Guideline:
Additional perioperative assessment
Bibliographic Source(s)
- Committee on Perioperative Evaluation (CAPO) Brazilian Society of Cardiology. Additional perioperative assessment. In: I guidelines for perioperative evaluation. Arq Bras Cardiol 2007;89(6):e194-7. [20 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Prevention
Risk Assessment
Intended Users
Physicians
Guideline Objective(s)
- To refine and unify the terminology used by the entire multidisciplinary team including the patients and their family
- To establish new routines change indication for surgery according to the information obtained during the perioperative evaluation
Target Population
Any patient who requires surgery
Interventions and Practices Considered
- Circumstances for requesting non-invasive cardiac testing
- Resting left ventricular function testing (transthoracic echocardiography nuclear ventriculography contrast ventriculography)
- Exercise electrocardiography
- Myocardial scintigraphy with and without pharmacologic stress testing (e.g. dobutamine dipyridamole) as appropriate
- Dobutamine stress echocardiography
- Holter monitor (routine use not recommended)
- Coronary cineangiography (routine use not recommended)
Major Outcomes Considered
- Perioperative adverse coronary event rate
- Perioperative cardiovascular complications
- Perioperative cardiovascular mortality
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
- Sufficient evidence from multiple randomized trials or meta-analyses
- Limited evidence from single randomized trial or non-randomized studies
- Evidence only from case reports and series
- Expert opinion or standard of care
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The participants of these guidelines were chosen among health sciences specialists with hands on and academic experience thus being characterized as clinical researchers.
The adopted methodology and evidence levels were the same as those used in earlier documents by the Brazilian Society of Cardiology.
Recommendations
- The guidelines must be based on evidences.
- Class division must be used when applicable.
- Degrees of recommendation must be used when applicable according to the levels of evidence.
Rating Scheme for the Strength of the Recommendations
Degree or Class of Recommendation
Class I: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb: Usefulness/efficacy is less well established by evidence/opinion
Class III: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmful
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
The definitions for levels of evidence (A-D) and classes of recommendation (I-III) are provided at the end of the "Major Recommendations" field.
Non-invasive Testing
Moderate-risk patients who will be submitted to vascular surgeries should always have a non-invasive test to detect myocardial ischemia (Class I Level of evidence D).
Recommendations for Requesting Non-invasive Tests
Class I
- Indicated for patients with intermediate clinical predictors and who will be submitted to vascular surgeries
Class IIa
- Indicated when at least two of the three items below are present
- Presence of angina functional classes I or II history of myocardial infarction or pathological Q wave previous or compensated heart failure diabetes mellitus or renal failure
- Low functional capacity: less than 4 maximum exercise tolerance units (METs)
- High-risk surgeries: peripheral vascular surgeries or aortic surgery lengthy surgeries with considerable blood loss or shifts in body fluids
Class IIb
- Indicated for patients who have not undergone functional testing in the previous two years and who have
- Coronary artery disease or
- At least two risk factors for coronary artery disease (CAD) (hypertension smoking dyslipidemia diabetes mellitus positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test.
Recommendations for Analyzing Resting Left Ventricular (LV) Function
Class I
- Clinical suspicion of aortic stenosis; Level of Evidence B
Class IIa
- Patients with congestive heart failure (CHF) without previous assessment of ventricular function; Level of Evidence D
- Grade III obesity; Level of Evidence D
- Preoperative assessment of liver transplant; Level of Evidence D
Class IIb
- Detection of valvular heart disease; Level of Evidence B
Class III
- Routinely for all patients; Level of Evidence D
Recommendations for Requesting a Perioperative Exercise Electrocardiogram
Class IIa
- Indicated when the two factors below are present
- Presence of intermediate clinical predictors of risk: angina functional class I or II history of myocardial infarction or pathological Q wave previous or compensated heart failure diabetes mellitus or renal failure
- High-risk surgery: aortic or peripheral vascular surgeries lengthy surgeries with considerable blood loss or shifts in body fluids
Class IIb
- Indicated for patients without a functional assessment in the previous two years and
- Known to have coronary artery disease
- With at least two risk factors for CAD (hypertension smoking dyslipidemia diabetes mellitus positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test
- Routinely for all patients
Dobutamine Stress Echocardiography
Evidences indicate that low-risk patients will not benefit from non-invasive tests unless their functional capacity is low (<4METs) and they are candidates for high-risk surgeries (Level of Evidence B). On the other hand patients with 3 or more minor clinical predictors should be considered intermediate-risk patients. (Level of Evidence D) All patients with intermediate risk for cardiac events and low functional capacity (<4METs) and those with good or excellent functional capacity (>4METs) who will be submitted to high-risk surgeries (Level of Evidence B) must undergo stress echocardiography. Consider doing a coronary cineangiography in patients with major clinical predictors for cardiovascular events. (Level of Evidence B).
Recommendations for Stress Echocardiography/Stress Myocardial Perfusion Scintigraphy
Class I
- Indicated for intermediate-risk patients who will be submitted to vascular surgeries
Class IIa
- Indicated when at least two of the following factors are present
- Presence of intermediate clinical predictors of risk: angina functional class I or II history of myocardial infarction or pathological Q wave previous or compensated heart failure diabetes mellitus or renal failure
- Low functional capacity: below 4 METs
- High-risk surgeries: peripheral vascular or aortic surgeries lengthy surgeries with considerable blood loss or shifts of body fluids
Class IIb
- Indicated for patients who have not been submitted to functional assessment in the previous two years and
- Known to have coronary artery disease
- With at least two risk factors for CAD (hypertension smoking dyslipidemia diabetes mellitus positive family history)
Class III
- In patients who are not candidates for myocardial revascularization and whose non-cardiac surgical plan cannot be changed because of the results of a functional test
- Routinely for all patients
Recommendations for Coronary Cineangiography
Class I
- High-risk non-invasive test
- Presence of major clinical predictors
- High-risk acute coronary syndrome
- Positive non-invasive test with proven ischemia and LV dysfunction
Class IIa
- Low- or moderate-risk non-invasive test with preserved ventricular function
Class III
- Patients who are not candidates for myocardial revascularization
Definitions:
Levels of Evidence
- Sufficient evidence from multiple randomized trials or meta-analyses
- Limited evidence from single randomized trial or non-randomized studies
- Evidence only from case reports and series
- Expert opinion or standard of care
Class of Recommendation
Class I: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb: Usefulness/efficacy is less well established by evidence/opinion
Class III: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmful
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for most of the recommendations (see the "Major Recommendations" field).
Potential Benefits
- Effective use of perioperative cardiovascular testing
- Reduction of risk for perioperative cardiovascular complications and mortality
- Prevention of perioperative cardiovascular complications
- Prevention of perioperative cardiovascular mortality
Potential Harms
Not stated
Contraindications
Patients with aortic aneurysms should not be submitted to dobutamine or exercise stress whereas dipyridamole should be avoided in the presence of bilateral carotid stenosis greater than 70%.
Qualifying Statements
- Data or scientific evidences are not always available to allow all the different situations to be analyzed. As customary in medical practice minute analysis of the patient and problem and the common sense of the team must prevail.
- The surgical intervention does not finish when the patient is bandaged or leaves the operating room. The concept of the word perioperative includes the need for a postoperative surveillance whose intensity is determined by the individual level of risk of the patient.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Safety
Bibliographic Source(s)
- Committee on Perioperative Evaluation (CAPO) Brazilian Society of Cardiology. Additional perioperative assessment. In: I guidelines for perioperative evaluation. Arq Bras Cardiol 2007;89(6):e194-7. [20 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Brazilian Society of Cardiology
Guideline Committee
Not stated
Composition of Group that Authored the Guideline
Writing Committee Members: Danielle Menosi Gualandro; Claudio Pinho; Gilson Feitosa; Bruno Caramelli
Task Force Members: Alina Coutinho Rodrigues Feitosa; Beatriz Ayub; Bruno Caramelli; Carisi A. Polanczyk; Carolina L. Zilli Vieira; Claudio Pinho; Daniela Calderaro; Danielle Menosi Gualandro; Denise Iezzi; Dirk Schreen; Dimas T. Ikeoka; Elbio Antonio D'Amico; Elcio Pfeferman; Emerson Quintino de Lima; Emmanuel de Almeida Burdmann; Fábio Santana Machado; Filomena Regina Barbosa Gomes Galas; Gilson Soares Feitosa-Filho; Heno Ferreira Lopes; Henrique Pachón; João César Nunes Sbano; José Augusto Soares Barreto Filho; José L. Andrade; Roberto Henrique Heinisch; Luciana Moraes dos Santos; Luciana S. Fornari; Ludhmila Abrahão Hajjar; Luis Eduardo P. Rohde; Luiz Francisco Cardoso; Marcelo Luiz Campos Vieira; Maristela C. Monachini; Pai Ching Yu; Paula Ribeiro Villaça; Paulo Grandini; Renato S. Bagnatori; Roseny dos Reis Rodrigues; Sandra F. Menosi Gualandro; Walkiria Samuel Avila; Wilson Mathias Jr.
Support: Committee on Perioperative Evaluation (CAPO) Brazilian Society of Cardiology
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Journal of Arquivos Brasileiros de Cardiologia.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on June 3 2008. The information was verified by the guideline developer on July 2 2008.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. For reproduction of these guidelines please contact Bruno Caramelli Comissão de Avaliacão Perioperatória da Brasileira de Cardiologia – CAPO Alameda Santos 705 - 11° andar São Paulo SP Brazil CEP: 01419-001.
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