Preoperative Evaluation of Preoperative Evaluation of Cardiac Patient for Cardiac Patient for Noncardiac surgeryNoncardiac surgery

Dr Balaji AsegaonkarDr Balaji Asegaonkar MD,DNB (Anaesthesia)MD,DNB (Anaesthesia)

Consultant cardiac anaesthesiologistConsultant cardiac anaesthesiologist Ozone Anaesthesia Group, Ozone Anaesthesia Group,

Aurangabad. Aurangabad.

CASE 1CASE 1

65 YR MALE ,HT SINCE 5 YRS,DM SINCE 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD5 YRS ON INSULIN AND IHD

ANGIOPLASTY DONE 10 MONTHS BACK ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTSWITH DRUG ELUTING STENTS

ON DUAL ANTIPLATELATE AGENTSON DUAL ANTIPLATELATE AGENTS TO BE POSTED FOR TURP TO BE POSTED FOR TURP

CASE 2CASE 2

70 YR MALE ,HYPERTENSIVE, DIABETIC 70 YR MALE ,HYPERTENSIVE, DIABETIC & SEVERE OSTEOARTHRITIS.& SEVERE OSTEOARTHRITIS.

SMOKER FOR LAST 30 YRS.SMOKER FOR LAST 30 YRS.

TO BE POSTED FOR TKRTO BE POSTED FOR TKR

CASE 3CASE 3

80 YRS MALE, HT, IHD- POST PLASTY,80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCEPOOR EFFORT TOLERANCE EF 25 %EF 25 % TO BE POSTED FOR CATARACTTO BE POSTED FOR CATARACT

Let’s face it…Let’s face it…

The surgical population is older, sicker, The surgical population is older, sicker, on more medications, and having more on more medications, and having more & more cardiac interventions.& more cardiac interventions.

There is a subset of your patients for There is a subset of your patients for whom the patient, the surgeon, or you whom the patient, the surgeon, or you may have questions about may have questions about cardiovascular risk.cardiovascular risk.

So what do you do?So what do you do?

Guess?…Argue?…Worry?…Refer everyone Guess?…Argue?…Worry?…Refer everyone cardiological investigationscardiological investigations

OR do a thorough, focused exam.OR do a thorough, focused exam.

Followed by the Followed by the individualizedindividualized application of application of some authoritative guidelines…some authoritative guidelines…

……for evaluation, risk stratification, and for evaluation, risk stratification, and management…management…

……and refer, delay, or cancel only when and refer, delay, or cancel only when appropriate. appropriate.

Authoritative guidelines…..?Authoritative guidelines…..?

Evidence based medicine.Evidence based medicine. Based on research findings, expert opinion, Based on research findings, expert opinion,

and consensus .and consensus . Cardiovascular authority, like American Cardiovascular authority, like American

College of Cardiology/American Heart College of Cardiology/American Heart Association.Association.

Anaesthesiology authority, like ASA. Anaesthesiology authority, like ASA.

Objectives:Objectives:

How to approach cardiac Patients.How to approach cardiac Patients. Risk stratification.Risk stratification. Modification of level of care.Modification of level of care. Discuss standard recommendation.Discuss standard recommendation.

focused focused approach……… approach………

We are not cardiologists, We simply need to We are not cardiologists, We simply need to recognize when a cardiac condition might recognize when a cardiac condition might affect the patient’s response to affect the patient’s response to anaesthesia, and what to do about it. We anaesthesia, and what to do about it. We need to be: need to be:

ThoroughThorough enough to find all significant enough to find all significant problems (sensitivity).problems (sensitivity).

FocusedFocused enough to consider only significant enough to consider only significant problems (specificity).problems (specificity).

 … …and Stepwise Approach?and Stepwise Approach?

Thorough, focused cardiac evaluation Thorough, focused cardiac evaluation ACC/AHA Guidelines for Perioperative ACC/AHA Guidelines for Perioperative

Cardiovascular Evaluation for Cardiovascular Evaluation for Noncardiac Surgery (2007).Noncardiac Surgery (2007).

Indicated cardiac testing and Indicated cardiac testing and consultation.consultation.

Optimization of cardiovascular function Optimization of cardiovascular function in relation to the demands of the in relation to the demands of the surgery and the anaesthesia.surgery and the anaesthesia.

The courage is knowledge of how to fear what ought to be feared & how

not to fear what ought not to be feared.

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A: Data derived from multiple randomized clinical trials or meta-analyses Multiple populations evaluated

Level B: Data derived from a single randomized trial or nonrandomized studies Limited populations evaluated

Level C: Only consensus of experts opinion, case studies, or standard of care

Very limited populations evaluated

Applying Classification of Recommendations and Level of Evidence

Level of Evidence:

So, lSo, let’s start with et’s start with …… The Preop portion of the ACC/AHA The Preop portion of the ACC/AHA

Guidelines, which is based on your Guidelines, which is based on your history and physical, plus indicated history and physical, plus indicated tests.tests.

Guidelines : Stepwise approach Guidelines : Stepwise approach

Need for surgery:Emergent vs Need for surgery:Emergent vs Urgent/Elective.Urgent/Elective.

Clinical Risk Predictors: Clinical Risk Predictors: (Major, Intermediate, Minor).(Major, Intermediate, Minor).

Functional capacity (Exercise Functional capacity (Exercise tolerance).tolerance).

ACC/AHA Guidelines: PreopACC/AHA Guidelines: Preop

Surgical Risk Predictors:Surgical Risk Predictors:(High, Intermediate, Low)(High, Intermediate, Low)

Recent coronary revascularization or Recent coronary revascularization or Evaluation.Evaluation.

Major Clinical Risk PredictorsMajor Clinical Risk Predictors

Unstable Coronary Syndromes: Unstable Coronary Syndromes: – Recent MI (Recent MI (> > 7 and 7 and < < 30 days).30 days).– Unstable angina (Canadian Class III-IV).Unstable angina (Canadian Class III-IV).

Decompensated CHF.Decompensated CHF. Significant Dysrhythmias.Significant Dysrhythmias.

– High-grade AV block.High-grade AV block.– Symptomatic ventricular dysrhythmias.Symptomatic ventricular dysrhythmias.– Supraventricular dysrhythmias with Supraventricular dysrhythmias with

uncontrolled ventricular rate. uncontrolled ventricular rate. Severe Valve Disease.Severe Valve Disease.

Intermediate Clinical Risk PredictorsIntermediate Clinical Risk Predictors

Mild angina (Canadian Class I - II).Mild angina (Canadian Class I - II).

Prior MI by history or pathological Q waves.Prior MI by history or pathological Q waves.

Compensated or prior CHF.Compensated or prior CHF.

Diabetes, especially IDDM.Diabetes, especially IDDM.

Renal Insufficiency (creatinine Renal Insufficiency (creatinine >> 2mg%). 2mg%).

Minor Clinical Risk PredictorsMinor Clinical Risk Predictors

Advanced age.Advanced age. Abnormal ECG (LVH, LBBB, ST-T Abnormal ECG (LVH, LBBB, ST-T

abnl).abnl). Rhythm other than sinus (e.g. a-fib).Rhythm other than sinus (e.g. a-fib). Low functional capacity (Low functional capacity (<< 4 METs). 4 METs). Hx CVA.Hx CVA. Uncontrolled HTN (Uncontrolled HTN (>>180 180 / >/ >110).110).

Cardiac Functional Classification:Cardiac Functional Classification:Canadian Cardiovascular SocietyCanadian Cardiovascular Society

I.I. No anginaNo angina with ordinary physical activity . with ordinary physical activity . AnginaAngina with strenuous exertion. with strenuous exertion.

II. II. Slight limitationSlight limitation of ordinary activity. of ordinary activity. III. III. Marked limitationMarked limitation of ordinary activity. of ordinary activity.

IV. IV. InabilityInability to carry on any physical activity to carry on any physical activity without discomfort. without discomfort. Angina Angina may be present may be present at at restrest..

Functional Capacity = Exercise Functional Capacity = Exercise ToleranceTolerance

MajorMajor clinical risk predictors are clinical risk predictors are sufficient alonesufficient alone to trigger further testing to trigger further testing or intervention before pt posted for Sx.or intervention before pt posted for Sx.

IntermediateIntermediate and and minorminor clinical risk clinical risk predictors are subject to a predictors are subject to a second stepsecond step::

Evaluation of cardiovascular Evaluation of cardiovascular functional functional capacitycapacity, i.e., , i.e., exercise toleranceexercise tolerance..

Exercise ToleranceExercise Tolerance Angina or anginal equivalents (DOE, Angina or anginal equivalents (DOE,

palpitations, fatigue)palpitations, fatigue)== Ischemic threshold. Ischemic threshold. Point where metabolic demand Point where metabolic demand >> supply supply Metabolic equivalent (MET): Metabolic equivalent (MET):

1 MET 1 MET == resting O2 consumption(VO2) resting O2 consumption(VO2) == 3.5mL/kg/min 3.5mL/kg/min

Functional capacity in METs:Functional capacity in METs:– Poor: Poor: << 4 4 – Mod: Mod: 4-7: 4-7: > 4> 4 is the “tipping is the “tipping

point”.point”. – Good: Good: 7-10. 7-10. – Excellent: Excellent: >> 10. 10.

Exercise Tolerance in METsExercise Tolerance in METs 1 MET: 1 MET: Eat, dress, use the toilet.Eat, dress, use the toilet. 2 METs: 2 METs: Household ambulation.Household ambulation. 3 METs: 3 METs: Light housework.Light housework.

Walk level ground 2-3 Walk level ground 2-3 MPH.MPH.

4 METs: 4 METs: Walk up one flight stairs.Walk up one flight stairs.Walk level ground 4 MPH.Walk level ground 4 MPH.

4-10 METs: 4-10 METs: Run short distance.Run short distance.Scrub floors, move Scrub floors, move

furniture.furniture. Moderate sports.Moderate sports. >>10 METs:10 METs: Strenuous sports.Strenuous sports.

Surgical Risk Predictors Surgical Risk Predictors

HighHigh ( (> > 5% Cardiac Death/MI).5% Cardiac Death/MI).Emergent major operation, espec. in Emergent major operation, espec. in

elderly,elderly, Aortic and other major vascular Aortic and other major vascular SxSx Peripheral vascular,Prolonged Peripheral vascular,Prolonged procedure. procedure.

IntermediateIntermediate ( (< < 5%).5%).Carotid endarterectomy, Head & neckCarotid endarterectomy, Head & neckIntraperitoneal, Intrathoracic, Prostate, Intraperitoneal, Intrathoracic, Prostate,

OrthoOrtho LowLow ( (< < 1%).1%).

Endoscopic, Superficial, Cataract, BreastEndoscopic, Superficial, Cataract, Breast

Procedure Details : AngioplastyProcedure Details : Angioplasty

Time since procedure.Time since procedure. Which artery. Which artery. Present medication.Present medication. Symptoms benefits.Symptoms benefits. Baseline ECG. Baseline ECG. Which stents.Which stents.

DRUG ELUTING STENTDRUG ELUTING STENT

ANTICACER DRUGS COATED.ANTICACER DRUGS COATED. SLOW RELEASE TILL 6 TO 8 MONTH.SLOW RELEASE TILL 6 TO 8 MONTH. NO ENDOTHELIAZATION.NO ENDOTHELIAZATION. LEAST CHANCE OF INSTENT LEAST CHANCE OF INSTENT

THROMBOSIS THROMBOSIS ANTIPLATELETS ANTIPLATELETS

Post plasty :Noncardiac surgeryPost plasty :Noncardiac surgery

Treatment for patients requiring PCI who need Treatment for patients requiring PCI who need subsequent surgerysubsequent surgery

Procedure Details : CABGProcedure Details : CABG

Time since procedure.Time since procedure. Which arteries grafted & Type of conduit.Which arteries grafted & Type of conduit. Present medication.Present medication. Symptoms benefits.Symptoms benefits. Baseline ECGBaseline ECG

Recommended stepwise approachRecommended stepwise approach

• STEP 1:STEP 1:

• How urgent noncardiac surgery is ?How urgent noncardiac surgery is ?

• p/o risk stratification & assessment done.p/o risk stratification & assessment done.

• All these are Gr V cases.All these are Gr V cases.

Step 2Step 2

Has Pt undergone coronary Has Pt undergone coronary revascularisation in past 5 yrs ?revascularisation in past 5 yrs ?

If yes & Pt has no s/s of cardiac problem – If yes & Pt has no s/s of cardiac problem – further detail cardiac testing not required. further detail cardiac testing not required.

Step 3Step 3

If Pt has any coronary evaluation in past If Pt has any coronary evaluation in past 2 yrs – revealing no significant CAD ,if there 2 yrs – revealing no significant CAD ,if there is no aggravations of s/s –no further testing is no aggravations of s/s –no further testing is needed.is needed.

Step 4Step 4

Does Pt have any major clinical predictors ?Does Pt have any major clinical predictors ?

Delay noncardiac surgery until problem has Delay noncardiac surgery until problem has identified & treated.identified & treated.

Step 5Step 5

If Pt have intermediate clinical predictors.If Pt have intermediate clinical predictors.

Consider functional capacity & surgery Consider functional capacity & surgery

specific risks.specific risks.

Decide accordingly weather further testing Decide accordingly weather further testing

needed or not.needed or not.

Step 6Step 6

Pt with intermediate predictor & mod to Pt with intermediate predictor & mod to excellent functional capacity can undergo excellent functional capacity can undergo intermediate Sx.intermediate Sx.

Pt with 2 or more intermediate predictor & Pt with 2 or more intermediate predictor & poor functional capacity OR mod functional poor functional capacity OR mod functional capacity but high risk Sx – further testing & capacity but high risk Sx – further testing & evaluation needed.evaluation needed.

Step 7Step 7

Noncardiac Sx safe in Pt with minor clinical Noncardiac Sx safe in Pt with minor clinical predictor & mod to excellent functional predictor & mod to excellent functional capacity.capacity.

Additional testing must for Pt with no clinical Additional testing must for Pt with no clinical predictors but poor functional capacity & predictors but poor functional capacity & who are facing high risk Sx.who are facing high risk Sx.

CASE 1CASE 1

65 YR MALE ,HT SINCE 5 YRS,DM SINCE 65 YR MALE ,HT SINCE 5 YRS,DM SINCE 5 YRS ON INSULIN AND IHD5 YRS ON INSULIN AND IHD

ANGIOPLASTY DONE 10 MONTHS BACK ANGIOPLASTY DONE 10 MONTHS BACK WITH DRUG ELUTING STENTSWITH DRUG ELUTING STENTS

TO BE POSTED FOR TURP TO BE POSTED FOR TURP

CASE 2CASE 2

70 YR FEMALE ,HYPERTENSIVE & 70 YR FEMALE ,HYPERTENSIVE & SEVERE OSTEOARTHRITIS.SEVERE OSTEOARTHRITIS.

CABG DONE 2 YRS BACK ON CABG DONE 2 YRS BACK ON ANTIPLATE, ANTI HT & STATINSANTIPLATE, ANTI HT & STATINS

TO BE POSTED FOR TKRTO BE POSTED FOR TKR

CASE 3CASE 3

80 YRS MALE, HT, IHD- POST PLASTY,80 YRS MALE, HT, IHD- POST PLASTY, POOR EFFORT TOLERANCEPOOR EFFORT TOLERANCE EF 25 %EF 25 % TO BE POSTED FOR CATARACTTO BE POSTED FOR CATARACT

Step 8Step 8

In documented CAD , if risk of coronary In documented CAD , if risk of coronary interventions or CABG exceeds proposed interventions or CABG exceeds proposed noncardiac Sx & if such Sx improves long noncardiac Sx & if such Sx improves long term prognosis of Pt – noncardiac Sx should term prognosis of Pt – noncardiac Sx should be done.be done.

Summary from ACC / AHASummary from ACC / AHA

Perioperative evaluation and mgmt of high-risk Perioperative evaluation and mgmt of high-risk cardiac patients for noncardiac surgery cardiac patients for noncardiac surgery requires careful teamwork and communication requires careful teamwork and communication between patient, surgeon, anesthesiologist, between patient, surgeon, anesthesiologist, physian or cardiologist. physian or cardiologist.

Indications for cardiac testing and treatments Indications for cardiac testing and treatments are the same as in the non-operative setting, are the same as in the non-operative setting, and should clearly affect patient management.and should clearly affect patient management.

Factors include the urgency of surgery, Factors include the urgency of surgery, patient-specific risk factors, and surgery-patient-specific risk factors, and surgery-specific considerations. specific considerations.

SummarySummary For many patients, noncardiac surgery For many patients, noncardiac surgery

represents their first opportunity for represents their first opportunity for assessment of short- and long-term cardiac assessment of short- and long-term cardiac risk. The consultant best serves the patient by risk. The consultant best serves the patient by making recommendations aimed at lowering making recommendations aimed at lowering the immediate perioperative cardiac risk, as the immediate perioperative cardiac risk, as well as assessing the need for postoperative well as assessing the need for postoperative risk stratification and interventions directed to risk stratification and interventions directed to modify cardic risk factors. modify cardic risk factors.

Future research should be directed at Future research should be directed at determining the value of routine prophylactic determining the value of routine prophylactic medical therapy vs. more extensive diagnostic medical therapy vs. more extensive diagnostic testing and interventions. testing and interventions.

Proposed Approach to the Management of Patients with Proposed Approach to the Management of Patients with Previous PCI Who Require Noncardiac SurgeryPrevious PCI Who Require Noncardiac Surgery

Balloon angioplasty

Bare-metalstent

Drug-elutingstent

Delay for elective or nonurgentsurgery

<14 days

Proceed to the operation room

with aspirin

Delay for elective or nonurgentsurgery

>30- 45 days<30- 45 days

Proceed to the operating room

with aspirin

>365 days

Previous PCI

Time since PCI

PCI, percutaneous coronary intervention

<365 days

>14 days

Proposed Treatment for Patients Requiring PCI Who Proposed Treatment for Patients Requiring PCI Who Need Subsequent SurgeryNeed Subsequent Surgery

Balloonangioplasty

Bare-metal stent

Drug-eluting stent

14-29 days 30-365 days >365 days

Bleeding risk of surgery

Timing of surgery

Acute MI, H risk ACS, or H risk cardiac anatomy

Stent & continue dual antiplatelet therapylow

Not low

Recommendations for Perioperative Beta-Recommendations for Perioperative Beta-Blocker TherapyBlocker Therapy

Surgery No Clinical Risk Factors

CAD or High Risk (1 or

more clinical risk factors)

Patients Currently

Taking Beta Blockers

Vascular Class llb, Level of Evidence: B

Class lla, Level of Evidence: B

Class 1, Level of Evidence: C

Intermediate risk

… Class lla, Level of Evidence: B

Class 1, Level of Evidence: C

Low risk … … Class 1, Level of Evidence: C

Recommendations for Statin TherapyRecommendations for Statin Therapy

For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued.

For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable.

For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures,statins may be considered.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Aims on evaluationAims on evaluation

Delay case for treatment of unstable Delay case for treatment of unstable symptoms.symptoms.

Modification of intraoperative or Modification of intraoperative or postoperative (e.g. ICU) monitoring.postoperative (e.g. ICU) monitoring.

Aims on evaluationAims on evaluation

Modification of perioperative medical Modification of perioperative medical therapy.therapy.

Coronary or valve procedure before Coronary or valve procedure before noncardiac surgery.noncardiac surgery.

Modification of location of careModification of location of care

Rest ECG: IndicationsRest ECG: Indications

Class IClass I:Recent angina with intermed-high :Recent angina with intermed-high risk clinical predictors for intermed-high risk risk clinical predictors for intermed-high risk procedure.procedure.

Class IIaClass IIa: Asymptomatic diabetics.: Asymptomatic diabetics. Class IIbClass IIb: Prior coronary revascularization : Prior coronary revascularization

or cardiac hospital admission. or cardiac hospital admission. Asymptomatic malesAsymptomatic males > > 45 or females 45 or females >> 55 55 with 2 CAD risk factors.with 2 CAD risk factors.

Class IIIClass III: Asymptomatic pts. For low-risk : Asymptomatic pts. For low-risk proceduresprocedures

Rest ECG: Significant FindingsRest ECG: Significant Findings

Path.Q waves (Path.Q waves (> > 0.4s wide, or 0.4s wide, or > > 25% of R, in 2 25% of R, in 2 contiguous leads): Size and extent predict LVEF, contiguous leads): Size and extent predict LVEF, long term mortality. long term mortality.

Horizontal or downsloping ST depression Horizontal or downsloping ST depression >> 0.5mm, LVH with strain pattern (ST depression 0.5mm, LVH with strain pattern (ST depression ++ TWI in I, II, III, AVL or AVF, V5, V6), LBBB with TWI in I, II, III, AVL or AVF, V5, V6), LBBB with CAD predict increased perioperative risk and long CAD predict increased perioperative risk and long term mortality.term mortality.

Significant dysrhythmias: High-grade AV block, Significant dysrhythmias: High-grade AV block, symptomatic ventricular dysrhythmias, symptomatic ventricular dysrhythmias, supraventricular dysrhythmias with uncontrolled supraventricular dysrhythmias with uncontrolled rate. rate.

Echocardiogram: IndicationsEchocardiogram: Indications

Asymptomatic murmurs :Asymptomatic murmurs :Class IClass I: : Diastolic, continuous, holosystolic, mid Diastolic, continuous, holosystolic, mid

& late systolic, III/VI murmurs.& late systolic, III/VI murmurs.

Class IIaClass IIa: : Murmur assoc with abnl cardiac Murmur assoc with abnl cardiac palpation or auscultation, abnl ECG or CXR.palpation or auscultation, abnl ECG or CXR.

Class IIIClass III: : II/VI midsystolic innocent murmur. Dx II/VI midsystolic innocent murmur. Dx of “silent” AR or MR without murmur, to of “silent” AR or MR without murmur, to recommend endocarditis prophylaxisrecommend endocarditis prophylaxis..

Echocardiogram: IndicationsEchocardiogram: Indications

Symptomatic murmur:Symptomatic murmur:–Class IClass I: : SS//S of CHF, MI, syncope, S of CHF, MI, syncope,

infective endocarditis, thromboembolisminfective endocarditis, thromboembolism

–Class IIAClass IIA: : SS//S possibly non-cardiacS possibly non-cardiac..

–Class IIIClass III: : SS//S non-cardiac dz with S non-cardiac dz with midsystolic “innocent” murmurmidsystolic “innocent” murmur

Stress Testing: ECG or EchoStress Testing: ECG or Echo

Normal rest ECG Normal rest ECG →→ ECG stress, Abnl ECG ECG stress, Abnl ECG → Echo→ Echo– Class IClass I: Dx of intermediate probability CAD, : Dx of intermediate probability CAD,

Prognosis of CAD or s/p ACS, Eval of med tx. Prognosis of CAD or s/p ACS, Eval of med tx. Proof of ischemia before revascularization.Proof of ischemia before revascularization.

– Class IIaClass IIa: Evaluate exercise tolerance in : Evaluate exercise tolerance in unreliable historian. unreliable historian.

– Class IIbClass IIb: Dx of high or low probability CAD, : Dx of high or low probability CAD, Resting ST depression Resting ST depression < < 1mm, On digoxin, LVH 1mm, On digoxin, LVH by ECG, Dx of restenosis in high-risk by ECG, Dx of restenosis in high-risk asymptomatic .asymptomatic .

– Class IIIClass III: Resting pre-excitation or ST depression : Resting pre-excitation or ST depression >> 1mm, Routine screening. 28 1mm, Routine screening. 28

Recommendations for CAG in Preop Recommendations for CAG in Preop EvaluationEvaluation

Class I: Patients With Suspected or Known CAD Evidence for high risk of adverse outcome based on noninvasive test

results. Angina unresponsive to adequate medical therapy. Unstable angina, particularly when facing intermediate-risk* or high-

risk* noncardiac surgery. Equivocal noninvasive test results in patients at high clinical risk

undergoing high-risk* surgery. Class IIa Multiple markers of intermediate clinical risk and planned vascular

surgery (noninvasive testing should be considered first). Moderate to large ischemia on noninvasive testing but without high-risk

features and lower left ventricular ejection fraction. Nondiagnostic noninvasive test results in patients at intermediate

clinical risk undergoing high-risk* noncardiac surgery. Urgent noncardiac surgery while convalescing from acute MI.

Recommendations for CAG in Preop Recommendations for CAG in Preop EvaluationEvaluation

Class IIb Perioperative MI. Medically stabilized class III or IV angina and planned low-risk or

minor* surgery. Class III Low-risk* noncardiac surgery with known CAD and no high-risk

results on noninvasive testing. Asymptomatic after coronary revascularization with excellent

exercise capacity (greater than or equal to 7 METs). Mild stable angina with good left ventricular function and no high-

risk noninvasive test results. Noncandidate for coronary revascularization owing to

concomitant medical illness, severe left ventricular dysfunction (e.g., left ventricular ejection fraction less than 0.20), or refusal to consider revascularization.

Candidate for liver, lung, or renal transplant less than 40 years old, as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.