Circulation Journal JCS GUIDELINES Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2008) – Digest Version – JCS Joint Working Group Table of Contents Introduction to the Revised Guidelines ·············· 989 4. Adults With Congenital Heart Disease ·················· 1000 I Outline ······································································· 990 5. Aortic Diseases ····················································· 1001 1. Outline of Diagnosis and Evaluation ······················· 990 6. Peripheral Arterial Disease 2. Outline of General Management ····························· 992 (Abdomen, Neck, and Lower Extremities) ············ 1003 3. Pregnancy/Delivery and Heart Disease ·················· 994 7. Pulmonary Artery Disease ···································· 1004 8. Idiopathic Cardiomyopathy ··································· 1005 II Descriptions ··························································· 996 9. Arrhythmias ··························································· 1005 1. Ischemic Heart Disease ·········································· 996 References ································································ 1007 2. Valvular Heart Disease ··········································· 998 3. Treatment of Congenital Heart Disease Before Corrective Surgery ·················································· 999 (Circ J 2011; 75: 989 – 1009) Introduction to the Revised Guidelines As the population ages, more elderly patients are undergo- Class I: Conditions for which there is evidence for and/or ing surgery. An increasing number of patients with heart general agreement that the procedure/treatment is disease are undergoing noncardiac surgery, and guidelines useful. for perioperative cardiovascular evaluation and management Class II: Conditions for which there is conflicting evidence for patients undergoing noncardiac surgery have become nec- regarding the usefulness of a procedure/treatment. essary. The Committee on Preparation for “the Guidelines for Class IIa: Weight of opinion is in favor of usefulness. Perioperative Cardiovascular Evaluation and Management Class IIb: Usefulness is less well established by evidence. for Noncardiac Surgery”, which was established in 2001 at the Class III: Conditions for which there is evidence and general request of the Scientific Committee of the Japanese Circula- agreement that a procedure/treatment is not useful. tion Society, published the first edition of the guidelines in 2002. Five years have passed since the release of the first edition While the ACC/AHA Guidelines for Perioperative Cardio- of the guidelines, during which time surgical treatment has vascular Evaluation for Noncardiac Surgery highlighted the become more common among elderly patients and the diag- perioperative management of patients with ischemic heart nostic and treatment techniques for heart disease have further disease, our guidelines were intended to comprehensively advanced. The guidelines were thus revised to reflect these describe ischemic heart disease and other common heart dis- changes. eases which physicians often encounter during noncardiac In the present edition, we added to and substantially revised surgery, and include risk management during pregnancy and the descriptions about the role of percutaneous coronary in- delivery. In the present guidelines, the evidence and general tervention (PCI), focusing on drug eluting stents (DES), and agreement on the efficacy of diagnostic and treatment pro- aortic stent grafts during the treatment of patients undergoing cedures are classified into Class I to III to help practitioners noncardiac surgery. The descriptions of other cardiovascular use the guidelines efficiently. diseases were also revised to reflect new findings. Released online March 18, 2011 Mailing address: Scientific Committee of the Japanese Circulation Society, 8th Floor CUBE OIKE Bldg., 599 Bano-cho, Karasuma Aneyakoji, Nakagyo-ku, Kyoto 604-8172, Japan. E-mail: [email protected] This English language document is a revised digest version of Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery reported at the Japanese Circulation Society Joint Working Groups performed in 2007 (website: http://www. j-circ.or.jp/guideline/pdf/JCS2008_kyo_d.pdf). Joint Working Groups: The Japanese Circulation Society, The Japanese Coronary Association, The Japanese Association for Thoracic Sur- gery, The Japan Surgical Society, The Japanese Society of Pediatric Cardiology and Cardiac Surgery, The Japanese Society for Cardio- vascular Surgery, The Japanese College of Cardiology, The Japanese Heart Failure Society, The Japanese Society of Anesthesiologists ISSN-1346-9843 doi: 10.1253/circj.CJ-88-0009 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected] Circulation Journal Vol.75, April 2011 990 JCS Joint Working Group However, it is quite difficult to conduct prospective ran- obtained in this area of study described in the present guide- domized clinical studies in patients undergoing surgery, who lines may include many biases, as in the case of the first are often in critical condition, and the data from such studies edition. are also limited in many countries. Please note that the data I Outline plications by scoring of relevant factors such as the Cardiac 1. Outline of Diagnosis and Evaluation Risk Index System (CRIS) in Table 2 have been proposed.8 In order to determine treatment strategies of noncardiac sur- (2) Preoperative Evaluation gery and obtain information necessary to ensure safe surgery, In principle, preoperative cardiovascular evaluation should history taking and physical examination should be performed be performed using noninvasive techniques. However, Holter to identify patients in whom the risk for cardiovascular com- ECG and echocardiography are not useful in evaluating the plications is high, and diagnosis and evaluation should then risk of perioperative myocardial infarction. Appropriate tech- be performed. Physicians should at this point also consider niques must be used, even if they are invasive. In addition, the long-term risk of cardiovascular disease as well. In gen- there is little pathological significance to a slight increase in eral, the risk for cardiac complications is high among patients cardiothoracic ratio that results from horizontal position of with a marked decrease in exercise capacity (≤ 4 metabolic the heart due to obesity or other causes, or a single supraven- equivalents [METs]), and careful evaluation of such patients tricular extrasystole, ectopic sinus rhythm, atrial fibrillation, is often necessary. a single unifocal ventricular extrasystole, or first degree atrio- ventricular block in patients with excellent exercise capacity. (1) Risk Classification Unnecessary examinations should be avoided. Since the inci- The risk factors for cardiac complications during the peri- dence of serious complications of invasive examinations such operative period are classified as shown inTable 1.1–7 Patients as cardiac catheterization and cervical angiography is about with major risk factors require intensive care during the peri- 1%,9,10 such examinations must be reserved for patients in operative period. In some cases, non-urgent noncardiac sur- whom the results of examination will significantly contribute gery must be postponed or cancelled in patients with major to the improvement of prognosis and results of noncardiac risk factors. Systems to predict the incidence of cardiac com- surgery. Table 3 lists the criteria for indication of preopera- Table 1. Risk Factors for Cardiac Complications During Table 2. Cardiac Risk Index System (CRIS) the Perioperative Period of Noncardiac Surgery Points 1) Major risk factors History Age >70 years 5 • Unstable coronary artery disease Myocardial infarction in previous 10 Myocardial infarction occurring 7 to 30 days before surgery 6 months with clinical signs/symptoms and laboratory findings of myocardial ischemia detectable on noninvasive examina- Aortic stenosis 3 tions, unstable angina, or severe angina (Canadian Class Physical S3 gallop, jugular venous distention, 11 III or IV angina) examination or congestive heart failure • Decompensated congestive heart failure ECG Rhythm other than sinus 7 • Severe arrhythmias >5 PVC/min 7 Advanced atrioventricular block General status and PaO2 <60 mmHg 3 Symptomatic ventricular arrhythmia laboratory findings Supraventricular arrhythmia associated with abnormal ven- PaCO2 >50 mmHg 3 tricular rates Potassium <3 mEq/L 3 • Severe valvular disease BUN >50 mg/dL 3 2) Intermediate risk factors Creatinine >3 mg/dL 3 • Mild angina (Canadian Class I or II angina) Bedridden 3 • History of myocardial infarction with abnormal Q waves Surgery Emergency 4 • History of compensated congestive heart failure or conges- Intrathoracic 3 tive heart failure Intraabdominal 3 • Diabetes mellitus Aortic 3 • Renal failure Incidence of cardiac complications 3) Mild risk factors Class I (0 to 5 points): 1%, Class II (6 to 12 points): 5%, • Advanced age Class III (13 to 25 points): 11%, Class IV (>– 26 points): 22% • Abnormal ECG (left ventricular hypertrophy, left bundle PVC, premature ventricular contraction; PaO2, partial pressure of branch block, ST-T abnormalities) arterial oxygen; PaCO2, partial pressure of arterial carbon dioxide; • Rhythm other than sinus BUN,