Abstract
The American College of Cardiology/American Heart Association (ACC/AHA) and the American
College of Physicians (ACP) have disseminated guidelines to assess preoperative cardiac
risks before noncardiac surgery. The objectives of this study were to determine if
these guidelines differ in preoperative recommendations for a group of patients, and
whether these recommendations differ from actual provider recommendations. In this
retrospective cohort study, patient characteristics and physician recommendations
were abstracted from electronic medical records of consecutive patients attending
a Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1,
1998. Patient characteristics were used to determine what preoperative cardiac testing
should have been ordered if each guideline was followed. Possible recommendations
included operation without testing (OWT), noninvasive stress testing (NST), cardiac
catheterization (CC), or cancel or delay surgery (OTHER). Recommendations were compared
using statistical tests for agreement. Of the 138 patients identified, most underwent
moderate-risk surgeries. Recommendations for preoperative testing were discordant
between guidelines for 17% of patients (κ = 0.38). Guidelines never agreed on the
need for NST. Extreme differences in recommendations (i.e., one recommends OWT, the
other CC) occurred in 9 patients (7%). Physicians ordered NST more often (n = 27)
than either guideline. In this subgroup of patients where providers ordered a NST,
the 2 guidelines significantly differed (κ = 0.26). When applied to real patients
being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in
recommendations for preoperative cardiac testing. Results have implications for implementation,
management, and practitioner adherence to published guidelines.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Attributes of clinical guidelines that influence use of guidelines in general practice.BMJ. 1998; 317: 858-861
- Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery.Ann Intern Med. 2000; 133: 356-359
- Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049
- Outcomes and cost implications of a clinical-based algorithm to guide the discriminate use of stress imaging before noncardiac surgery.Am Heart J. 1997; 134: 83-92
- Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).J Am Coll Cardiol. 1996; 27: 910-948
- ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery–executive summary.J Am Coll Cardiol. 2002; 39: 542-553
- Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery.Ann Intern Med. 1997; 127: 309-312
- Perioperative assessment and management of risk from coronary artery disease.Ann Intern Med. 1997; 127: 313-328
- ACC/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery.Circulation. 1996; 93: 1280-1317
- Exact inference for contingency tables with ordered categories.J Am Stat Assoc. 1990; 85: 453-458
- The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174
- Clinical practice guidelines.Am J Surg. 1997; 173: 32-34
- Evidence-based guidelines and critical pathways for quality improvement.Pediatrics. 1999; 103: 225-232
- Assessing cardiac risk assessment.Arch Intern Med. 2000; 159: 2226-2227
- How physicians can help create useful clinical practice guidelines.Cleve Clin J Med. 1999; 66: 601-605
- Establishing practice guidelines for surgical blood management.Am J Surg. 1995; 170: 16S-20S
- Practice guidelines for practicing doctors.J Gen Intern Med. 1998; 13: 714-715
- Impact of new guidelines on physicians’ ordering of preoperative tests.J Gen Intern Med. 1999; 14: 166-172
- Cardiac risk of noncardiac surgery.N Engl J Med. 1989; 321: 1330-1332
- Do ophthalmologists, anesthesiologists, and internists agree about preoperative testing in healthy patients undergoing cataract surgery?.Arch Ophthal. 1995; 113: 1248-1256
- Supine exercise capacity identifies patients at low risk for perioperative cardiovascular events and predicts long-term survival.Am J Med. 2000; 108: 334-336
- The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery.N Engl J Med. 1999; 341: 1789-1794
- Reducing cardiac risk in noncardiac surgery.N Engl J Med. 1999; 341: 1838-1840
Article info
Publication history
Accepted:
February 24,
2003
Received in revised form:
February 24,
2003
Received:
October 17,
2002
Footnotes
☆Dr. Gordon was supported by a VA Health Services Research and Development Career Development Award (RCD-00038-2) and the Veterans’ Administration VISN-4 Mental Illness Research, Education, and Clinical Center, Washington, DC.
Identification
Copyright
© 2003 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
