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01-02-2017 | Comparison of 2014 ACCAHA vs. ESC guidelines Editorial
Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery and the 2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular assessment and management
Published in: Journal of Nuclear Cardiology | Issue 1/2017
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Two sets of clinical practice guidelines (Table 1) were published in 2014 related to the cardiovascular assessment of patients undergoing noncardiac surgery: one endorsed by the American College of Cardiology and the American Heart Association (2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery),1 and the other by the European Society of Cardiology and the European Society of Anaesthesiology (2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular Assessment and Management).2 We have previously summarized the ACC/AHA guidelines in the Journal focusing on the recommendations pertaining to noninvasive imaging and coronary revascularization.3 Since many of our readers are not familiar with both sets of guidelines, we will present here the recommendations from both documents side-by-side (Tables 2, 3, 4, 5, 6, 7). The Class (I, IIa, IIb, III) and the level of evidence (A, B, C) are shown next to each recommendation. We also include a flowchart comparing the stepwise approach of both guidelines toward the evaluation of patients undergoing noncardiac surgery (Figure 1). Our summary will be followed by 2 editorials: The first by Kristensen 4 summarizes the ESC/ESA guidelines focusing on the changes that have been introduced compared to previous versions of these guidelines. The editorial raises awareness to situations where imaging, angiography, and revascularization are and are not indicated in this setting. The second editorial by Port 5 reflects on the similarities and the differences between the 2 sets of guidelines and the implications of these to clinical care. It highlights situations whereby imaging may be indicated by one set of guidelines but not the other. We hope that this new series initiated by the Journal will provide an important service to the imaging community by highlighting the similarities and the differences between the American and the European guidelines and providing a perspective that may not be apparent from reading one set of guidelines.
Table 1
Comparison of ACC/AHA and ESC/ESA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery
|
Characteristic
|
ACC/AHA
|
ESC/ESA
|
|---|---|---|
|
Year of publication
|
2014
|
2014
|
|
Length of document in pages
|
61
|
49
|
|
References
|
490
|
279
|
|
Recommendations
|
69
|
120
|
|
Recommendations relevant to imaging
|
16
|
19
|
|
Class of recommendations
|
||
|
Class I
|
15
|
50
|
|
Class IIa
|
17
|
30
|
|
Class IIb
|
21
|
26
|
|
Class III
|
16
|
14
|
|
Level of evidence (LOE)
|
||
|
LOE A
|
3
|
9
|
|
LOE B
|
38
|
44
|
|
LOE C
|
28
|
67
|
Table 2
Recommendations regarding perioperative ECG
|
Indication
|
AHA/ACC
|
EHS/ESA
|
||
|---|---|---|---|---|
|
Class
|
LOE
|
Class
|
LOE
|
|
|
Patients with risk factors undergoing intermediate- or high-risk surgery
|
I
|
C
|
||
|
Patients with known CAD, significant arrhythmia, peripheral arterial disease, cerebrovascular disease or other cardiac structural abnormalities, except those undergoing low-risk surgery
|
IIa
|
B
|
||
|
Patients with risk factors undergoing low-risk surgery
|
IIb
|
C
|
||
|
Patients with no risk factors, age >65 years undergoing intermediate-risk surgery
|
IIb
|
C
|
||
|
Asymptomatic patients without known CAD except those undergoing low-risk surgery
|
IIb
|
B
|
||
|
Patients with no risk factors scheduled for low-risk surgery
|
III
|
B
|
||
|
Asymptomatic patients undergoing low-risk surgery
|
III
|
B
|
||
Table 3
Recommendations regarding perioperative assessment of left ventricular (LV) function
|
Indication
|
AHA/ACC
|
EHS/ESA
|
||
|---|---|---|---|---|
|
Class
|
LOE
|
Class
|
LOE
|
|
|
Patients with dyspnea of unknown origin
|
IIa
|
C
|
||
|
Heart failure patients with worsening dyspnea or change in clinical status
|
IIa
|
C
|
||
|
Reassessment of LV function in stable patients with known LV dysfunction without an assessment within a year
|
IIb
|
C
|
||
|
Patients undergoing high-risk surgery
|
IIb
|
C
|
||
|
Routine preoperative evaluation of LV function
|
III
|
B
|
||
|
Routine assessment prior to low- or intermediate-risk surgery
|
III
|
C
|
||
Table 4
Recommendations regarding stress testing for myocardial ischemia
|
Recommendation
|
AHA/ACC
|
EHS/ESA
|
||
|---|---|---|---|---|
|
Class
|
LOE
|
Class
|
LOE
|
|
|
For patients with >2 risk factors* and poor functional capacity (<4 METs) undergoing high-risk surgery imaging stress test is recommended
|
I
|
C
|
||
|
For patients with elevated risk** and excellent functional capacity (>10 METS), it is reasonable to forgo further exercise testing with cardiac imaging and proceed with surgery
|
IIa
|
B
|
||
|
For patients with elevated risk** and poor functional capacity (<4 METs), it is reasonable to undergo pharmacologic stress testing, if it will change management
|
IIa
|
B
|
||
|
For patients with elevated risk** and unknown functional capacity, it is reasonable to perform exercise testing to assess functional capacity, if it will change management
|
IIb
|
B
|
||
|
For patients with elevated risk** and moderate-to-good functional capacity (METS 4-10), it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery
|
IIb
|
B
|
||
|
For patients with elevated risk** and poor functional capacity (<4 METs) it may be reasonable to perform exercise testing with cardiac imaging, if it will change management
|
IIb
|
C
|
||
|
For patients with 1–2 risk factors and poor functional capacity (<4 METs) undergoing intermediate- or high-risk surgery, imaging stress test may be considered
|
IIb
|
C
|
||
|
Routine stress testing is not useful for low-risk surgery
|
III
|
B
|
III
|
C
|
Table 5
Recommendations regarding coronary angiography
|
Recommendation
|
AHA/ACC
|
EHS/ESA
|
||
|---|---|---|---|---|
|
Class
|
LOE
|
Class
|
LOE
|
|
|
Indications for preoperative angiography and revascularization are similar to those in the the nonsurgical setting
|
I
|
C
|
||
|
STEMI in the setting of nonurgent noncardiac surgery
|
I
|
A
|
||
|
NSTEMI in setting of nonurgent noncardiac surgery
|
I
|
B
|
||
|
Patients with proven ischemia and unstabilized chest pain* on optimal medical therapy, undergoing nonurgent noncardiac surgery
|
I
|
C
|
||
|
Stable cardiac patients undergoing nonurgent carotid endarterectomy
|
IIb
|
B
|
||
|
Routine coronary angiography is not recommended
|
III
|
C
|
||
|
Stable patients undergoing low-risk surgery
|
III
|
C
|
||
Table 6
Recommendations regarding elective coronary revascularization prior to noncardiac surgery
|
Indication
|
AHA/ACC
|
EHS/ESA
|
||
|---|---|---|---|---|
|
Class
|
LOE
|
Class
|
LOE
|
|
|
Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to clinical practice guidelines
|
I
|
C
|
I
|
B
|
|
Late revascularization after successful noncardiac surgery should be considered in accordance to clinical practice guidelines
|
I
|
C
|
||
|
Prophylactic revascularization before high-risk surgery may be considered, depending on the extent of the stress–induced perfusion defect
|
IIb
|
B
|
||
|
Routine revascularization before low- and intermediate-risk surgeries in patients with known CAD is not recommended
|
III
|
B
|
||
|
Routine revascularization is not recommended before noncardiac surgery exclusively to reduce perioperative events
|
III
|
B
|
||
Table 7
Surgical risk estimate of 30-day cardiovascular risk of myocardial infarction and cardiovascular death according to ESC/ESA guidelines
|
Low-risk surgery (<1%)
|
Intermediate-risk surgery (1–5%)
|
High-risk surgery (>5%)
|
|---|---|---|
|
Superficial surgery
|
Intraperitoneal
|
Pulmonary or liver transplant
|
|
Breast
|
Carotid, Symptomatic
|
Total cystectomy
|
|
Dental
|
Intrathoracic minor
|
Aortic and major vascular surgery
|
|
Endocrine: Thyroid
|
Peripheral arterial angioplasty
|
Duodeno-pancreatic surgery
|
|
Reconstructive
|
Endovascular aneurysm repair
|
Liver-resection bile duct surgery
|
|
Eye
|
Head and neck surgery
|
Esophagectomy
|
|
Carotid, symptomatic
|
Major orthopedic, neurological, gynecologic or urological procedure
|
Repair of perforated bowel
|
|
Minor gynecologic
|
Renal transplant
|
Adrenal Resection
|
|
Minor orthopedic
|
Pneumonectomy
|
|
|
Minor urologic
|
Figure 1
Comparison of stepwise approach based on AHA/ACC and ESC/ESA guidelines. * Unstable angina, acute hart failure, significant cardiac arrhythmia, symptomatic valvular heart disease, myocaridal infarction within the past 30 days and residual myocardial ischemia. **See Table 6. § Estimation of risk based on the Revised Cardiac Risk Index score or the American College of Surgeons NSQIP risk calculator. ¶ According to the Revised Cardiac Risk Index Score
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