Guideline Title
2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Bibliographic Source(s)
American College of Cardiology Foundation/American Heart Association Task Force, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery, Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009 Nov 24;54(22):e13-e118. [595 references] PubMed
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW, American College of Cardiology, American Heart Association Task Force on Practice Guidelines (writing Committee, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007 Oct 23;50(17):e159-241. [584 references]
full-text:
National Guideline Clearinghouse | 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Practice Guidelines: Full Text
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery, Lee A. Fleisher MD, FACC, FAHA, Chair, 2007 Writing Committee Member, Joshua A. Beckman MD, FACC, 2007 Writing Committee Member, Kenneth A. Brown MD, FACC, FAHA†, 2007 Writing Committee Member, Hugh Calkins MD, FACC, FAHA‡, 2007 Writing Committee Member, Elliot L. Chaikof MD§, 2007 Writing Committee Member, Kirsten E. Fleischmann MD, MPH, FACC, 2007 Writing Committee Member, William K. Freeman MD, FACC, 2007 Writing Committee Member, James B. Froehlich MD, MPH, FACC, 2007 Writing Committee Member, Edward K. Kasper MD, FACC, 2007 Writing Committee Member, Judy R. Kersten MD, FACC¶, 2007 Writing Committee Member, Barbara Riegel DNSc, RN, FAHA, 2007 Writing Committee Member and John F. Robb MD, FACC#, 2007 Writing Committee Member
Preamble (UPDATED)
It is essential that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies. The production of clinical practice guidelines can provide a foundation for a variety of other applications such as performance measures, appropriateness use criteria, clinical decision support tools, and quality improvement tools.
The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines is charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and directs this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update, or revise recommendations for clinical practice.
Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against particular treatments or procedures, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of tests or therapies are considered as well as the frequency of follow-up and cost-effectiveness. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.
The ACCF/AHA Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all such relationships that might be perceived as relevant to the writing effort. If a writing committee member develops a new relationship with industry during their tenure, they are required to notify guideline staff in writing. These statements are reviewed by the parent task force, reviewed by all members in conjunction with each conference call and/or meeting of the writing committee, updated as changes occur and ultimately published as an appendix to the document. Please refer to the methodology manual for ACCF/AHA Guideline Writing Committees for further description of the relationships with industry and other entities policy (1). See Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry pertinent to this guideline.
These practice guidelines produced are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions. (See Appendix 3 for a list of abbreviations frequently used in this document.) Clinicians should consider the quality and availability of expertise in the area where care is provided. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The recommendations reflect a consensus of expert opinion after a thorough review of the available current scientific evidence and are intended to improve patient care.
Patient adherence to prescribed and agreed upon medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles.
If these guidelines are used as the basis for regulatory or payer decisions, the goal should be quality of care and the patient's best interest. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient. Consequently, there are circumstances in which deviations from these guidelines are appropriate.
The guidelines will be reviewed annually by the ACCF/AHA Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution. The executive summary and recommendations are published in the October 23, 2007, issues of the Journal of the American College of Cardiology and Circulation. The full-text guidelines are e-published in the same issue of these journals and posted on the ACC (www.acc.org) and AHA (my.americanheart.org) World Wide Web sites. Copies of the full-text guidelines and the executive summary are available from both organizations.
This document is a republication of the “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery” (2), revised to incorporate updated recommendations and text from the “2009 ACCF/AHA Focused Update on Perioperative Beta Blockade” (3). Recommendations have been updated with new information that has emerged from clinical trials or other ACCF/AHA guideline or consensus documents. For easy reference, this online-only version denotes sections that have been updated.
Alice K. Jacobs, MD, FACC, FAHA, Chair, ACCF/AHA Task Force on Practice Guidelines
Sidney C. Smith, Jr., MD, FACC, FAHA, Immediate Past Chair, ACCF/AHA Task Force on Practice Guidelines
1. Introduction/Definition of the Problem (UPDATED)
The 2007 full-text guidelines represent an update to those published in 2002 and are intended for physicians and nonphysician caregivers who are involved in the preoperative, operative, and postoperative care of patients undergoing noncardiac surgery. They provide a framework for considering cardiac risk of noncardiac surgery in a variety of patient and surgical situations. The writing committee that prepared these guidelines strove to incorporate what is currently known about perioperative risk and how this knowledge can be used in the individual patient.
The tables and algorithms provide quick references for decision making. The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient's current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. No test should be performed unless it is likely to influence patient treatment. The goal of the consultation is the optimal care of the patient.
1.1. Methodology and Evidence Review (UPDATED)
The 2007 guidelines writing committee conducted a comprehensive review of the literature relevant to perioperative cardiac evaluation published since the last publication of these guidelines in 2002. Literature searches were conducted in the following databases: PubMed, MEDLINE, and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register). Searches were limited to the English language, the years 2002 through 2007, and human subjects. Related-article searches were conducted in MEDLINE to find additional relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches.
Major search topics included perioperative risk, cardiac risk, noncardiac surgery, intraoperative risk, postoperative risk, risk stratification, cardiac complication, cardiac evaluation, perioperative care, preoperative evaluation, preoperative assessment, and intraoperative complications. Additional searches cross-referenced these topics with the following subtopics: troponin, myocardial infarction (MI), myocardial ischemia, Duke activity status index, functional capacity, dobutamine, adenosine, venous thrombosis, thromboembolism, warfarin, percutaneous transluminal coronary angioplasty (PTCA), stent, adrenergic beta agonists, echocardiography, anticoagulant, beta blocker, coronary artery bypass surgery, valve, diabetes mellitus, wound infection, blood sugar control, normothermia, body temperature changes, body temperature regulation, hypertension, pulmonary hypertension, anemia, aspirin, arrhythmia, implantable defibrillator, artificial pacemaker, pulmonary artery catheters, Swan-Ganz catheter, and platelet aggregation inhibitors.
As a result of these searches, more than 400 relevant, new articles were identified and reviewed by the committee for the revision of these guidelines. Using evidence-based methodologies developed by the ACCF/AHA Task Force on Practice Guidelines, the committee revised the guidelines text and recommendations.
For the 2009 focused update (3), late-breaking clinical trials presented at the 2008 annual scientific meetings of the ACC, AHA, and European Society of Cardiology, as well as selected other data through June 2009, were reviewed by the standing guideline writing committee along with the parent task force and other experts to identify those trials and other key data that may impact guideline recommendations. Recent trial data and other clinical information were considered important enough to prompt a focused update of the “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery” (2). This update addresses predominantly the prophylactic use of beta blockers perioperatively to minimize cardiac risk, but it does not cover other legitimate uses of beta blockers (e.g., as an adjunct in anesthetic regimens, for intraoperative control of heart rate or blood pressure, or to achieve heart rate control in common perioperative arrhythmias such as atrial fibrillation).
When considering the new data for this focused update, the writing group faced the task of weighing evidence from studies enrolling large numbers of subjects outside North America. While noting that practice patterns and the rigor applied to data collection, as well as the genetic make-up of subjects, may influence the observed magnitude of a treatment's effect, the writing group believed the data were relevant to formulation of recommendations for perioperative management in North America. The reasons for this decision include the following: 1) The use of detailed protocol-driven management strategies likely reduced treatment variability among sites; and 2) it may be impractical to expect that the thousands of patients undergoing noncardiac surgery who are needed to meet the estimated sample size for contemporary clinical trials would be enrolled exclusively at North American sites.
To provide clinicians with a comprehensive set of data, whenever possible, the exact event rates in various treatment arms of clinical trials are presented to permit calculation of the absolute risk difference and number needed to treat (NNT) or harm. The relative treatment effects are described either as odds ratio (OR), relative risk (RR), or hazard ratio (HR), depending on the format in the original publication.
The schema for classification of recommendations and level of evidence are summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of treatment effect and an estimate of the certainty of the treatment effect.
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J Am Coll Cardiol. 2009 Nov 24;54(22):e13-e118.
2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine; Society for Vascular Surgery, Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF.
Collaborators (17)Jacobs AK, Smith SC jR, Anderson JL, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Stevenson WG, Tarkington LG, Yancy CW.
PMID: 19926002 [PubMed - indexed for MEDLINE]
full-text:
2009 ACCF/AHA focused update on perioperative beta... [J Am Coll Cardiol. 2009] - PubMed result
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