New Guidelines Recommend Preop Evaluation Only for Patients with Active Heart Disease

DALLAS, Oct. 1 -- Preoperative evaluation of patients with heart disease should focus on determining current medical status, not providing clearance for surgery, according to an update of guidelines from the American Heart Association and American College of Cardiology.

In the preoperative evaluation before noncardiac surgery, "intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context," members of the AHA/ACC writing committee asserted online ahead of the Oct. 23 issues of Circulation and the Journal of the American College of Cardiology.

The authors further stated that "no test should be performed unless it is likely to influence patient treatment." The evaluation should prepare physicians to "make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period."

The end result of the preoperative evaluation, the authors said, should be to develop a clinical risk profile that peri- and postoperative caregivers can use to make treatment decisions.

In an update of their 2002 joint guidelines, the two organizations emphasized that many patients with heart disease can safely undergo noncardiac surgery without first having an intervention-such as coronary angioplasty or bypass surgery-to treat the heart disease.

"Several trials now show that in people without symptomatic heart disease, fixing the heart first doesn't make much of a difference in how well they do in surgery," said Lee A. Fleisher, M.D., of the University of Pennsylvania in Philadelphia, chair of the guideline writing committee.

Preoperative evaluation and treatment should be limited to patients who have "active" cardiac conditions, such as unstable angina, decompensated heart failure, significant arrhythmias, or severe heart valve disease.

Recommendations in the update also include:

• Continuation of statins or other cholesterol-lowering therapy
• Discontinuation of existing antiplatelet therapy for the shortest period of time possible
• Continuation of aspirin therapy, if possible, in patients who have drug-eluting coronary stents and require urgent noncardiac surgery that necessitates temporary cessation of other antiplatelet therapy
• Beta blockers should be continued in patients undergoing surgery who are receiving them to treat angina, symptomatic arrhythmias, hypertension or other ACC/AHA Class I guideline indications
• Consideration of angioplasty or bypass surgery in advance of noncardiac surgery only for patients who have severe or symptomatic heart disease
• Elective noncardiac surgery is not recommended within four to six weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting stent implantation if thienopyridine or aspirin therapy will need to be discontinued perioperatively
• Adherence to principles employed in the nonoperative setting when deciding whether to pursue a specific test or treatment