Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery and the 2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular assessment and management

Two sets of clinical practice guidelines (Table 1) were published in 2014 related to the cardiovascular assessment of patients undergoing noncardiac surgery: one endorsed by the American College of Cardiology and the American Heart Association (2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery),1 and the other by the European Society of Cardiology and the European Society of Anaesthesiology (2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular Assessment and Management).2 We have previously summarized the ACC/AHA guidelines in the Journal focusing on the recommendations pertaining to noninvasive imaging and coronary revascularization.3 Since many of our readers are not familiar with both sets of guidelines, we will present here the recommendations from both documents side-by-side (Tables 2, 3, 4, 5, 6, 7). The Class (I, IIa, IIb, III) and the level of evidence (A, B, C) are shown next to each recommendation. We also include a flowchart comparing the stepwise approach of both guidelines toward the evaluation of patients undergoing noncardiac surgery (Figure 1). Our summary will be followed by 2 editorials: The first by Kristensen 4 summarizes the ESC/ESA guidelines focusing on the changes that have been introduced compared to previous versions of these guidelines. The editorial raises awareness to situations where imaging, angiography, and revascularization are and are not indicated in this setting. The second editorial by Port 5 reflects on the similarities and the differences between the 2 sets of guidelines and the implications of these to clinical care. It highlights situations whereby imaging may be indicated by one set of guidelines but not the other. We hope that this new series initiated by the Journal will provide an important service to the imaging community by highlighting the similarities and the differences between the American and the European guidelines and providing a perspective that may not be apparent from reading one set of guidelines.

Table 1 Comparison of ACC/AHA and ESC/ESA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery

Table 2 Recommendations regarding perioperative ECG

Table 3 Recommendations regarding perioperative assessment of left ventricular (LV) function

Table 4 Recommendations regarding stress testing for myocardial ischemia

Table 5 Recommendations regarding coronary angiography

Table 6 Recommendations regarding elective coronary revascularization prior to noncardiac surgery

Table 7 Surgical risk estimate of 30-day cardiovascular risk of myocardial infarction and cardiovascular death according to ESC/ESA guidelines

Figure 1

Comparison of stepwise approach based on AHA/ACC and ESC/ESA guidelines. * Unstable angina, acute hart failure, significant cardiac arrhythmia, symptomatic valvular heart disease, myocaridal infarction within the past 30 days and residual myocardial ischemia. **See Table 6. § Estimation of risk based on the Revised Cardiac Risk Index score or the American College of Surgeons NSQIP risk calculator. ¶ According to the Revised Cardiac Risk Index Score