?
(step 6)
If If
normal abnormal

No Coronary
ravascularization
according to
Proceed to surgery
existing CPGs
according to GDMT OR
(class I)
alternate strategies
(noninvasive treatment,
palliation)
(step 7)

FIGURE 1. Stepwise approach to perioperative cardiac assessment for coronary artery disease [1 ,2 ]. ACS, acute && &&

coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CPG, clinical practice guideline;
DASI, Duke Activity Status Index; GDMT, guideline-directed medical therapy; HF, heart failure; MACE, major adverse cardiac
event; MET, metabolic equivalent; NB, no benefit; NSQIP, National Surgical Quality Improvement Program; PCI, percutaneous
coronary intervention; RCRI, Revised Cardiac Risk Index; STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable
angina/non-ST-elevation myocardial infarction; VHD, valvular heart disease.

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 Update on perioperative care of the cardiac patient for noncardiac surgery Ghadimi and Thompson

Table 2. Duke Activity Status Index

Activity Metabolic equivalents

Can you . . .
1. take care of yourself, that is, eating, dressing, bathing, or using the toilet? 2.75
2. walk indoors, such as around your house? 1.75
3. walk a block or two on level ground? 2.75
4. climb a flight of stairs or walk up a hill? 5.50
5. run a short distance? 8.00
6. do light work around the house like dusting or washing dishes? 2.70
7. do moderate work around the house like vacuuming, sweeping floors, or carrying groceries? 3.50
8. do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? 8.00
9. do yardwork like raking leaves, weeding, or pushing a power mower? 4.50
10. have sexual relations? 5.25
11. participate in moderate recreational activities like golf, bowling, dancing, doubles 6.00
tennis, or throwing a baseball or football?
12. participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? 7.50

Data from Hlatky et al. [3].

stress testing) and/or intervention (e.g., coronary
revascularization). Once again, discussion with
the patient and the patients wishes to proceed
&&
are incorporated into the algorithm [1 ,2 ]. This
algorithm differs from the 2007 version in that it
incorporates a clinical pause when high-risk
patients with poor-to-indeterminate functional
capacity are identified rather than proceed immedi-
ately to noninvasive testing [4,5]. Instead of auto-
EVALUATION FOR MAJOR ADVERSE
CARDIAC EVENTS
The 2014 update begins with the preoperative assess-
&&
ment of the cardiac patient undergoing noncardiac
surgery. A preoperative 12-lead ECG is recommended
for patients with CAD, arrhythmias, peripheral artery
disease, cerebrovascular disease, and structural car-
diac disease unless they are undergoing low risk
surgery (Class IIa recommendation, LoE B) [1 ,2 ].
&& &&

matically performing noninvasive testing, the
patient, surgeon, and perioperativist can discuss
whether or not the test results will affect either
surgical or perioperative management. If further
testing will not impact the surgical plan or perio-
perative care, then the high-risk patient should
either directly proceed to surgery or be considered
for alternative therapy such as noninvasive treat-
ment or palliative strategies.
This review will highlight key information
extracted from the comprehensive guideline devel-
To emphasize, routine preoperative ECG is not help-
ful in patients undergoing low-risk surgery regardless
of the burden of cardiovascular disease or risk factors.
Postoperative ECG is recommended in patients with
a clinical suspicion for myocardial ischemia, infarc-
tion, and arrhythmia after non-cardiac surgery; how-
ever, routine postoperative ECGs in asymptomatic
patients is not useful. The measurement of laboratory
markers of myocardial injury (e.g., troponins) is in
the high-risk patient if such measurements of injury
will lead to intervention (Class IIb, LoE B) [1 ,2 ].
&& &&

oped through critical analysis of nearly 500 refer-
&& &&
enced articles [1 ,2 ]. Specifically, we will focus on
important updates in the evaluation of myocardial
ischemia, perioperative management of medical
therapy in patients with risk factors for cardiovas-
Evaluation of markers of injury are recommended in
patients at high risk for MACE who may benefit from
such an intervention and that routine management
is not recommended without patient selection (Class
&&
II, LoE B) [1 ,2 ].
&&

cular disease, and management of established dis-

ease after percutaneous coronary intervention and
stent implantation. In addition, our discussion of
perioperative medical therapy will include manage-
ment of b-blockers, angiotensin-converting enzyme
inhibitors (ACEi) and a2-agonists (e.g., clonidine).
Management of antiplatelet therapy and timing of
surgery will be addressed in patients with estab-
lished cardiovascular disease with or without cor-
onary revascularization.
UPDATES ON BETA-BLOCKER THERAPY
The 2014 ACC/AHA guideline provides recommen-
dations for perioperative b-blockade based on
multiple research articles, including a recent meta-
&
analysis by Wijeysundera et al. [6 ]. The key findings
of this document were not impacted by the
exclusion of other publications determined to pos-
sess questionable scientific integrity [7,8]. Although a

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Anesthesia and medical disease
comprehensive report has been incorporated into the
2014 update on the ACC/AHA perioperative guide-
line, there are two recommendations of particular
interest. First, b-blockade should be continued in
patients undergoing noncardiac surgery who have
been prescribed these medications chronically (Class
I, LoE B). This recommendation recognizes that
patients on chronic B-blocker therapy benefit from
b-blocker administration beyond the immediate
indication of heart rate control and the acute
reduction in myocardial oxygen consumption. Sec-
ond, it is recommended that b-blockers not be
initiated within 1 day of noncardiac surgery.
Although the administration of B-blockers may pre-
vent nonfatal myocardial infarction (MI) when
initiated in the immediate preoperative period, the
benefit of MI prevention is outweighed by the
increased risk of may stroke, hypotension, and death
&& &&
(Class III, LoE B) [1 ,2 ,9].
UPDATE ON ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
ACEi and angiotensin-receptor blockers (ARBs)
are among the most commonly prescribed antihy-
pertensives, and both have been shown to have
cardiovascular and metabolic effects beyond their
antihypertensive properties. The popularity of ACEi
and ARBs as antihypertensives partially relate to their
demonstrated outcome and mortality benefit in
patients with MI with residual left ventricular dys-
function, heart failure, and diabetic kidney disease
with respect to prevention of the progression to end-
stage renal disease. However, data on the potential
risks and benefits of their continuation in the peri-
operative period is limited to observational trials with
propensity-matched cohorts. A very large retrospec-
tive study of 79 000 patients undergoing noncardiac
surgery compared patients taking ACEi with patients
not on ACEi. An analysis of a matched, nested cohort
of the study demonstrated increased transient intra-
operative hypotension among patients taking ACEi,
but failed to show any difference in other outcomes
[10]. Of note, clinical practice guidelines recommend
continuing ACEi in the setting of acute heart failure
treatment or hypertension [11,12]. Based on the
available data, it is reasonable to continue ACEi or
ARBs perioperatively (Class IIa, LoE B). However, if
ACEi or ARBs are held before surgery, it is recom-
mended that they be restarted as soon as clinically
feasible in the postoperative period (Class IIa, LoE C).
RISK OF MAJOR ADVERSE CARDIAC
EVENTS AND a2-AGONISTS
a2-Agonists, such as clonidine, should be avoided
in the prevention of MACE in patients undergoing
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noncardiac surgery (Class III, LoE B). A prospective,
randomized trial (135 centers, n 10 010) evaluated
clonidine (0.2 mg/day) in patients with cardiovascu-
lar disease after they had undergone noncardiac
&
surgery [13 ]. Clonidine was initiated preoperatively
and continued postoperatively for 72 h. Clonidine
was not found to reduce the 30-day incidence of
death or nonfatal MI after surgery [hazard ratio
(HR) 1.08; 95% confidence interval (CI) 0.031.26;
P 0.29] [13 ]. Clonidine administration did, how-
&
ever, increase the risk of nonfatal cardiac arrest (HR
3.20; 95% CI 1.178.73; P 0.02) and clinically sig-
nificant hypotension (HR 1.32; 95% CI 1.241.40;
&
P < 0.001) [13 ].
ASPIRIN THERAPY IN PATIENTS WITHOUT
CORONARY STENTS
The effects of aspirin have also been evaluated by the
perioperative ischemia evaluation (POISE-2) investi-
gators in patients undergoing noncardiac surgery
without recent history of coronary stent placement
&
[14 ]. Patients at risk for MACE were separated into
whether or not they were taking preoperative aspirin.
Patients who were not previously on aspirin
(n 5628) were randomized to receive aspirin (initial
dose 200 mg followed by 100 mg daily) or placebo on
the day of surgery and for 30 days after surgery.
Patients previously on aspirin (n 4382) were also
randomized to receive aspirin (similar dosing as
above) or placebo beginning on the day of surgery
and for 7 days postoperatively and then asked to
resume their preoperative dosing regimen. Aspirin
administration did not decrease the incidence of
death or nonfatal MI at 30 days after surgery (HR
0.99; 95% CI 0.861.15; P 0.92) [14 ]. Aspirin
&
exposure did, however, increase the risk of clinically
significant bleeding (HR 1.23; 95% CI 1.011.49;
P 0.04) [14 ]. Based on these data, the 2014 ACC/
&
AHA guideline strongly recommends against routine
aspirin therapy without previous coronary stent
&& &&
implantation (Class III, LoE B) [1 ,2 ].
Aspirin administration, however, is recom-
mended when risks of myocardial ischemia exceed
&& &&
risk of surgical bleeding (Class III, LoE C) [1 ,2 ].
The guideline therefore recommends strong con-
sideration be given to the administration of aspirin
for elective noncardiac surgery without history of
percutaneous coronary intervention and stenting
when the risk of myocardial ischemia exceeds the
&& &&
risk of surgical bleeding (Class IIb, LoE B) [1 ,2 ].
DUAL ANTIPLATELET THERAPY AFTER
CORONARY STENT IMPLANTATION
Recommendations regarding patients with previous
history of coronary stent implantation underscore
Volume 28
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June 2015
 Update on perioperative care of the cardiac patient for noncardiac surgery Ghadimi and Thompson
the importance of maintaining stent patency and
minimizing the risk of perioperative stent throm-
bosis [15,16]. Dual antiplatelet therapy with aspirin
and P2Y12 platelet inhibitor should be continued
for urgent noncardiac surgery within 6 weeks of
percutaneous coronary intervention regardless of
stent type [bare metal stent or drug-eluting stent
&& &&
(DES)] (Class I, LoE C) [1 ,2 ].
Timing of elective noncardiac surgery after DES
placement can be considered after 180 days
(approximately 6 months) if the health risk of delay-
ing the surgery exceeds the risks of ischemia from
stent thrombosis due to cessation of antiplatelet
&& &&
agents (Class IIb, LoE B) [1 ,2 ]. This recommen-
dation is partly based upon a retrospective, cohort
study of noncardiac surgical patients (n 41 989;
MACE: n 1980/no MACE: n 40 009) conducted
at Veterans Affairs and non-Veterans Affairs hospi-
&
tals nationwide [17 ]. Duration of stent placement
to time or surgery was related to MACE within the
first 6 months after stent implantation but not if this
duration exceeded 6 months (adjusted odds ratio
&
0.92; 95% CI 0.821.05) [17 ]. These findings were
supported in another population-based, cohort
study from Canada (n 8116) [18].
With this in mind, the guideline recommends
elective noncardiac surgery should not be per-
formed within 30 days after bare metal stent and
within 12 months after DES implantations in patients
requiring discontinuation of antiplatelet therapy
before surgery as the chance of harm outweighs the
&& &&
benefits of cessation (Class III, LoE B) [1 ,2 ]. Aspirin
should be continued throughout the perioperative
period if reasonable or should be restarted in the
postoperative period with the P2Y12 platelet inhibi-
tor as soon as possible after surgery in patients
undergoing procedures requiring preoperative dis-
continuation of dual-antiplatelet therapy (Class I,
LoE C). Discussion among clinicians caring for the
patient with coronary stent implantation should
address the balance between risk of perioperative
coagulopathy from continuation of antiplatelet
agents and the risk of stent thrombosis as a result
&& &&
of discontinuation (Class I, LoE C) [1 ,2 ]. A sum-
mary of the recommendations related to the timing
Table 3. Percutaneous coronary intervention and
recommendations for timing of noncardiac surgery
Percutaneous Recommended delay of
coronary elective noncardiac
intervention surgery (days)
Angioplasty 14
Bare metal stent 30
Drug-eluting stent 365
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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
of elective noncardiac surgery after percutaneous
coronary interventions have been provided in
Table 3.
CONCLUSION
In summary, the 2014 ACC/AHA clinical practice
guideline for the perioperative cardiovascular evalu-
ation and management of patients undergoing non-
cardiac surgery is a comprehensive document that
addresses many management dilemmas throughout
&& &&
the perioperative period [1 ,2 ]. This brief review
addresses key concepts and recommendations that
are either new recommendations or changes from
prior versions of the perioperative guideline.
Acknowledgements
The authors would like to thank Dr Lee A. Fleisher, Dr
Kirsten E. Fleischmann, and the other members of the
2014 ACC/AHA guideline writing committee for their
significant contribution to this important document.
Financial support and sponsorship
This work was supported by the Department of Anes-
thesiology, Duke University School of Medicine, Durham,
NNC.
Conflicts of interest
There are no conflicts of interest.
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Circulation 2012; 126:13551362.
Volume 28
Number 3
June 2015