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2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation. 2014 Dec 9;130 (24):e278-333. doi: 10.1161/CIR.0000000000000106. Epub 2014 Aug 1.
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ADA Updates Guidelines for Cardiovascular Risk Management in Diabetes. In the new ADA guideline, recommendations were made regarding managing hypertension and blood pressure, abnormal lipid profiles, coronary heart disease, and lifestyle interventions.
2014 AHA/ACC Valvular Heart Disease Guideline: Executive Summary 2473 12.2. Native Valve Regurgitation 12.2.1. Diagnosis and Follow-Up Class I 1. All patients with suspected valve regurgitation should undergo a clinical evaluation and TTE before pregnancy.
Current recommendations for perioperative cardiovascular evaluation and management for noncardiac surgery are based largely on clinical experience and observational studies, with few prospective RCTs.
In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy to represent optimal medical therapy as defined by ACC/AHA guideline (primarily Class I)–recommended therapies.
The focus of this CPG is the perioperative cardiovascular evaluation and management of the adult patient undergoing noncardiac surgery. This includes preoperative risk assessment and cardiovascular testing, as well as (when indicated) perioperative pharmacological (including anesthetic) management and perioperative monitoring that includes devices and biochemical markers. This CPG is intended to inform all the medical professionals involved in the care of these patients. The preoperative evaluation of the patient undergoing noncardiac surgery can be performed for multiple purposes, including 1) assessment of perioperative risk (which can be used to inform the decision to proceed or the choice of surgery and which includes the patient’s perspective), 2) determination of the need for changes in management, and 3) identification of cardiovascular conditions or risk factors requiring longer-term management. Changes in management can include the decision to change medical therapies, the decision to perform further cardiovascular interventions, or recommendations about postoperative monitoring. This may lead to recommendations and discussions with the perioperative team about the optimal location and timing of surgery (eg, ambulatory surgery center versus outpatient hospital, or inpatient admission) or alternative strategies.
In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful. (Level of Evidence: C)
Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs. 95, 96 (Level of Evidence: C) (See Table A in Appendix 3 for related recommendations.)
The emergency use of perioperative transesophageal echocardiogram is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy, if expertise is readily available. (Level of Evidence: C)
In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated attempts at direct-current cardioversion may be made after adjusting the location of the electrodes, applying pressure over the electrodes or following administration of an antiarrhythmic medication.327(Level of Evidence: B)#N#Cardioversion is recommended when a rapid ventricular response to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF. (Level of Evidence: C)#N#Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. (Level of Evidence: C)
AV nodal ablation with permanent pacemaker implantation effectively controls and regularizes ventricular heart rate and , in selected patients, improves symptoms. Patients most likely to benefit include those with tachycardia-induced cardiomyopathy with ventricular rate control refractory to medical therapy. 280, 304 – 307 AV nodal ablation is usually reserved for elderly patients, because it leads to pacemaker dependency. Patients with symptoms refractory to medical therapy who are treated with AV nodal ablation and permanent pacemaker implantation have an improvement in cardiac symptoms, quality of life, and health care utilization. With this approach, no rate-control medications are necessary, but anticoagulation to prevent thromboembolism is required, based on the patient’s stroke risk as assessed by the CHA 2 DS 2 -VASc system. When this approach is under consideration, the patient must receive counseling to understand that this is an irreversible measure that results in a lifelong pacemaker dependency with its potential complications. Time permitting, pacemaker implantation may be performed 4 to 6 weeks before the AV node ablation to ensure proper pacemaker function, because malfunction due to lead dislodgment can be catastrophic. Sudden death secondary to torsades de pointes or ventricular fibrillation has been reported after AV junction ablation. This outcome is possibly related to increased dispersion of ventricular refractoriness produced by sudden heart rate slowing and ventricular pacing. 308 After ablation, the ventricular pacing rate is usually set between 90 bpm and 100 bpm and then gradually tapered over several months. 309, 310 RV apical pacing also creates a ventricular activation sequence that can lead to depressed ventricular function. In patients with left ventricular ejection fraction (LVEF) <35% and symptoms of HF, implantation of a biventricular pacing system is recommended. This procedure should also be considered for patients with less severe ventricular dysfunction. 18 In the BLOCK HF (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block) trial, patients with advanced AV block with LVEF <50% had improved clinical outcomes when treated with a biventricular pacemaker compared with RV apical pacing. 311 An upgrade to a biventricular pacing system should be considered for patients who have undergone AV nodal ablation coupled with an RV pacing system who develop moderate-to-severe LV systolic dysfunction. 312
For patients with AF or atrial flutter of 48 hours’ duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform TEE before cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks.164( Level of Evidence: B)#N#For patients with AF or atrial flutter of 48 hours’ duration or longer or when duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3 weeks before and 4 weeks after cardioversion.230,324,325(Level of Evidence: C)
Other atrial arrhythmias are often encountered in patients with AF. Atrial tachycardias are characterized by an atrial rate of ≥100 beats per minute (bpm) with discrete P waves and atrial activation sequences. Atrial activation is most commonly the same from beat to beat.
Stimulation of the renin-angiotensin-aldosterone system promotes structural and likely electrophysiological effects in the atrium and ventricle that increase arrhythmia susceptibility. 130 – 133 In addition to adverse hemodynamic effects, activation of multiple cell signaling cascades promotes increased intracellular calcium, hypertrophy, apoptosis, cytokine release and inflammation, oxidative stress, and production of growth-related factors that also stimulate fibrosis, as well as possible modulation of ion channel and gap-junction dynamics. Components of the renin-angiotensin-aldosterone system (including angiotensin II, angiotensin-converting enzyme [ACE], and aldosterone) are synthesized locally in the atrial myocardium and are increased during atrial tachypacing and AF. Variants in the ACE gene that increase angiotensin II plasma concentrations can elevate risk of AF, whereas selective cardiac overexpression of ACE causes atrial dilation, fibrosis, and increased susceptibility of AF. Therapy with these agents can reduce the occurrence of AF in patients with hypertension or left ventricular (LV) dysfunction but does not help prevent recurrence of AF in the absence of these other indications for these drugs (Section 6.2.1).
AF catheter ablation is associated with important risks of major complications. A 2010 international survey of radiofrequency catheter ablation procedures reported a 4.5% incidence of major complications, including a 1.3% rate of cardiac tamponade, a 0.94% rate of stroke or TIA, a 0.04% rate of atrial-esophageal fistula, and a 0.15% rate of death. 433 A European observational multinational registry reported a complication rate of 7.7%, of which 1.7% were major complications. 434 A report from a statewide inpatient database described a complication rate of 5% with a 9% readmission rate. 435 Much of the data on rates of complications is derived from experienced centers or voluntary registries.
For patients with AF or atrial flutter of less than 48 hours’ duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by long-term anticoagulation therapy.
The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is generally a useful tool to estimate 10-year risk of a first ASCVD event (available online at tools.acc.org/ASCVD-Risk-Estimator-Plus ).
10.34 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. A
The American Diabetes Association (ADA) has published its 2018 Clinical Standards of Medical Care guidelines focused on recommendations for the identification and management of cardiovascular (CV) risk factors in patients with diabetes.
Diabetes patients should have blood pressure measured at each routine visit as well as at home and multiple readings on separate days should be used to identify hypertension (≥140/90 mm Hg; Grade B recommendation).
The utilization of the ADA’s 2018 recommendations may hold both clinical and economic benefits, considering that “ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral artery disease, is the leading cause of morbidity and mortality in persons with diabetes and is the largest contributor to the direct and indirect costs of diabetes.”