2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

Abstract

HomeCirculationVol. 130, No. 242014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUB2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Lee A. Fleisher, MD, FACC, FAHA, Kirsten E. Fleischmann, MD, MPH, FACC, Andrew D. Auerbach, MD, MPH, Susan A. Barnason, PhD, RN, FAHA, Joshua A. Beckman, MD, FACC, FAHA, FSVM, Biykem Bozkurt, MD, PhD, FACC, FAHA, Victor G. Davila-Roman, MD, FACC, FASE, Marie D. Gerhard-Herman, MD, Thomas A. Holly, MD, FACC, FASNC, Garvan C. Kane, MD, PhD, FAHA, FASE, Joseph E. Marine, MD, FACC, FHRS, M. Timothy Nelson, MD, FACS, Crystal C. Spencer, JD, Annemarie Thompson, MD, Henry H. Ting, MD, MBA, FACC, FAHA, Barry F. Uretsky, MD, FACC, FAHA, FSCAI and Duminda N. Wijeysundera, MD, PhD, Evidence Review Committee Chair Lee A. FleisherLee A. Fleisher *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Kirsten E. FleischmannKirsten E. Fleischmann *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Andrew D. AuerbachAndrew D. Auerbach *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Susan A. BarnasonSusan A. Barnason *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Joshua A. BeckmanJoshua A. Beckman *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Biykem BozkurtBiykem Bozkurt *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Victor G. Davila-RomanVictor G. Davila-Roman *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Marie D. Gerhard-HermanMarie D. Gerhard-Herman *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Thomas A. HollyThomas A. Holly *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Garvan C. KaneGarvan C. Kane *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Joseph E. MarineJoseph E. Marine *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , M. Timothy NelsonM. Timothy Nelson *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Crystal C. SpencerCrystal C. Spencer *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Annemarie ThompsonAnnemarie Thompson *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Henry H. TingHenry H. Ting *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author , Barry F. UretskyBarry F. Uretsky *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡Society for Vascular Medicine Representative. §ACC/AHA Task Force on Practice Guidelines Liaison. ‖American Society of Nuclear Cardiology Representative. ¶American Society of Echocardiography Representative. #Heart Rhythm Society Representative. **American College of Surgeons Representative. ††Patient Representative/Lay Volunteer. ‡‡American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. §§ACC/AHA Task Force on Performance Measures Liasion. ‖‖Society for Cardiovascular Angiography and Interventions Representative. ¶¶Former Task Force member; current member during the writing effort. Search for more papers by this author and Duminda N. WijeysunderaDuminda N. Wijeysundera Search for more papers by this author Originally published1 Aug 2014https://doi.org/10.1161/CIR.0000000000000105Circulation. 2014;130:2215–2245Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 Table of ContentsPreamble 2216Introduction 22171.1. Methodology and Evidence Review 22171.2. Organization of the GWC 22181.3. Document Review and Approval 22181.4. Scope of the CPG 22191.5. Definitions of Urgency and Risk 2219Clinical Risk Factors: Recommendations 22202.1. Valvular Heart Disease 22202.2. Other Clinical Risk Factors 2221Approach to Perioperative Cardiac Testing 22213.1. Multivariate Risk Indices: Recommendations 22213.2. Stepwise Approach to Perioperative Cardiac Assessment: Treatment Algorithm 2221Supplemental Preoperative Evaluation: Recommendations 22214.1. The 12-Lead Electrocardiogram 22214.2. Assessment of Left Ventricular Function 22234.3. Exercise Testing 22234.4. Noninvasive Pharmacological Stress Testing Before Noncardiac Surgery 22244.5. Preoperative Coronary Angiography 2224Perioperative Therapy: Recommendations 22245.1. Coronary Revascularization Before Noncardiac Surgery 22245.2. Timing of Elective Noncardiac Surgery in Patients With Previous PCI 22245.3. Perioperative Beta-Blocker Therapy 22265.4. Perioperative Statin Therapy 22275.5. Alpha-2 Agonists 22275.6. Angiotensin-Converting Enzyme Inhibitors 22275.7. Antiplatelet Agents 22275.8. Perioperative Management of Patients With CIEDs 2228Anesthetic Consideration and Intraoperative Management: Recommendations 22286.1. Choice of Anesthetic Technique and Agent 22286.2. Intraoperative Management 2229Surveillance and Management for Perioperative MI: Recommendations 2229Future Research Directions 2230Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2237Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2239Appendix 3. Related Recommendations From Other CPGs 2244References 2230PreambleThe American College of Cardiology (ACC) and the American Heart Association (AHA) are committed to the prevention and management of cardiovascular diseases through professional education and research for clinicians, providers, and patients. Since 1980, the ACC and AHA have shared a responsibility to translate scientific evidence into clinical practice guidelines (CPGs) with recommendations to standardize and improve cardiovascular health. These CPGs, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.In response to published reports from the Institute of Medicine1,2 and the ACC/AHA’s mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Practice Guidelines (Task Force) began modifying its methodology. This modernization effort is published in the 2012 Methodology Summit Report3 and 2014 perspective article.4 The latter recounts the history of the collaboration, changes over time, current policies, and planned initiatives to meet the needs of an evolving health-care environment. Recommendations on value in proportion to resource utilization will be incorporated as high-quality comparative-effectiveness data become available.5 The relationships between CPGs and data standards, appropriate use criteria, and performance measures are addressed elsewhere.4Intended Use—CPGs provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but CPGs developed in collaboration with other organizations may have a broader target. Although CPGs may be used to inform regulatory or payer decisions, the intent is to improve quality of care and be aligned with the patient’s best interest.Evidence Review—Guideline writing committee (GWC) members are charged with reviewing the literature; weighing the strength and quality of evidence for or against particular tests, treatments, or procedures; and estimating expected health outcomes when data exist. In analyzing the data and developing CPGs, the GWC uses evidence-based methodologies developed by the Task Force.6 A key component of the ACC/AHA CPG methodology is the development of recommendations on the basis of all available evidence. Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only selected references are cited in the CPG. To ensure that CPGs remain current, new data are reviewed biannually by the GWCs and the Task Force to determine if recommendations should be updated or modified. In general, a target cycle of 5 years is planned for full revision.1The Task Force recognizes the need for objective, independent Evidence Review Committees (ERCs) to address key clinical questions posed in the PICOTS format (P=population; I=intervention; C=comparator; O=outcome; T=timing; S=setting). The ERCs include methodologists, epidemiologists, clinicians, and biostatisticians who systematically survey, abstract, and assess the quality of the evidence base.3,4 Practical considerations, including time and resource constraints, limit the ERCs to addressing key clinical questions for which the evidence relevant to the guideline topic lends itself to systematic review and analysis when the systematic review could impact the sense or strength of related recommendations. The GWC develops recommendations on the basis of the systematic review and denotes them with superscripted “SR” (ie, SR) to emphasize support derived from formal systematic review.Guideline-Directed Medical Therapy—Recognizing advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force designated the term “guideline-directed medical therapy” (GDMT) to represent recommended medical therapy as defined mainly by Class I measures—generally a combination of lifestyle modification and drug- and device-based therapeutics. As medical science advances, GDMT evolves, and hence GDMT is preferred to “optimal medical therapy.” For GDMT and all other recommended drug treatment regimens, the reader should confirm the dosage with product insert material and carefully evaluate for contraindications and possible drug interactions. Recommendations are limited to treatments, drugs, and devices approved for clinical use in the United States.Class of Recommendation and Level of Evidence—Once recommendations are written, the Class of Recommendation (COR; ie, the strength the GWC assigns to the recommendation, which encompasses the anticipated magnitude and judged certainty of benefit in proportion to risk) is assigned by the GWC. Concurrently, the Level of Evidence (LOE) rates the scientific evidence supporting the effect of the intervention on the basis of the type, quality, quantity, and consistency of data from clinical trials and other reports (Table 1).4Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceRelationships With Industry and Other Entities—The ACC and AHA exclusively sponsor the work of GWCs, without commercial support, and members volunteer their time for this activity. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All GWC members and reviewers are required to fully disclose current industry relationships or personal interests, from 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced GWC and requires that both the chair and a majority of GWC members have no relevant RWI (see Appendix 1 for the definition of relevance). GWC members are restricted with regard to writing or voting on sections to which their RWI apply. In addition, for transparency, GWC members’ comprehensive disclosure information is available as an online supplement. Comprehensive disclosure information for the Task Force is also available at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, genders, ethnicities, intellectual perspectives/biases, and scopes of clinical practice. Selected organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators.Individualizing Care in Patients With Associated Conditions and Comorbidities—The ACC and AHA recognize the complexity of managing patients with multiple conditions, compared with managing patients with a single disease, and the challenge is compounded when CPGs for evaluation or treatment of several coexisting illnesses are discordant or interacting.7 CPGs attempt to define practices that meet the needs of patients in most, but not all, circumstances and do not replace clinical judgment.Clinical Implementation—Management in accordance with CPG recommendations is effective only when followed; therefore, to enhance the patient’s commitment to treatment and compliance with lifestyle adjustment, clinicians should engage the patient to participate in selecting interventions on the basis of the patient’s individual values and preferences, taking associated conditions and comorbidities into consideration (eg, shared decision making). Consequently, there are circumstances in which deviations from these CPGs are appropriate.The recommendations in this CPG are the official policy of the ACC and AHA until they are superseded by a published addendum, focused update, or revised full-text CPG. The reader is encouraged to consult the full-text CPG8 for additional guidance and details about perioperative cardiovascular evaluation and noncardiac surgery, because the executive summary contains mainly the recommendations.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this CPG are, whenever possible, evidence based. In April 2013, an extensive evidence review was conducted, which included a literature review through July 2013. Other selected references published through May 2014 were also incorporated by the GWC. Literature included was conducted in human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this CPG. The relevant data are included in evidence tables in the Data Supplement available online. Key search words included but were not limited to the following: anesthesia protection; arrhythmia; atrial fibrillation; atrioventricular block; bundle branch block; cardiac ischemia; cardioprotection; cardiovascular implantable electronic device; conduction disturbance; dysrhythmia; electrocardiography; electrocautery; electromagnetic interference; heart disease; heart failure; implantable cardioverter-defibrillator; intraoperative; left ventricular ejection fraction; left ventricular function; myocardial infarction; myocardial protection; National Surgical Quality Improvement Program; pacemaker; perioperative; perioperative pain management; perioperative risk; postoperative; preoperative; preoperative evaluation; surgical procedures; ventricular premature beats; ventricular tachycardia; and volatile anesthetics.An independent ERC was commissioned to perform a systematic review of a critical question, the results of which were incorporated into this CPG. See the systematic review report published in conjunction with this CPG9 and its respective data supplements.1.2. Organization of the GWCThe GWC was composed of clinicians with content and methodological expertise, including general cardiologists, subspecialty cardiologists, anesthesiologists, a surgeon, a hospitalist, and a patient representative/lay volunteer. The GWC included representatives from the ACC, AHA, American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society for Vascular Medicine.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each from the ACC and the AHA; 1 reviewer each from the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, HRS, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, Society of Hospital Medicine, and Society for Vascular Medicine; and 24 individual content reviewers (including members of the ACC Adult Congenital and Pediatric Cardiology Section Leadership Council, ACC Electrophysiology Section Leadership Council, ACC Heart Failure and Transplant Section Leadership Council, ACC Interventional Section Leadership Council, and ACC Surgeons’ Council). Reviewers’ RWI information was distributed to the GWC and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the