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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).
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