Implementation of the ACC/AHA Guidelines for Preoperative Cardiac Risk Assessment in a General Medicine Preoperative Clinic: Improving Efficiency and Preserving Outcomes

Abstract

Background: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic. Methods: The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic. Results: Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p < 0.001) and hospital length of stay (6.5 days before, 5.6 days after; p = 0.055). β-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p < 0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p < 0.001). Conclusions: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and β-blocker therapy while preserving a low rate of cardiac complications.

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

“…64,65 It should be noted that this algorithm was not derived from a prospective study; rather, it was derived from the interpretation of data from various studies and the judgments of the committee members. 66 The few studies that have evaluated the reliability of the ACC/AHA algorithm have limitations: they had few cardiac events; they failed to demonstrate that the algorithm is effective in stratifying cardiac risk across the 3 strata proposed in the algorithm; and they did not compare the predictive accuracy of the ACC/AHA algorithm with the most accurate clinical risk indices (i.e., the Lee and Detsky indices).…”

Adherence to acc/aha guidelines on pre-operative assessment of cardiac patients for non-cardiac surgery: an audit of 100 consecutive cases

“…They found that guidelines implementation reduced preoperative noninvasive diagnostic testing by 11% (P=0.01) and preserved a low rate of peri-operative cardiac complications. 7 Almanaseer 8 Hoeks S E conducted a survey to determine adherence to the ACC/AHA guidelines 2002 on peri-operative care in daily clinical practice. This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice.…”

Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)—a cohort study

“…26 Consensus statements on cardiac risk stratification including who should undergo screening and revascularisation and management of patients with implanted cardiac stents have been developed and widely disseminated. [27][28][29] Perhaps this focus and attention on identifying and intervening on cardiac risk has mitigated the associations of smoking-related cardiovascular events with mortality, in both smokers and never smokers. Similar attention has not been given to preoperative risk stratification for postoperative pulmonary events.…”