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The American College of Cardiology (ACC) and the American Heart Association (AHA) have established a set of guidelines written by a consortium of physicians involved in the perioperative care of patients undergoing noncardiac surgery. These guidelines are a tool to help health-care providers assess the risk and benefit of surgery, determine the best timing, and consider other options. Quality preoperative evaluations take into consideration patient risk factors and preexisting conditions and order appropriate tests based on peer-reviewed evidence.

In the development of these guidelines, the authors classified each recommendation on the strength of the underlying studies:

  • Class I: There exists evidence or general agreement that treatment or procedure is useful and/or effective. Procedure/Treatment should be performed.

  • Class II: Conditions with conflicting evidence and/or controversy with regard to usefulness/efficacy of a procedure or therapy.

    • Class IIa: The amount of evidence and general opinion demonstrate that benefits likely outweigh risks; however, additional studies with focused objectives are still needed. It is reasonable to perform procedure/administer treatment.

    • Class IIb: Evidence and general opinion suggest a possible benefit with procedure/treatment. Additional studies with larger populations, and broad objectives are needed. A procedure or treatment may be considered.

  • Class III: Consensus agreement with respect to procedure or treatment is of no use or ineffective or can cause harm.


The ACC/AHA 2014 guidelines present a stepwise approach to perioperative cardiac assessment. This easy-to-follow algorithm synthesizes information obtained from history, physical examination, and ECG to predict a major adverse cardiac event (MACE). Instead of grouping surgical procedures into high/moderate/low-risk categories, this algorithm takes into account the underlying cardiac risk of the specific operation.

  • Step 1: Determine the presence of coronary artery disease (CAD) or risk factors for CAD. If the surgery is an emergency, then the patient should proceed to surgery with perioperative management based on the specific cardiac issues present (acute heart failure, dysrhythmias).

    1. Major clinical predictors associated with increased perioperative cardiovascular hazard include acute coronary syndrome (ACS) such as acute MI (<7 days before procedure), unstable or severe angina, decompensated HF, symptomatic arrhythmias, or severe valvular disease.

    2. Intermediate clinical predictors of increased cardiac risk include mild angina, history of MI (>1 month before procedure), compensated HF, preoperative creatinine greater than or equal to 2.0 mg/dL, and diabetes mellitus.

    3. Minor clinical risk predictors include advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension.

  • Step 2: If the surgery is not an emergency, the presence of ACS should be determined. Prompt cardiology consultation and management for myocardial ischemia is necessary.

  • Step 3: This step is the key feature of the algorithm. The risk of MACE should be calculated using one of two validated risk assessment calculators.

Lee’s Revised Cardiac Risk Index (RCRI) was published in 1999 based on data from 3 000 patients having non-cardiac surgery. ...

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