American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving a favourable clinical outcomeMargherita Cinello a,Gaetano Nucifora a,Massimo Bertolissi b,Luigi P.Badano a, Claudio Fresco a,Nevio Gonano c and Paolo M.Fioretti aObjectives The American College of Cardiology(ACC)and the American Heart Association(AHA)provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery.Even if previously validated as safe and effective in riskstratification,there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines.We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic.Methods One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation(from September2004to May 2005)were enrolled in the study and compared with a historical group of166patients operated from April2002to September2002.Preoperative resources utilization (cardiologic consultations,non-invasive diagnostic tests, coronary angiograms,coronary revascularizations)and clinical events[all-cause death,acute myocardial infarction (AMI)and acute myocardial ischaemia]occurring within 30days after surgical procedure were compared.Results Guidelines implementation reduced preoperative cardiologic consultations by21%(P<0.001)and preoperative non-invasive diagnostic testing by11%(P U0.01),and increased utilization of preoperative b-blockers by13%(P U0.01).Preoperative coronary angiograms(2%versus4%)and coronary revascularizations(3%versus2%)and all-cause death (1%versus2%),AMI(2%versus1%)and acute myocardial ischaemia(4%versus2%)during follow-up were similar in both groups.Conclusions Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization,improved medical treatment and preserved a low rate of perioperative cardiac complications.J Cardiovasc Med8:882–888Q2007 Italian Federation of Cardiology.Journal of Cardiovascular Medicine2007,8:882–888Keywords:ACC/AHA guidelines,anaesthesiologist-led preoperative clinic, cardiac risk stratification,outcome,resource utilization,vascular surgerya Cardiology Unit,Cardiopulmonary Science Department,b Department of Anaesthesiology and Intensive Care andc Vascular Surgery Unit,Surgical Science Department,Azienda Ospedaliero-Universitaria di Udine,Udine,Italy Correspondence and requests for reprints to Gaetano Nucifora,S.O.C.di Cardiologia,Azienda Ospedaliero-Universitaria di Udine,P.le S.Maria della Misericordia15,33100Udine,ItalyTel:+39432552441;fax:+39432482353;e-mail:gnucifora@cardionet.it Received4August2006Revised17October2006Accepted18October2006IntroductionCardiac events are responsible for30–60%of periopera-tive complications and are the cause of postoperative mortality following noncardiac surgery in more than 50%of patients[1–3].Patients undergoing noncardiac vascular surgery are in the highest-risk group.The American College of Cardiology(ACC)and the Ameri-can Heart Association(AHA)provided perioperative evaluation and management guidelines as evidence-based framework for assessing cardiac risk in a variety of patients and surgical situations including vascular surgery[4,5].Previous studies have tested and validated the ACC/AHA guidelines as being safe and effective in stratifying cardiac risk within a variety of vascular and other noncardiac surgical patient populations[6–11]. Nevertheless,there is still a gap between clinical practice and the recommendations of the ACC/AHA guidelines with respect to cardiac investigation of patients scheduled for vascular surgery[12–15].According to these considerations,we conducted a study to assess the effects on perioperative clinical outcome and resource utilization of an ACC/AHA guidelines-based strategy for risk-stratification of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic.The resultsOriginalarticle1558-2027ß2007Italian Federation of Cardiologywere compared with our prior experience of not imple-menting the ACC/AHA guidelines.Our hypothesis was that the application of these guidelines in preoperative evaluations could limit resource utilization with preser-vation of perioperative outcomes.MethodsThe study has been preceded by a multidisciplinary consensus between vascular surgeons,anaesthesiologists and cardiologists of the Azienda Ospedaliero-Universitaria di Udine,Udine,Italy,to strictly implement the ACC/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery [5]in the routine risk assessment performed before all elective vascular surgery procedures.Patients and study interventionFrom September 2004to May 2005,164consecutive patients who were scheduled for elective vascular surgery underwent routine preoperative assessment in a dedicated anaesthesiologist-led preoperative outpatient clinic.All patients received a complete evaluation consisting of medical history,physical examination,electrocardiogram,blood cell count and chemistry,chest roentgenogram,colour and duplex Doppler ultrasonography of the carotid arteries and any further testing deemed necessary by the attending anaesthesiologist,such as spirometry and airway reversibility studies,pulse oximetry and arterial blood gas analysis.During assessment,anaesthesiologists placed particular emphasis on the detection of clinical predictors of increased cardiovascular risk,and ascertaining patients ’functional capacity,as outlined by the ACC/AHA guidelines.According to the algorithm proposed in the ACC/AHA guidelines,a decision was taken as to whether the patient could bene fit from referral to a cardiologist for medical management and risk factor modi fication,non-invasive stress testing or coronary angiography.The attending anaesthesiologist subsequently reviewed the results of additional tests or interventions performed as well as specialist opinions.A decision was then made regarding the feasibility of planned procedure.If the potential bene fits of surgery were felt to outweigh the estimated risks,the patient was listed for surgery.A flow-chart of the study is depicted in Fig.1.Details regarding ACC/AHA guidelines-based decision-making algorithm implemented in the study are reported in the Appendix.To establish baseline clinical practice prior to guideline implementation,we retrospectively studied,by chart review,clinical features,preoperative assessment,preoperative treatment and outcomes in 166consecutive patients who were seen in the preoperative clinic before scheduled elective vascular surgery between April 2002and September 2002.No speci fic protocols for assess-ment of preoperative cardiovascular evaluation before noncardiac surgery were applied in that period.Data collectionDemographic characteristics,risk factors for coronary artery disease,a history of ischemic heart disease,current presence of symptoms or signs of heart disease,type of vascular surgery and risk of surgical procedure as de fined by the ACC/AHA guidelines,preoperative use of b -blocker therapy,preoperative cardiologic consultation and use of preoperative non-invasive diagnostic test,preoperative cardiac catheterization and preoperative percutaneous or surgical coronary revascularization were collected in all patients.A history of ischaemic heart disease was de fined as the presence of previous acute myocardial infarction (AMI),typical angina and percutaneous or surgical coronary revascularization.Effective implementation of the ACC/AHA guidelines in the study group was assessed evaluating the adherence to the ACC/AHA guidelines-based decision-making algorithm (see Appendix).Deaths for all causes,cardiac deaths,AMI and episodes of acute myocardial ischaemia within 30days after surgical procedure were also recorded.Cardiac death was de fined as death from intractable dysrhythmia,cardiogenic shock or AMI;all other postoperative deaths were considered noncardiac.Perioperative AMI was de fined as occurring of suggestive symptoms and/or electrocardiographic ischemic changes in association with an elevation of diagnostic serum cardiac biomarkers.Perioperative myocardial ischemia was diagnosed according to the presence of suggestive symptoms and/or electrocardio-graphic ischemic changes.Study end-points and statistical analysisThe main study end-points were the assessment of preoperative resource utilization (i.e.cardiologicImplementation of the ACC/AHA guidelines for perioperative cardiac risk assessment Cinello et al .883Fig.1REFERRAL FROM SURGICAL CLINIC T OANAESTHESIOLOGIST CLINICRISK STRA TIFICA TION ACCORDING T O ACC/AHA GUIDELINESReferral for cardiological assessment MEDICAL CONDITION OPTIMIZED AND DECISION ON SURGICAL INTERVENTIONSURGERY W HEN APPROPRIA TEAUDIT OF OUTCOME DA T AFlow-chart of the study.For details regarding ACC/AHA guidelines-based decision-making algorithm,see Appendix.consultations,use of preoperative non-invasive cardiac testing,use of preoperative cardiac catheterization and use of percutaneous or surgical preoperative coronary revascularization),adverse cardiac events occurring within30days after surgical procedure(cardiac death, AMI,acute myocardial ischemia)and30-day all-cause deaths.For continuous variables,data were summarized using mean value as a measure of location,and standard deviation as a measure of shape.Percentages were calculated when appropriate.The control and study groups were compared using the chi-square test for discrete variables,Student’s t-test for normally distrib-uted continuous variables,and the Mann–Whitney U-test for non-normally distributed continuous variables.P<0.05was considered statistically signifi-cant.All analyses were performed using SPSS statistical software for Windows,release13.0(SPSS Inc.,Chicago, Illinois,USA).ResultsBaseline demographic and clinical characteristics are shown in Table1.No significant differences were seen between the two groups with respect to age,gender distribution,almost all risk factors for coronary artery disease,history of ischemic heart disease,and current presence of angina or congestive heart failure.Patients in the intervention group were more likely to be active smokers(43%versus29%;P¼0.009).The two groups had undergone similar types of sched-uled vascular surgery and the evaluated risk of surgical procedure also was similar.Table2shows preoperative testing and management for both groups.Guidelines implementation achieved a significant reduction in the utilization of preoperative cardiologic consultations(34%to13%;P<0.001) and preoperative non-invasive diagnostic testing (18%to7%;P¼0.01).The preoperative utilization of b-adrenergic blocker treatment increased significantly (19%to32%;P¼0.01).ACC/AHA guidelines were strictly implemented in156 (95%)patients of the study group.Adverse cardiac events occurring within30days after surgical procedure are shown in Table3.Overall rates of perioperative cardiac complications were similar and infrequent in both groups.Almost all perioperative cardiac complications occurred among patients who were referred for high-risk surgical procedures(Table4).884Journal of Cardiovascular Medicine2007,Vol8No11 Table1Baseline demographic and clinical characteristicsStudy group (n¼164)Control group(n¼166)PAge(years)71Æ874Æ8NS Male sex126(77%)118(71%)NS Hypertension125(76%)111(67%)NS Diabetes62(38%)42(25%)NS Dyslipidemia62(38%)42(25%)NS Smoking70(43%)48(29%)0.009 History of IHD65(40%)75(45%)NS Current angina12(7%)7(4%)NS Current CHF8(5%)1(1%)NS Type of surgeryAortic(abdominal)56(34%)36(22%)NS Carotid68(42%)83(50%)Peripheral vascular40(24%)47(28%)Risk of surgical procedureIntermediate77(47%)86(52%)NS High87(53%)80(48%)Variables are presented as meanÆSD or number(percentages in parentheses). IHD,Ischemic heart disease;CHF,congestive heart failure.Table2Preoperative testing and managementStudy group(n¼164)Control group(n¼166)P Preoperative b-blocker53(32%)32(19%)0.01 Cardiologic consultations22(13%)56(34%)<0.001 Non-invasive diagnostic testing,total11(7%)30(18%)0.012-D rest echocardiography2(1%)13(8%)Exercise ECG stress test2(1%)9(6%) Pharmacological stressmyocardial scintigraphy1(1%)4(2%)Pharmacological stressechocardiography6(4%)4(2%)Coronary angiography3(2%)6(4%)NS PCI2(3%)1(1%)NS CABG01(1%)NSVariables are presented as number(percentages in parentheses).PCI,Percuta-neous coronary intervention;CABG,coronary artery bypass grafting.Table3Adverse cardiac events occurring within30days after surgical procedureStudy group(n¼164)Control group(n¼166)P Cardiac death00NS AMI7(4%)3(2%)NS Acute myocardial ischaemia3(2%)1(1%)NS Cardiac death,AMI or acutemyocardial ischaemia10(6%)4(3%)NS All-cause death2(1%)3(2%)NSVariables are presented as number(percentages in parentheses).AMI,Acute myocardial infarction.Table4Adverse cardiac events occurring within30days after surgical procedure according to the risk of surgical procedureIntermediate risk(n¼163)High risk(n¼167)P Cardiac death00NS AMI0(%)10(6%)0.004 Acute myocardial ischaemia1(1%)3(2%)NS Cardiac death,AMI or acutemyocardial ischaemia1(1%)13(8%)0.003 All-cause death2(1%)3(2%)NSVariables are presented as number(percentages in parentheses).AMI,Acute myocardial infarction.DiscussionThe present study demonstrates that implementation of the ACC/AHA guidelines for cardiac assessment prior to noncardiac surgery[5]in the routine risk assessment performed before elective vascular surgery procedures reduces preoperative cardiologic consultations and non-invasive cardiac diagnostic testing and increases the use of b-blockers therapy, preserving very low cardiac complications rates.This effect was achieved after a multidisciplinary consensus between vascular surgeons,anaesthesiologists and cardiologists to incorporate guidelines-based decision making algorithms into the preoperative evaluation routinely performed in a consultant anaesthesiologist-led preoperative clinic.The prevalence of coronary artery disease in patients undergoing noncardiac vascular surgery and the haemo-dynamic stress often associated with vascular surgery accounts for the increased risk of perioperative myocardial ischemic events observed in previous studies [1–3].Our study population has multiple risk factors for coronary artery disease and a previous history of ischemic heart disease in a large proportion;furthermore,approxi-mately one-half of the patients had scheduled high-risk surgical procedures(i.e.aortic and peripheral vascular surgery).Therefore,these patients constitute a group at potential risk for perioperative cardiac complications. Perioperative assessment for prevention of cardiac com-plications is thus an important task of the anaesthesiologist. An approach based on routine cardiac work-up prior to vascular surgery was shown to be time-consuming, expensive and not completely safe and so cannot be recommended[16,17].Thesefindings created a require-ment for guidance in the preoperative risk-stratification of such patients.A number of risk indices based on a set of clinical risk factors have been therefore developed to estimate the risk of perioperative cardiac complications [18–22]and the ACC and the AHA have developed clinical guidelines for preoperative cardiac risk stratifica-tion on the basis of expert opinion and the best available evidence[4,5].Previous studies have tested and validated the ACC/AHA guidelines as being safe and effective in stratifying cardiac risk within a variety of vascular and other noncardiac surgical patient populations[6–11].Our study confirms these data,although it is not sufficiently powered to detect modest changes in outcomes. Nevertheless,these guidelines are rarely strictly imple-mented[12–15,23–30].Effective implementation of guidelines is not simple;physicians do not always agree with clinical practice guidelines and guideline recommen-dations often do not include all possible clinical scenarios. Thus,these guidelines could be not fully incorporated in clinical practice.Despite these baseline difficulties,a strict implementation of the ACC/AHA guidelines has been achieved in the majority of patients undergoing elective vascular surgery procedures in our study.Previous studies have shown that disagreement between clinical practice and the ACC/AHA guidelines primarily occurs with regard to b-blocker therapy implementation, requests of preoperative cardiologic consultations and performance of non-invasive diagnostic testing[12–15, 23–30].Adequately powered,blinded randomized controlled trials on b-blocker therapy in patients undergoing noncardiac surgery are still lacking[31],but many previous studies have reported a positive association between b-blocker use and a reduction of perioperative cardiovascular mortality and morbidity in patients undergoing noncardiac surgery, irrespective of whether patients were scheduled for high or intermediate-risk surgery[23,32].Furthermore,ACC/ AHA guidelines categorized the use of b-blockers in patients undergoing vascular surgery at high cardiac risk with ischemia detected during preoperative testing as a class I recommendation,and they gave a class IIa recom-mendation to use perioperative b-blocker therapy in patients undergoing vascular surgery with documented coronary artery disease or multiple clinical risk factors [5,25].The mechanisms by which b-blockers exert their perioperative cardioprotective effect are multifactorial. b-blockers decrease the exaggerated sympathetic response during the perioperative period,which is associated with an increased myocardial oxygen demand,heart rate and myocardial contractility[33,34].Furthermore,b-blockers reduce shear stress across atheromatous plaques,thereby decreasing theincidence of plaque rupture and consequent acute coronary thrombosis and reduce the incidence of dysrhythmias[35,36].However,the preoperative use of b-blockers in suitable patients with no contraindications is still too low in the routine clinical practice[24,26].The concerns of anaesthesiologists regarding the applicability of trial data to a particular patient,about prescribing oral medications to patients without scheduled follow-up and about adverse drug effects could explain their reluctance to prescribe b-blockers[24,26].Moreover,concerns still persist that b-blockers could aggravate symptoms of peripheral arterial disease[37];although b-blockers were considered to be relatively contraindicated in patients with peripheral arterial disease,it is now well known that b-blockers(especially b1selective b-blockers and b-blockers with b1-blocking properties)do not adversely affect walking capacity,symptoms of intermittent claudi-cation,and peripheral skin microcirculation[37,38].Our study suggests that specific interventions direct to improve implementation of ACC/AHA guidelines should be performed because they may increase the proportion of patients who receive preoperative b-blockade; however,32%of patients receiving b-blockers in the study group is still suboptimal,despite the scheduledImplementation of the ACC/AHA guidelines for perioperative cardiac risk assessment Cinello et al.885intermediate or high-risk surgical procedure;efforts are needed to further improve preoperative prophylactic b-blockade,as a consequence of its beneficial effects and the recently documented failure of invasive measures to prevent perioperative adverse cardiac events[23, 32,39].Substantial challenges to the effective implementation of ACC/AHA guidelines also remain regarding performance of preoperative cardiologic consultations and preopera-tive non-invasive diagnostic tests to assess cardiac risk before noncardiac surgery.Cardiologic consultations are frequently overused because they do not result in alterations in perioperative testing or management.This small yield stems from frequently non-specific consult requests;as a result, the consultant often makes broadly inclusive,general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not influence the patient’s outcome but pro-longs the hospital stay[27–29].Moreover,practitioners frequently recommend more non-invasive tests than those outlined in the ACC/AHA guidelines[13].Routine use of rest-echocardiography and non-invasive stress tests cannot be recommended because the positive predictive value of these diagnostic modalities is extremely low among this group of patients[40–42].This is particularly true among patients who are at clinical low risk(i.e.those without any identified clinical markers for cardiac com-plications)[12].In this patient group,the guidelines algorithms argue for conservative application of expens-ive tests and treatment;by contrast,stress tests are useful among patients with intermediate or high clinical risk, especially if referred to high-risk surgical procedures [40,43].Some authors have recently suggested that ACC/AHA guidelines have little or no impact on cardiovascular care because their implementation does not modify the frequency of perioperative cardiac complications[15]. The development of ACC/AHA guidelines in patients seen a decade or more ago,when perioperative care, anaesthesia techniques,endovascular and open surgical interventions,and operative mortality were quite different from their current status,could explain this finding[44].However,similarly to other previous studies[12,45,46],our study shows the benefits of the ACC/AHA guidelines.Their institution-wide intro-duction has important economic drawbacks,reducing the number and improving the yield of resource utilization(in particular,cardiologic consultations and non-invasive cardiac diagnostic testing).Ulti-mately,these effects allow delivery of high-quality, cost-effective care that is so important to the safe risk-assessment and delivery of noncardiac surgery in the new millennium.This study has some limitations that should be acknowledged;first,it involves a single institution’s evaluation of guidelines implementation.Second,it is not randomized but used a historical group as control, retrospectively selected by chart review,the limitations of which are well known.Third,it is a low sample size study with reduced statistical power to identify differences in clinical outcome between the two groups.In summary,perioperative risk stratification of patients being considered for noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic is improved when ACC/AHA guidelines-based tools are implemented. 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