Guidelines for Cardiac Management in Noncardiac Surgery Are Poorly Implemented in Clinical Practice: Results from a Peripheral Vascular Survey in The Netherlands

Background: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice.

Methods: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations.

Results: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs ([beta]-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result.     

Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery

PURPOSE: We assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) task force guidelines for perioperative cardiac evaluation could reliably stratify cardiac risk before aortic surgery. METHODS: We retrospectively applied the guidelines to a closed database, set up prospectively. The setting was a referral center in an institutional practice with hospitalized patients. The closed database included 133 patients who had a routine cardiac examination, which comprised an estimation of functional capacity and noninvasive testing, before aortic surgery. This cardiac evaluation led to the proposal of coronarography in 23 patients and to treating an underlying coronary artery disease in 21 patients (including three myocardial revascularizations). One patient died after myocardial revascularization, and two patients died of cardiac causes after aortic surgery. The algorithm of the ACC/AHA guidelines was applied independently by two investigators to each patient's file that was included in the existing database. The main outcome measure was a comparison between cardiac risk stratification with the ACC/AHA guidelines and the results of the routine cardiac evaluation. RESULTS: The ACC/AHA guidelines were successfully applied to all 133 files by the two investigators. After applying the algorithm, 73 patients were stratified as low cardiac risk, and 60 patients were stratified as high risk. The 21 patients who had undergone a preoperative coronary artery disease optimization were stratified as high risk by means of the ACC/AHA guidelines. The patients who died from cardiac causes were stratified as high risk by means of the ACC/AHA guidelines, whereas none of the patients stratified as low risk died during hospitalization. CONCLUSION: The ACC/AHA guidelines were effective in stratifying cardiac risk by using clinical predictors and an estimate of the physical capacity of the patient. Their use may allow a reduction in unnecessary noninvasive testing in patients stratified as being at low risk, while permitting the selection of all patients likely to benefit from preoperative coronary artery disease optimization.     

The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial

OBJECTIVE: To evaluate the validity of preoperative cardiac stress testing using clinical predictors from the American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation before Noncardiac Surgery in patients undergoing vascular surgery. DESIGN: Prospective, randomized pilot study. SETTING: Academic medical center. PARTICIPANTS: Patients undergoing elective abdominal aortic, infrainguinal, and carotid vascular surgery. INTERVENTIONS: After stratification by American College of Cardiology/American Heart Association (ACC/AHA) Guideline parameters, 99 patients were randomized to preoperative cardiac stress testing or to no stress testing and followed for up to 12 months postoperatively for adverse cardiac outcomes. MEASUREMENTS AND MAIN RESULTS: Before hospital discharge of 46 patients who underwent preoperative stress testing, 7 (15%) had inducible ischemia with no adverse postoperative cardiac outcomes, whereas only 1 (3%) of 39 patients (85%) with no ischemia had a nonfatal adverse cardiac outcome (p = not significant). Of 53 patients without preoperative stress testing, only 2 (4%) had a nonfatal adverse postoperative cardiac outcome. There were no cardiac deaths. At 12-month follow-up in 79 (80%) patients, there was 1 nonfatal adverse cardiac outcome (no stress test) and 1 cardiac death (abnormal stress test), reflecting a 1% 12-month cardiac morbidity and mortality. CONCLUSION: In this small prospective, randomized study evaluating the validity of preoperative cardiac stress testing using ACC/AHA Guidelines before major vascular surgery, preoperative cardiac stress testing offered no incremental value for determining postoperative adverse cardiac outcomes. Larger randomized clinical trials are needed to confirm these findings.     

Audit sur l’évaluation cardiaque préopératoire avant une chirurgie non cardiaque : utilité d’un aide-mémoire pour améliorer l’adhésion des anesthésistes aux recommandations de l’American College of Cardiology/American Heart Association (ACC/AHA)

Introduction

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder.

Methods

The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier.

Results

During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease.

Discussion

The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery.     

Perioperaive evaluation and management in vascular surgery especially for arteriosclerosis obliterans

Perioperative cardiac event is relatively high in vascular surgery for arteriosclerosis obliterans (ASO), which is a major cause of postoperative death. ACC/AHA guideline and revised cardiac risk index (CRI) were advocated to assess risk factor stratification and to manage risk reduction. ACC/AHA guideline categorized all vascular procedures except carotid endarterectomy as high risk. Because almost all patients with ASO were aged and/or inactive, noninvasive testing was necessary in almost all patients by the stepwise bayesian strategy. Patients with revised CRI less than 1 point dominated about three fourths of all patients, whose prevalence and incidence of ischemic heart disease (IHD) were 2.5% and 1.3%, respectively. It seemed appropriate to apply noninvasive testing only for patients with revised CRI more than 2 points, and high risk indicated coronary angiography. Electrocardigrams obtained at baseline, immediately, and on the first 2 days after surgery appear to be cost-effective to diagnose IHD. Use of cardiac biomarkers was reserved for patients at high risk and those with clinical, or ECG evidence of myocardial infarction (MI). Beta-blockers or alpha-agonists were effective to reduce incidence of perioperative IHD. Although even optimal preoperative assessment and perioperative management, some patients will have perioperative MI.     

Low utility of dobutamine stress echocardiograms in the preoperative evaluation of patients scheduled for noncardiac surgery

In this study, we examined the utility of preoperative dobutamine stress echocardiograms (DSE) obtained for 85 patients in accordance with guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA). The medical record of each patient was reviewed to identify the clinical criteria that indicated the need for a DSE, the DSE results, therapeutic interventions rendered as a result of the DSE, and any perioperative cardiac morbidity. The DSE was positive for inducible ischemia in 4 patients (4.7%), negative in 74 (87.1%), and nondiagnostic in 7 (8.2%). DSEs that were obtained for 48 patients because of a history of diabetes mellitus, mild angina, or "minor clinical predictors" produced only negative results. Of the four patients with positive DSE results, three underwent coronary angiography, and one of those three underwent bypass grafting before surgery. An additional 29 patients received a preoperative DSE but were excluded from the study because the criteria for ordering the DSE did not meet the ACC/AHA guidelines. No patient had any perioperative morbidity related to myocardial ischemia. The total patient charge for the 85 DSEs obtained at our institution was US$104,635. Use of the ACC/AHA guidelines for preoperative DSEs does not appear to be cost-effective. However, the current algorithm could be significantly improved by altering the criteria for obtaining preoperative DSEs. IMPLICATIONS: This study was a retrospective review of 85 patient charts that found a low cost-effectiveness of using American College of Cardiology/American Heart Association guidelines for obtaining preoperative dobutamine stress echocardiograms. Suggested modifications of these guidelines should improve their specificity with no loss in sensitivity.     

Critical appraisal of cardiac risk stratification before elective vascular surgery

This study was undertaken to evaluate the efficacy of the cardiac risk stratification protocol proposed by the American College of Cardiology/American Heart Association (ACC/AHA) in predicting cardiac morbidity and mortality associated with elective, major arterial surgery. Cardiac risk stratification using ACC/AHA guidelines was done on 425 consecutive patients before 481 elective cerebrovascular (n = 146), aortic/inflow (n = 166), or infrainguinal (n = 169) procedures at an academic Veterans Affairs Medical Center. Cardiac risk was stratified as low, intermediate, or high based on clinical risk factors, such as, Eagle criteria, history of cardiac intervention, patient functional status, results of noninvasive cardiac stress testing, and coronary angiography with coronary revascularization performed when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of surgery were compared between the various risk stratification groups. Univariate and multivariate analyses were used to identify clinically useful prognostic variables from the preoperative cardiac evaluation algorithm. Overall mortality (1.7%), cardiac death (0.4%), and adverse cardiac event (4.8%) rates were low, but cardiac death and morbidity were increased (p < 0.05) in high-risk stratified patients (3.4%, 11.9%) compared to intermediate (0%, 2.8%) and low (0%, 4.0%) cardiac risk groups. The presence of 3-vessel angiographic coronary artery occlusive disease was an independent predictor of cardiac morbidity, while inducible ischemia by cardiac stress imaging was not. Previous coronary revascularization was associated with increased mortality as was the development of a non-cardiac complication. Cardiac risk assessment identified 78 (18%) patients with indications for coronary angiography. Angiographic findings resulted in coronary artery intervention (9-angioplasty; 4-bypass grafting) in 13 (3%) patients who experienced no adverse cardiac events after the planned vascular surgery (15 procedures). Cardiac risk stratification using ACC/AHA guidelines can predict adverse cardiac events associated with elective vascular surgery; however, protocol modification by increased reliance on Eagle criteria and less use of cardiac stress testing can improve identification of the "highest risk" patients who may benefit from prophylactic coronary intervention.     

麻醉科住院医师通常不能恰当使用2007美国心脏病学会／美国心脏协会（ACC／AHA）指南评估模拟患者

背景2007美国心脏病学会／美国心脏协会（American College of Cardiology/American Heart Association, ACC/AHA）有关围术期心脏评估与非心脏手术医疗保障的指南是围术期心脏评估的公认标准。麻醉培训计划要求教授这些评估方法。我们评估了美国全国范围内麻醉科住院医师在评估临床常见场景下模拟患者时能够正确使用ACC／AHA指南所建议的测试评估方法的百分比人数。方法24所培训机构中的麻醉科住院医师志愿者参加,设置以外科手术、患者危险因素和患者功能能力为特征的6种场景。均随机分配所有场景和针对每种场景的5种推荐建议。分配之前,美国24所不同培训机构的高级麻醉医师与2007年ACC／AHA指南的第一作者一同确认该网络调查的推荐建议恰当。结果参加的548名住院医师占美国麻醉科培训医师的12％,包括48名PGY-1S（麻醉专科培训前第一年）、166名临床麻醉工作一年的住院医师（CA-1）、161名CA-2s和173名CA-3s。评估活动性心脏病的患者时,建议的评估与指南一致的住院医师为78％（95％可信上限）。然后,在剩余的5种场景中,给出恰当建议的住院医师为46％（95％可信上限）。结论结果显示,美国全国范围内不足一半的麻醉科住院医师能够正确地应用术前心脏评估标准的方法。必须进一步研究来阐明正确的干预措施,如决策支持工具的应用、增加常规使用指南的清晰度、调整教育计划和（或）负责教员更熟悉该教材。     

Preoperative cardiac evaluation does not improve or predict perioperative or late survival in asymptomatic diabetic patients undergoing elective infrainguinal arterial reconstruction

OBJECTIVE: Patients undergoing infrainguinal arterial reconstruction frequently have increased cardiac risk factors. Diabetic patients are often asymptomatic despite advanced cardiac disease. This study investigates whether preoperative cardiac testing improves the outcome in diabetic patients at risk for cardiac disease. METHODS: We retrospectively reviewed all patients undergoing lower-extremity arterial reconstructions in a 32-month period from July 1999 to February 2002. Of the 433 patients identified undergoing 539 procedures, 295 had diabetes mellitus and considered in this study. The patients were stratified into two groups according to the present American College of Cardiology, American Heart Association (ACC/AHA) algorithm. We identified 140 patients with two or more of ACC (Eagle) criteria who met the inclusion criteria for a preoperative cardiac evaluation. These patients were separated into two groups: those undergoing a cardiac work-up (WU) according to the ACC/AHA algorithm and those not undergoing the recommended work-up (NWU). Outcomes included perioperative mortality, postoperative myocardial infarction, congestive heart failure, arrhythmia, and length of hospitalization. Significance of association was assessed by the Fisher exact test. Length of hospitalization was compared using the Kruskal-Wallis rank sum test. Survival data was analyzed with the Kaplan-Meier method. RESULTS: One hundred forty patients met the criteria for moderate risk. There were 61 patients in the NWU group and 79 in the WU group. Ten patients in the WU group underwent preoperative coronary revascularization (6 had percutaneous transluminal coronary angioplasty, 4 underwent coronary artery bypass grafting). There was no difference between perioperative mortality (WU, 1%; NWU, 2%; P = 1.00) or in postoperative cardiac morbidity, including myocardial infarction, congestive heart failure, and arrhythmia requiring treatment (WU, 5%; NWU, 6%; P = .71). There were no perioperative deaths and one episode of congestive heart failure in the group that had preoperative coronary revascularization. Median length of hospitalization was 10 days in the WU group and 8 days in the NWU group ( P = .11). Patient survival at 12 months for the NWU, WU, and revascularized groups was 85.3%, 78.5%, and 80.0%, respectively; 36-month survival was 73.6%, 62.9%, and 80.0%, respectively. The three survival curves did not differ significantly ( P = .209). CONCLUSIONS: Preoperative cardiac evaluation, as defined by the ACC/AHA algorithm, does not predict or improve postoperative morbidity, mortality, or 36-month survival in asymptomatic, diabetic patients undergoing elective lower-extremity arterial reconstruction. These data do not support the current ACC/AHA recommendations as a standard of care for diabetic patients with an intermediate clinical predictor who undergo peripheral arterial reconstruction, a high-risk surgical procedure.     

Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines

Study ObjectiveTo determine if practicing anesthesiologists recommend preoperative evaluations consistent with the 2007 ACC/AHA guidelines on perioperative care.DesignSurvey instrument.SettingAcademic medical center.SubjectsASA membership.MeasurementsIn this Web-based survey, participants were presented with 6 clinical scenarios characterized by surgical procedure and the patient's clinical condition (ie, clinical risk factors and functional capacity). Scenarios and possible recommendations were presented randomly. Participants were asked to select the recommendation they considered to be most consistent with the Guidelines. The percentage of participants selecting the recommendation most consistent with the 2007 Guidelines was recorded.Main ResultsOf the 22,504 actively practicing members of the ASA who were sent a survey, 1,595 actively practicing self-selected anesthesiologists responded. For one of 6 scenarios, patients with an active cardiac condition, the upper 95% confidence bound for the percent selecting a recommendation consistent with the Guidelines was 82%. For the remaining 5 scenarios, the upper 95% confidence bound for the percent of anesthesiologists with an appropriate recommendation did not exceed 40%. With the exception of the scenario describing a patient with an active cardiac condition, respondents were more likely to provide recommendations consistent with the Guidelines if they had been in practice less than 5 years or worked in a teaching environment.ConclusionWhen evaluating simulated patients, practicing anesthesiologists who are ASA members did not recommend preoperative evaluations that were consistent with the 2007 ACC/AHA Guidelines.     

Anesthesiologists’ preferences for preoperative cardiac evaluation before vascular surgery: results of a mail survey

Study ObjectiveTo investigate whether anesthesiologists’ decisions to request preoperative cardiac evaluation (cardiologist consultation, echocardiography, and cardiac stress testing) before vascular surgery were influenced by patient comorbidity and magnitude of surgery; and to explore whether factors unrelated to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines influence these decisions.DesignSurvey instrument.SettingUniversity medical center.Subjects2,000 U.S. anesthesiologists who were mailed a survey.MeasurementsSix factors in a hypothetical patient presenting for vascular surgery [gender, race (white vs. black), age (65 yrs vs. 85 yrs), comorbidities (sick vs. healthy), functional status, and magnitude of surgical stress] were evaluated. Respondents were asked about their demographics, practice patterns, and how they would manage the hypothetical patient.Main ResultsOf 2,000 mailed surveys, 439 U.S. anesthesiologists responded (22%). Multivariate ordinal logistic regression analysis showed that anesthesiologists were more likely to recommend preoperative cardiology consultation for patients with more comorbidities [odds ratio = 5.53; 95% confidence interval (CI) = 3.76, 8.15], for those with poorer functional status (odds ratio = 1.45; 95% CI = 1.02, 2.07), for those undergoing a more significant surgery (odds ratio = 1.61; 95% CI = 1.13, 2.30), as the clinicians’ estimated risk of perioperative myocardial infarction increased (P < 0.001), or if they only infrequently anesthetized patients such as the one described in the scenario (P = 0.05). They also would request a preoperative echocardiogram for patients with more comorbidities (odds ratio = 2.58; 95% CI = 1.80, 3.68) and for those undergoing a more significant surgery (odds ratio = 1.59; 95% CI = 1.12, 2.25). A preoperative stress test was recommended for patients with more comorbidities (odds ratio = 3.01; 95% CI = 2.06, 4.38) and for those with a more significant surgery (odds ratio = 1.74; 95% CI = 1.15, 2.63). Other factors associated with request for a preoperative stress test were female gender of the anesthesiologist (odds ratio = 1.79; 95% CI = 1.11, 2.87), those with less experience with such patients (P = 0.05), and those from New England (odds ratio = 2.16; 95% CI = 1.01, 4.62).ConclusionsAnesthesiologists’ preferences for preoperative cardiac evaluation are generally consistent with evidence-based and expert-based AHA/ACC guidelines. However, other physician factors (ie, gender, years in practice, and familiarity with the surgical procedure) also influenced these decisions.     

Implementing ACC/AHA guidelines for the preoperative management of patients with coronary artery disease scheduled for noncardiac surgery: effect on perioperative outcome

STUDY OBJECTIVE: To review the new consensus guidelines for cardiac testing for the patient with cardiac disease scheduled for elective, noncardiac surgery, and their impact on cardiac functional testing. DESIGN: Retrospective chart review study. SETTING: Tertiary care medical center. PATIENTS: 181 patients scheduled for elective, major surgery who met American College of Cardiology/American Heart Association (ACC/AHA) criteria for a preoperative stress test. INTERVENTIONS: A variety of tests were ordered, including treadmill stress testing, persantine-thallium imaging, dobutamine echocardiography, and exercise stress echocardiography. MEASUREMENTS: The numbers of and outcome of the stress tests and the cardiac outcome of the patients who underwent cardiac testing and surgery were recorded. MAIN RESULTS: Abnormal tests occurred in 27 patients. Two patients declined treatment, eight patients had primary medical management, and the remainder (17) had cardiac catheterization. Results included no lesion (2 patients), angioplasty (4 patients), angioplasty plus stenting (1 patient), coronary artery bypass grafting (CABG) (4 patients), and delineated lesions treated with medical optimization (6 patients). One patient had CABG and declined further surgery. One patient had myocardial infarction 6 months after surgery that was treated by medical management after cardiac catheterization. The other 23 patients had surgery without cardiac complication within 1 year of surgery. Only 15% (27/180) of the patients with indications for a stress test had a positive result. Even fewer patients had any alteration of the perioperative period. Despite this finding, cardiac morbidity was very low. CONCLUSIONS: The guidelines for stress test may be over-sensitive, and further prospective clinical studies are indicated.     

Preoperative cardiac evaluation of the vascular surgery patient--an anesthesia perspective

The morbidity and mortality associated with vascular surgery procedures are largely the results of cardiac events. National guidelines have been regularly proposed and updated by the American College of Cardiology (ACC)/American Heart Association (AHA) to ensure optimal perioperative management and risk stratification. Controversy remains between experts and other cardiology societies regarding several patient care issues including revascularization before surgery, timing of β-blocker therapy, and the administration of antiplatelet therapy. Several landmark articles recently published have helped to modify the guidelines in the hope of improving vascular patient outcomes. In this review, we searched all recent available literature pertaining to perioperative cardiac evaluation before major vascular surgery. We propose an algorithm for preoperative cardiac evaluation, which is a modification to the AHA recommendations. Incorporated in this algorithm are recent published pivotal articles that can help in guiding physicians caring for the vascular patient requiring major operative or endovascular interventions.     

American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery

BACKGROUND: Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. METHODS: We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. RESULTS: The use of preoperative stress testing (88% to 47%; P <.00001), cardiac catheterization (24% to 11%; P <.05), and coronary revascularization (25% to 2%; P <.00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P <.0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P =.29) but lower for patients at low risk after guideline implementation (31% versus 61%; P =.003). CONCLUSION: Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.     

Perioperatives kardiales Vorgehen bei nichtkardiochirurgischen Eingriffen

Since November 2009, the first European guidelines on perioperative cardiac care for non-cardiac surgery have been published by the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). The following article will describe the most important recommendations of these guidelines and discuss the clinically relevant differences to the corresponding recommendations of the current guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA).     

Thirty-day and one-year predictors of death in noncardiac major surgical procedures

BACKGROUND: We evaluated the predictive value of the American College of Cardiology/American Heart Association (ACC/AHA) cardiac risk classification, as well as other potential risk factors (procedure risk, smoking, obesity, hyperlipidemia, and renal insufficiency), on all-cause mortality at 30 days and at 1 year postoperatively. METHODS: In the year 2000, 1238 consecutive patients undergoing general anesthesia for various noncardiac surgical procedures at the Houston Veterans Affairs Medical Center were screened preoperatively and classified according to the ACC/AHA guidelines. Patients' charts were reviewed for the above-mentioned risk factors. RESULTS: A logistic regression analysis demonstrated that older age and higher procedure risk were associated with higher 30-day mortalities (P = 0.0012 and 0.0441, respectively). The ACC/AHA classification was positively correlated with mortality at 1 year (P = 0.0071). CONCLUSIONS: The ACC/AHA classification predicts mortality at 1 year but not at 30 days for major noncardiac surgeries; procedure-related risk is a better predictor of 30-day postoperative mortality in our patient population.     

Antibiotic Prophylaxis Guideline Awareness and Antibiotic Prophylaxis Use Among New York State Dermatologic Surgeons

BACKGROUND: Use of antibiotic prophylaxis in dermatologic surgery patients remains controversial and several sets of guidelines exist. OBJECTIVE: We investigated dermatologic surgeon's awareness of the American Heart Association (AHA) 1997 antibiotic prophylaxis guidelines, their use of prophylactic antibiotics, and their practices as compared with the Haas and Grekin's 1995 antibiotic prophylaxis guidelines. METHODS: We mailed postage-paid questionnaires regarding AHA guideline awareness and antibiotic prophylaxis use to the 235 New York State members of the American Society for Dermatologic Surgery (ASDS). We received 87 replies. RESULTS: Most participants recognize AHA guidelines and claim to follow them. We reiterate previous studies' findings. Most dermatologic surgeons use antibiotics appropriately. However, antibiotics are occasionally overused or dosed outside the guidelines. Many participants prescribe antibiotics based on a patient's other physicians' recommendations. Notably, erythromycin is sometimes used, an antibiotic the AHA no longer recommends. CONCLUSION: Dermatologic surgeons commonly use antibiotic prophylaxis to prevent bacterial endocarditis. Based on previous studies, though, the risk of endocarditis following cutaneous surgery is low and thus the use of antibiotic prophylaxis is controversial. Although this practice is appropriate for high-risk patients when skin is contaminated, it is not recommended for noneroded, noninfected skin. We report that dermatologists may be aware of the guidelines, but only seem to partially follow them. Further studies are still needed to establish optimal guidelines.     

Surgery for esophageal cancer complicate with cardiovascular disease

A risk of cardiac complications is one of the most significant risks to patient undergoing major surgery. Especially, for the patients with cancer, the preoperative management can be complex. The direct effect of cancer and side effect of prior chemotherapy or radiation therapy should be considered. The 2007 American College of Cardiology/American Heart Association( ACC/AHA) guidelines on perioperative cardiovascular evaluation for noncardiac surgery concluded that 3 elements must be assessed to determine the risk of cardiac event. The preoperative risk in a patient is initially assessed by the presence or absence of clinical predictors of increased perioperative cardiovascular risk, the patient's level of cardiac function, and the underlying risk of the surgical procedure. Here we will provide an overview of issue that are relevant to patients with esophageal cancer.     

When should a cardiologist refer a patient with aortic valve disease to a surgeon?

In general, aortic stenosis and regurgitation are the 2 main aortic valve diseases which require surgical treatment. Surgical indication for each has been described in detail in the guidelines established by the Japanese Circulation Society and American Heart Association/American College of Cardiology (AHA/ACC). Most of the cases we daily encounter in clinical practice can be managed within the guideline, although the patient's many other factors are needed to be taken into consideration. On the contrary, in those cases with the conditions which are not mentioned in the guidelines, diagnosis and decisions are always difficult to make. In this article, we are to discuss how to manage cases within and without the guidelines.     

Preoperative cardiac evaluation of patients with acute hip fracture

The goals of the present study were to assess if there is an association between preoperative cardiac evaluation and surgery timing in patients with a hip fracture, to evaluate the relationship between surgery timing and postoperative morbidity and mortality, and to determine if the proper patients are being selected for noninvasive cardiac testing based on the practice guidelines published by the American College of Cardiology/American Heart Association Task Force. Surgery delay secondary to cardiac clearance may be a risk factor for increased postoperative complications that is independent of a patient's general medical condition. Surgical treatment of acute hip fractures may be delayed by many factors besides preoperative cardiac clearance, but it is the job of the orthopedic surgeon, who best understands the importance of timely surgery for a hip fracture, to minimize delays. Careful screening of patients who have sustained a hip fracture can improve overall outcomes by minimizing the number of patients whose surgical treatment is unnecessarily delayed for cardiac clearance.