2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation Are Usually Incorrectly Applied by Anesthesiology Residents Evaluating Simulated Patients

Abstract

The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the accepted standard for perioperative cardiac evaluation. Anesthesiology training programs are required to teach these algorithms. We estimated the percentage of residents nationwide who correctly applied suggested testing algorithms from the ACC/AHA guidelines when they evaluated simulated patients in common clinical scenarios. Anesthesiology resident volunteers at 24 training programs were presented with 6 scenarios characterized by surgical procedure, patient's risk factors, and patient's functional capacity. Scenarios and 5 possible recommendations per scenario were both presented in randomized orders. Senior anesthesiologists at 24 different United States training programs along with the first author of the 2007 ACC/AHA guidelines validated the appropriate recommendation to this web-based survey before distribution. The 548 resident participants, representing 12% of anesthesiology trainees in the United States, included 48 PGY-1s (preliminary year before anesthesia training), 166 Clinical Anesthesia Year 1 (CA-1) residents, 161 CA-2s, and 173 CA-3s. For patients with an active cardiac condition, the upper 95% confidence bound for the percent of residents who recommended evaluations consistent with the guidelines was 78%. However, for the remaining 5 scenarios, the upper 95% confidence bound for the percent of residents with an appropriate recommendation was 46%. The results show that fewer than half of anesthesiology residents nationwide correctly demonstrate the approach considered the standard of care for preoperative cardiac evaluation. Further study is necessary to elucidate the correct intervention(s), such as use of decision support tools, increased clarity of guidelines for routine use, adjustment in educational programs, and/or greater familiarity of responsible faculty with the material.