American College of Cardiology

EAGLE ET AL., PERIOPERATIVE CARDIOVASCULAR EVALUATION FOR NONCARDIAC SURGERY UPDATE
http://www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm

ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

Appendix I—Definition of Terminology

• Acute coronary syndrome—Any constellation of clinical signs or symptoms suggestive of acute myocardial infarction (MI) or unstable angina. This syndrome includes patients with acute MI, ST-segment elevation MI, non-ST-segment elevation MI, enzyme-diagnosed MI, biomarker-diagnosed MI, late ECG-diagnosed MI, and unstable angina. This term is useful to generically refer to patients who ultimately prove to have one of these diagnoses to describe management alternatives at a time before the diagnosis is ultimately confirmed. This term is also used prospectively to identify those patients at a time of initial presentation who should be considered for treatment of acute MI or unstable angina.
• Acute myocardial infarction—an acute process of myocardial ischemia with sufficient severity and duration to result in permanent myocardial damage. Clinically, the diagnosis of permanent myocardial damage is typically made when there is a characteristic rise and fall in cardiac biomarkers indicative of myocardial necrosis that may or may not be accompanied by the development of Q waves on the ECG. Permanent myocardial damage may also be diagnosed when histologic evidence of myocardial necrosis is observed on pathologic examination.
• Angina pectoris—a clinical syndrome typically characterized by a deep, poorly localized chest, arm, or jaw discomfort that is reproducible and associated with physical exertion or emotional stress and relieved promptly (i.e., less than 5 minutes) by rest or sublingual nitroglycerin. The discomfort of angina is often hard for patients to describe, and many patients do not consider it to be "pain." Patients with unstable angina may have discomfort with all the qualities of typical angina except that episodes are more severe and prolonged and may occur at rest with an unknown relationship to exertion or stress. In most, but not all, patients these symptoms reflect myocardial ischemia resulting from significant underlying coronary artery disease.
• Arrhythmias—irregularity of the heartbeat caused by damage to or defect in the heart tissue and its electrical system. Arrhythmias considered major predictors of increased perioperative cardiovascular risk include high-grade atrioventricular block, symptomatic ventricular arrhythmias in the presence of underlying heart disease, and supraventricular arrhythmias with uncontrolled ventricular rate.
• Atypical chest pain—pain, pressure, or discomfort in the chest, neck, or arms not clearly exertional or not otherwise consistent with pain or discomfort of myocardial ischemic origin.
• Cardiomyopathy—disease or disorder of the heart muscle that results in weakening and/or stiffness of the heart muscle, heart enlargement, and left ventricular wall changes. Dilated and hypertrophic cardiomyopathy are associated with an increased incidence of perioperative heart failure.
• Cerebrovascular disease—a general classification determined by one or more of the following: 1) cerebrovascular accident (stroke), as documented by loss of neurologic function caused by an ischemic event with residual symptoms at least 24 h after onset; 2) reversible ischemic neurologic deficit, as documented by a loss of neurologic function caused by ischemia with symptoms at least 24 h after onset but with complete return of function within 72 h; 3) transient ischemic attack, as documented by a loss of neurologic function caused by ischemia that was abrupt in onset but with complete return of function within 24 h; 4) unresponsive coma greater than 24 h; or 5) noninvasive carotid test with greater than 75% occlusion.
• Coronary artery disease—the atherosclerotic narrowing of the major epicardial coronary arteries (see also "myocardial ischemia")
• Coronary revascularization—includes percutaneous coronary intervention of any type (balloon angioplasty, atherectomy, stent, or other) and/or coronary artery bypass graft.
• Functional capacity/functional status—determined by patient's ability to perform activities of daily living, quantified in metabolic equivalents (METs). Perioperative cardiac and long-term risk are increased in patients unable to meet a 4-MET demand during most normal daily activities. Decreased functional capacity may be caused by several factors, including inadequate cardiac reserve, advanced age, transient myocardial dysfunction from myocardial ischemia, deconditioning, and poor pulmonary reserve.
• Heart failure—a clinical syndrome characterized in most patients by dyspnea and fatigue at rest and/or with exertion caused by underlying structural and/or functional heart disease. Manifestations include neuroendocrine activation, sodium and water retention, edema, reflex control abnormalities, vascular and endothelial dysfunction, and skeletal muscle dysfunction.
• Hypercholesterolemia—total cholesterol greater than 200 mg per dl, low-density lipoprotein greater than or equal to 130 mg per dl, high-density lipoprotein less than 30 mg per dl, or admission cholesterol greater than 200 mg per dl. Also includes patients with a history of hypercholesterolemia diagnosed and/or treated by a physician.
• Hypertension—blood pressure greater than 140 mmHg systolic or 90 mmHg diastolic on at least 2 occasions. Also, documented by history of treatment for hypertension with medication, diet, and/or exercise, or current use of antihypertensive pharmacologic therapy.
• Ischemic heart disease—a form of heart disease in which the primary manifestations result from myocardial ischemia due to atherosclerotic coronary artery disease. This term encompasses a spectrum of patients ranging from the asymptomatic preclinical phase to acute myocardial infarction and sudden cardiac death.
• Likelihood—used in these guidelines to refer to the probability of an underlying diagnosis or outcome.
• Myocardial ischemia—inadequate circulation of blood to the heart muscle due to obstructions of heart arteries (see also "coronary artery disease").
• Orthostatic hypotension—low blood pressure precipitated by moving from a lying or sitting position to standing up straight. Postural orthostatic tachycardia syndrome, a 28 beats-per-minute or greater increase in heart rate on standing, is a type of mild orthostatic intolerance.
• Perioperative cardiac evaluation—consideration of cardiac risk due to noncardiac surgery in a variety of patients in preoperative, operative, and postoperative care. The purpose of perioperative cardiac evaluation is to assess 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 can be used in making treatment decisions.
• Peripheral vascular disease—a disorder that occurs when arteries are blocked by atherosclerotic plaque. Patients most frequently present with claudication, aching that occurs with walking and subsides with rest.
• Previous myocardial infarction—indicates that a patient has had at least one documented myocardial infarction eight or more days before examination. Documented evidence of previous myocardial infarction is defined as at least two of the following: 1) prolonged (greater than 20 min) typical chest pain not relieved by rest or nitrates; 2) biochemical evidence of myocardial necrosis (this can be manifested as creatine kinase-MB greater than upper limit of normal, total creatine kinase greater than 2 times the upper limit of normal, or troponin greater than the upper diagnostic limit); 3) new wall-motion abnormalities; or 4) at least two serial ECGs with (a) elevation in ST-T segments documented in 2 or more contiguous leads and/or (b) Q waves that are 0.03 seconds in width or greater than one third of the total QRS complex documented in 2 or more contiguous leads.
• Pulmonary hypertension—systolic pulmonary artery pressure greater than 60 mmHg or pulmonary vascular resistance greater than 260 dyne per sec per cm5.
• Renal failure—renal insufficiency resulting in an increase in serum creatinine to more than 2 mg per dl (or a 50% or greater increase over an abnormal baseline level) measured before the procedure or that requires dialysis.
• Risk—high, intermediate, and low risk in these guidelines refer to the probability of future adverse cardiac events, particularly death or myocardial infarction.
• Stable angina—angina without a change in frequency or pattern for at least the past six weeks. Angina is controlled by rest and/or oral or transcutaneous medications.
• Tamponade—fluid in the pericardial space documented by echocardiography or other methods that result in systemic hypotension requiring intervention.
• Unstable angina—An acute process of myocardial ischemia that is not of sufficient severity and duration to result in permanent myocardial damage. Patients with unstable angina typically do not present with ST-segment elevation on the ECG and do not release biomarkers indicative of myocardial necrosis into the blood.
• Unstable coronary disease—general classification of risk, including recent myocardial infarction with evidence of ischemic risk by clinical symptoms or noninvasive study, unstable or severe angina, or new or poorly controlled ischemia-mediated heart failure.