ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).

Lee A. Fleisher, Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliott Chaikof, Kirsten E. Fleischmann, William K. Freeman, James B. Froehlich, Edward K. Kasper, Judy R. Kersten, Barbara Riegel, John F. Robb, Sidney C. Smith, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, David P. Faxon, Valentin Fuster, Jonathan L. HalperinLoren F. Hiratzka, Sharon A. Hunt, Bruce W. Lytle, Rick Nishimura, Richard L. Page, Barbara Riegel

Research output: Contribution to journalArticle

88 Citations (Scopus)

Abstract

Purpose of the Expedited Update: Since the publication of the previous guidelines on perioperative cardiovascular evaluation for noncardiac surgery in 2002, the issue of perioperative beta blockade for non-cardiac surgery has taken on increased importance. Specifically, the Physicians Consortium for Performance Improvement and the Surgical Care Improvement Project have both identified perioperative beta blockade as a quality measure. Given the importance of these quality measures for both public reporting and eventual pay-for-performance, and the recent series of publications on the subject, it became imperative to update the recommendations related to beta blockade. Therefore, we have chosen to expedite the review of the literature on perioperative beta blockade in order to produce recommendations that can be used in these national quality initiatives. In general, ACC/AHA Class I and III indications for therapy identify potential dimensions of care and processes for performance measurement; however, not all Class I and III guidelines recommendations should be selected for performance measurement (1). Furthermore, Class IIa and Class IIb recommendations are not considered for stand-alone measures. Please note that the full 2002 Guideline on Perioperative Cardiovascular Evaluation for Noncardiac Surgery is being updated and represents current ACC/AHA policy, with the exception of the text and tables in the perioperative beta-blocker therapy section. This focused update replaces the beta-blocker section in the 2002 Guideline and is considered current ACC/AHA policy until the update of the full guideline is published. Please note that Table 2, "Clinical Predictors of Increased Perioperative Cardiovascular Risk," is currently under review and may be modified as part of the update of the full guideline. Organization of Committee and Evidence Review: The Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy reviewed the literature relevant to perioperative cardiac evaluation since the last publication of these guidelines in 2002. Literature searches were conducted in PubMed/MEDLINE. Searches were limited to the English language, 2002 through 2006, and human subjects. In addition, related-article searches were conducted in MEDLINE to find further relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches. As a result of these searches, 23 published articles and 1 abstract were identified and reviewed by the committee for the expedited update of the Beta-Blocker section. Using evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, the committee updated the guideline text and recommendations. These classes summarize the recommendations for procedures or treatments as follows: • Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective. • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful. In addition, the weight of evidence in support of the recommendation is listed as follows: • Level of Evidence A: Data derived from multiple, randomized, clinical trials. • Level of Evidence B: Data derived from a single-randomized trial or non-randomized studies. • Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. The schema for classification of recommendations and level of evidence is summarized in Figure 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. {A textbox is presented}. The Committee consisted of acknowledged experts in general cardiology as well as persons with recognized expertise in more specialized areas including anesthesiology, cardiovascular surgery, echocardiography, electrophysiology, interventional cardiology, nuclear cardiology, vascular medicine, and vascular surgery; both academic and private sectors were represented. The following organizations assigned official representatives: the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Vascular Surgery, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions. This document was reviewed by 2 official reviewers nominated by the ACC; 2 official reviewers nominated by the AHA; 1 official reviewer from the ACC/AHA Task Force on Practice Guidelines as well as reviewers from the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions; and 20 content reviewers, including members from American College of Cardiology Foundation (ACCF) Cardiac Catheterization Committee, ACCF Peripheral Vascular Disease Committee, ACCF Cardiovascular Clinical Imaging Committee, ACCF Echocardiography Committee, ACCF Clinical Electrophysiology Committee, AHA Council on Cardiopulmonary Perioperative and Critical Care Leadership Committee, AHA Council on Cardiovascular Surgery and Anesthesia Leadership Committee, and the AHA Council on Clinical Cardiology, Electrocardiography, and Arrhythmias Committee.

Original languageEnglish (US)
Pages (from-to)2343-2355
Number of pages13
JournalJournal of the American College of Cardiology
Volume47
Issue number11
DOIs
StatePublished - Jun 6 2006
Externally publishedYes

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Advisory Committees
Practice Guidelines
Cardiology
Guidelines
Therapeutics
Publications
Electrophysiology
MEDLINE
Echocardiography
Organizations
Incentive Reimbursement
Committee Membership
Perioperative Care
Weights and Measures
Anesthesiology
Private Sector
Peripheral Vascular Diseases
Expert Testimony
Critical Care
Standard of Care

ASJC Scopus subject areas

  • Nursing(all)

Cite this

ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery : Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). / Fleisher, Lee A.; Beckman, Joshua A.; Brown, Kenneth A.; Calkins, Hugh; Chaikof, Elliott; Fleischmann, Kirsten E.; Freeman, William K.; Froehlich, James B.; Kasper, Edward K.; Kersten, Judy R.; Riegel, Barbara; Robb, John F.; Smith, Sidney C.; Jacobs, Alice K.; Adams, Cynthia D.; Anderson, Jeffrey L.; Antman, Elliott M.; Faxon, David P.; Fuster, Valentin; Halperin, Jonathan L.; Hiratzka, Loren F.; Hunt, Sharon A.; Lytle, Bruce W.; Nishimura, Rick; Page, Richard L.; Riegel, Barbara.

In: Journal of the American College of Cardiology, Vol. 47, No. 11, 06.06.2006, p. 2343-2355.

Research output: Contribution to journalArticle

Fleisher, LA, Beckman, JA, Brown, KA, Calkins, H, Chaikof, E, Fleischmann, KE, Freeman, WK, Froehlich, JB, Kasper, EK, Kersten, JR, Riegel, B, Robb, JF, Smith, SC, Jacobs, AK, Adams, CD, Anderson, JL, Antman, EM, Faxon, DP, Fuster, V, Halperin, JL, Hiratzka, LF, Hunt, SA, Lytle, BW, Nishimura, R, Page, RL & Riegel, B 2006, 'ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).', Journal of the American College of Cardiology, vol. 47, no. 11, pp. 2343-2355. https://doi.org/10.1016/j.jacc.2006.02.028
Fleisher, Lee A. ; Beckman, Joshua A. ; Brown, Kenneth A. ; Calkins, Hugh ; Chaikof, Elliott ; Fleischmann, Kirsten E. ; Freeman, William K. ; Froehlich, James B. ; Kasper, Edward K. ; Kersten, Judy R. ; Riegel, Barbara ; Robb, John F. ; Smith, Sidney C. ; Jacobs, Alice K. ; Adams, Cynthia D. ; Anderson, Jeffrey L. ; Antman, Elliott M. ; Faxon, David P. ; Fuster, Valentin ; Halperin, Jonathan L. ; Hiratzka, Loren F. ; Hunt, Sharon A. ; Lytle, Bruce W. ; Nishimura, Rick ; Page, Richard L. ; Riegel, Barbara. / ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery : Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). In: Journal of the American College of Cardiology. 2006 ; Vol. 47, No. 11. pp. 2343-2355.
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title = "ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).",
abstract = "Purpose of the Expedited Update: Since the publication of the previous guidelines on perioperative cardiovascular evaluation for noncardiac surgery in 2002, the issue of perioperative beta blockade for non-cardiac surgery has taken on increased importance. Specifically, the Physicians Consortium for Performance Improvement and the Surgical Care Improvement Project have both identified perioperative beta blockade as a quality measure. Given the importance of these quality measures for both public reporting and eventual pay-for-performance, and the recent series of publications on the subject, it became imperative to update the recommendations related to beta blockade. Therefore, we have chosen to expedite the review of the literature on perioperative beta blockade in order to produce recommendations that can be used in these national quality initiatives. In general, ACC/AHA Class I and III indications for therapy identify potential dimensions of care and processes for performance measurement; however, not all Class I and III guidelines recommendations should be selected for performance measurement (1). Furthermore, Class IIa and Class IIb recommendations are not considered for stand-alone measures. Please note that the full 2002 Guideline on Perioperative Cardiovascular Evaluation for Noncardiac Surgery is being updated and represents current ACC/AHA policy, with the exception of the text and tables in the perioperative beta-blocker therapy section. This focused update replaces the beta-blocker section in the 2002 Guideline and is considered current ACC/AHA policy until the update of the full guideline is published. Please note that Table 2, {"}Clinical Predictors of Increased Perioperative Cardiovascular Risk,{"} is currently under review and may be modified as part of the update of the full guideline. Organization of Committee and Evidence Review: The Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy reviewed the literature relevant to perioperative cardiac evaluation since the last publication of these guidelines in 2002. Literature searches were conducted in PubMed/MEDLINE. Searches were limited to the English language, 2002 through 2006, and human subjects. In addition, related-article searches were conducted in MEDLINE to find further relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches. As a result of these searches, 23 published articles and 1 abstract were identified and reviewed by the committee for the expedited update of the Beta-Blocker section. Using evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, the committee updated the guideline text and recommendations. These classes summarize the recommendations for procedures or treatments as follows: • Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective. • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful. In addition, the weight of evidence in support of the recommendation is listed as follows: • Level of Evidence A: Data derived from multiple, randomized, clinical trials. • Level of Evidence B: Data derived from a single-randomized trial or non-randomized studies. • Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. The schema for classification of recommendations and level of evidence is summarized in Figure 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. {A textbox is presented}. The Committee consisted of acknowledged experts in general cardiology as well as persons with recognized expertise in more specialized areas including anesthesiology, cardiovascular surgery, echocardiography, electrophysiology, interventional cardiology, nuclear cardiology, vascular medicine, and vascular surgery; both academic and private sectors were represented. The following organizations assigned official representatives: the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Vascular Surgery, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions. This document was reviewed by 2 official reviewers nominated by the ACC; 2 official reviewers nominated by the AHA; 1 official reviewer from the ACC/AHA Task Force on Practice Guidelines as well as reviewers from the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions; and 20 content reviewers, including members from American College of Cardiology Foundation (ACCF) Cardiac Catheterization Committee, ACCF Peripheral Vascular Disease Committee, ACCF Cardiovascular Clinical Imaging Committee, ACCF Echocardiography Committee, ACCF Clinical Electrophysiology Committee, AHA Council on Cardiopulmonary Perioperative and Critical Care Leadership Committee, AHA Council on Cardiovascular Surgery and Anesthesia Leadership Committee, and the AHA Council on Clinical Cardiology, Electrocardiography, and Arrhythmias Committee.",
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year = "2006",
month = "6",
day = "6",
doi = "10.1016/j.jacc.2006.02.028",
language = "English (US)",
volume = "47",
pages = "2343--2355",
journal = "Journal of the American College of Cardiology",
issn = "0735-1097",
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TY - JOUR

T1 - ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery

T2 - Focused Update on Perioperative Beta-Blocker Therapy. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).

AU - Fleisher, Lee A.

AU - Beckman, Joshua A.

AU - Brown, Kenneth A.

AU - Calkins, Hugh

AU - Chaikof, Elliott

AU - Fleischmann, Kirsten E.

AU - Freeman, William K.

AU - Froehlich, James B.

AU - Kasper, Edward K.

AU - Kersten, Judy R.

AU - Riegel, Barbara

AU - Robb, John F.

AU - Smith, Sidney C.

AU - Jacobs, Alice K.

AU - Adams, Cynthia D.

AU - Anderson, Jeffrey L.

AU - Antman, Elliott M.

AU - Faxon, David P.

AU - Fuster, Valentin

AU - Halperin, Jonathan L.

AU - Hiratzka, Loren F.

AU - Hunt, Sharon A.

AU - Lytle, Bruce W.

AU - Nishimura, Rick

AU - Page, Richard L.

AU - Riegel, Barbara

PY - 2006/6/6

Y1 - 2006/6/6

N2 - Purpose of the Expedited Update: Since the publication of the previous guidelines on perioperative cardiovascular evaluation for noncardiac surgery in 2002, the issue of perioperative beta blockade for non-cardiac surgery has taken on increased importance. Specifically, the Physicians Consortium for Performance Improvement and the Surgical Care Improvement Project have both identified perioperative beta blockade as a quality measure. Given the importance of these quality measures for both public reporting and eventual pay-for-performance, and the recent series of publications on the subject, it became imperative to update the recommendations related to beta blockade. Therefore, we have chosen to expedite the review of the literature on perioperative beta blockade in order to produce recommendations that can be used in these national quality initiatives. In general, ACC/AHA Class I and III indications for therapy identify potential dimensions of care and processes for performance measurement; however, not all Class I and III guidelines recommendations should be selected for performance measurement (1). Furthermore, Class IIa and Class IIb recommendations are not considered for stand-alone measures. Please note that the full 2002 Guideline on Perioperative Cardiovascular Evaluation for Noncardiac Surgery is being updated and represents current ACC/AHA policy, with the exception of the text and tables in the perioperative beta-blocker therapy section. This focused update replaces the beta-blocker section in the 2002 Guideline and is considered current ACC/AHA policy until the update of the full guideline is published. Please note that Table 2, "Clinical Predictors of Increased Perioperative Cardiovascular Risk," is currently under review and may be modified as part of the update of the full guideline. Organization of Committee and Evidence Review: The Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy reviewed the literature relevant to perioperative cardiac evaluation since the last publication of these guidelines in 2002. Literature searches were conducted in PubMed/MEDLINE. Searches were limited to the English language, 2002 through 2006, and human subjects. In addition, related-article searches were conducted in MEDLINE to find further relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches. As a result of these searches, 23 published articles and 1 abstract were identified and reviewed by the committee for the expedited update of the Beta-Blocker section. Using evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, the committee updated the guideline text and recommendations. These classes summarize the recommendations for procedures or treatments as follows: • Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective. • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful. In addition, the weight of evidence in support of the recommendation is listed as follows: • Level of Evidence A: Data derived from multiple, randomized, clinical trials. • Level of Evidence B: Data derived from a single-randomized trial or non-randomized studies. • Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. The schema for classification of recommendations and level of evidence is summarized in Figure 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. {A textbox is presented}. The Committee consisted of acknowledged experts in general cardiology as well as persons with recognized expertise in more specialized areas including anesthesiology, cardiovascular surgery, echocardiography, electrophysiology, interventional cardiology, nuclear cardiology, vascular medicine, and vascular surgery; both academic and private sectors were represented. The following organizations assigned official representatives: the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Vascular Surgery, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions. This document was reviewed by 2 official reviewers nominated by the ACC; 2 official reviewers nominated by the AHA; 1 official reviewer from the ACC/AHA Task Force on Practice Guidelines as well as reviewers from the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions; and 20 content reviewers, including members from American College of Cardiology Foundation (ACCF) Cardiac Catheterization Committee, ACCF Peripheral Vascular Disease Committee, ACCF Cardiovascular Clinical Imaging Committee, ACCF Echocardiography Committee, ACCF Clinical Electrophysiology Committee, AHA Council on Cardiopulmonary Perioperative and Critical Care Leadership Committee, AHA Council on Cardiovascular Surgery and Anesthesia Leadership Committee, and the AHA Council on Clinical Cardiology, Electrocardiography, and Arrhythmias Committee.

AB - Purpose of the Expedited Update: Since the publication of the previous guidelines on perioperative cardiovascular evaluation for noncardiac surgery in 2002, the issue of perioperative beta blockade for non-cardiac surgery has taken on increased importance. Specifically, the Physicians Consortium for Performance Improvement and the Surgical Care Improvement Project have both identified perioperative beta blockade as a quality measure. Given the importance of these quality measures for both public reporting and eventual pay-for-performance, and the recent series of publications on the subject, it became imperative to update the recommendations related to beta blockade. Therefore, we have chosen to expedite the review of the literature on perioperative beta blockade in order to produce recommendations that can be used in these national quality initiatives. In general, ACC/AHA Class I and III indications for therapy identify potential dimensions of care and processes for performance measurement; however, not all Class I and III guidelines recommendations should be selected for performance measurement (1). Furthermore, Class IIa and Class IIb recommendations are not considered for stand-alone measures. Please note that the full 2002 Guideline on Perioperative Cardiovascular Evaluation for Noncardiac Surgery is being updated and represents current ACC/AHA policy, with the exception of the text and tables in the perioperative beta-blocker therapy section. This focused update replaces the beta-blocker section in the 2002 Guideline and is considered current ACC/AHA policy until the update of the full guideline is published. Please note that Table 2, "Clinical Predictors of Increased Perioperative Cardiovascular Risk," is currently under review and may be modified as part of the update of the full guideline. Organization of Committee and Evidence Review: The Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy reviewed the literature relevant to perioperative cardiac evaluation since the last publication of these guidelines in 2002. Literature searches were conducted in PubMed/MEDLINE. Searches were limited to the English language, 2002 through 2006, and human subjects. In addition, related-article searches were conducted in MEDLINE to find further relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches. As a result of these searches, 23 published articles and 1 abstract were identified and reviewed by the committee for the expedited update of the Beta-Blocker section. Using evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, the committee updated the guideline text and recommendations. These classes summarize the recommendations for procedures or treatments as follows: • Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective. • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective, and in some cases may be harmful. In addition, the weight of evidence in support of the recommendation is listed as follows: • Level of Evidence A: Data derived from multiple, randomized, clinical trials. • Level of Evidence B: Data derived from a single-randomized trial or non-randomized studies. • Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. The schema for classification of recommendations and level of evidence is summarized in Figure 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. {A textbox is presented}. The Committee consisted of acknowledged experts in general cardiology as well as persons with recognized expertise in more specialized areas including anesthesiology, cardiovascular surgery, echocardiography, electrophysiology, interventional cardiology, nuclear cardiology, vascular medicine, and vascular surgery; both academic and private sectors were represented. The following organizations assigned official representatives: the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Vascular Surgery, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions. This document was reviewed by 2 official reviewers nominated by the ACC; 2 official reviewers nominated by the AHA; 1 official reviewer from the ACC/AHA Task Force on Practice Guidelines as well as reviewers from the Society for Vascular Medicine and Biology, American Society of Nuclear Cardiology, Heart Rhythm Society, American Society of Echocardiography, Society of Cardiovascular Anesthesiologists, and the Society for Cardiovascular Angiography and Interventions; and 20 content reviewers, including members from American College of Cardiology Foundation (ACCF) Cardiac Catheterization Committee, ACCF Peripheral Vascular Disease Committee, ACCF Cardiovascular Clinical Imaging Committee, ACCF Echocardiography Committee, ACCF Clinical Electrophysiology Committee, AHA Council on Cardiopulmonary Perioperative and Critical Care Leadership Committee, AHA Council on Cardiovascular Surgery and Anesthesia Leadership Committee, and the AHA Council on Clinical Cardiology, Electrocardiography, and Arrhythmias Committee.

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