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)

Revised Table 5. Prognostic Gradient of Ischemic Responses During an ECG-Monitored Exercise Test*

Patients with suspected or proven CAD
High risk
Ischemia induced by low-level exercise† (less than 4 METs or heart rate less than 100 bpm or less than 70% age predicted) manifested by one or more of the following:

• Horizontal or downsloping ST depression greater than 0.1 mV
• ST-segment elevation greater than 0.1 mV in noninfarct lead
• Five or more abnormal leads
• Persistent ischemic response greater than 3 min after exertion
• Typical angina

Intermediate risk
Ischemia induced by moderate-level exercise* (4 to 6 METs or heart rate 100 to 130 bpm [70 to 85% age predicted) manifested by one or more of the following:

• Horizontal or downsloping ST depression greater than 0.1mV
• Typical angina
• Persistent ischemic response greater than 1 to 3 min after exertion
• Three to four abnormal leads

Low risk
No ischemia or ischemia induced at high-level exercise* (greater than 7 METs or heart rate greater than 130 bpm [greater than 85% age predicted) manifested by:

• Horizontal or downsloping ST depression greater than 0.1 mV
• Typical angina
• One or two abnormal leads

Inadequate test
Inability to reach adequate target workload or heart rate response for age without an ischemic response. For patients undergoing noncardiac surgery, the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test.

ECG indicates electrocardiographically; MET, metabolic equivalent; bpm, beats per minute.
*Based on references 32 and 37-43. †Workload and heart rate estimates for risk severity require adjustment for patient age. Maximum target heart rates for 40- and 80-year-old subjects on no cardioactive medication are 180 and 140 bpm, respectively (32,37-43).