New appropriate use criteria offer framework for preop cardiac testing

A group of cardiology societies, led by the American College of Cardiology (ACC), released criteria to guide the use of imaging in preoperative cardiovascular evaluations.

The new appropriate use criteria were developed by the ACC, the American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons and published by JACC on Aug. 26

The criteria are meant to guide care for patients undergoing nonemergent, noncardiac surgery and offer a framework to assess the value of imaging by the presence or absence of underlying cardiac disease or altered functional status and type of surgical procedure. For 182 clinical scenarios, an expert panel rated the appropriateness of tests on a scale of 1 to 9. The tests included various types of echocardiograms with or without stress, electrocardiograms (EKGs), coronary calcium scoring, coronary angiography, chest CT, myocardial perfusion imaging (MPI), and MRI.

For patients with no known or suspected heart disease and no new or worsening symptoms and good functional status (≥4 metabolic equivalents), imaging is only suggested as potentially appropriate before high-risk surgeries (echo for nonvascular surgery, echo and stress EKG for vascular surgery). For patients with lower functional status, stress echo and MPI may be appropriate before intermediate-risk nonvascular surgery, echo and all stress tests (except EKG) may be appropriate before intermediate-risk vascular surgery, and echo and all stress modalities may be appropriate before all high-risk surgeries. More complex recommendations are offered for patients with known or suspected heart disease or recent cardiovascular testing.

“Preoperative risk assessment has become a part of the daily practice of many medical professionals, and having a concise, accurate, and easy-to-use framework to guide appropriate

imaging selection prior to nonemergent noncardiac surgery can be extremely useful,” the document said. “However, we acknowledge that not all patients are the same and local and institutional expertise may influence the choice of imaging modality in preoperative assessment, particularly for those undergoing solid organ transplantation. There is conflicting evidence on the utility of preoperative imaging for risk assessment in patients undergoing noncardiac surgery. This document aims to assist clinicians in determining a reasonable course in the evaluation of patients incorporating functional status, signs and symptoms, type of surgery, and prior imaging studies.”