New guideline details how to manage CVD risk before, during and after noncardiac surgery

The 2024 guideline for cardiovascular management of adults undergoing noncardiac surgery reflects a decade of updates and new evidence since the guideline’s last release in 2014. It is published in Circulation and simultaneously in JACC.

The “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery” presents the latest evidence for the appropriate assessment of cardiovascular disease risk for patients scheduled for noncardiac surgery and management of cardiovascular disease risk factors before, during and after noncardiac surgery.

The recommendations address patient evaluations and assessments, use of cardiovascular testing and screening, and evidence-based management of cardiovascular conditions and risks before, during and after surgery in those patients.

“There is a wealth of new evidence about how best to evaluate and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery,” said Chair of the guideline writing group Annemarie Thompson, M.D., M.B.A., FAHA, a professor of anesthesiology, medicine and population health sciences at Duke University Medical Center in Durham, North Carolina.

“Worldwide, there are approximately 300 million noncardiac surgeries each year, which underscores the need to summarize and interpret the evidence to assist clinicians in managing patients who present for surgery,” Thompson said.

“This new guideline is a comprehensive review of the latest research to help inform clinicians who manage perioperative patients, with the ultimate goal of restoring health and minimizing cardiovascular complications.”

The guideline targets the many disciplines of health care professionals who care for people undergoing surgery that requires general or regional anesthesia and who have known or potential cardiovascular risk.

“From prior studies, conditions such as high blood pressure, type 2 diabetes, age older than 55 in men and 65 in women, smoking and obesity are known risk factors that predispose patients to cardiovascular disease. Others have a family history of premature coronary artery disease, which can also put them at increased risk,” Thompson said.

“This guideline is written with the understanding that these and other cardiovascular risk factors and conditions can contribute to negative surgical outcomes if they are unrecognized or not optimized before surgery.”

Perioperative management of cardiovascular conditions

As in 2014, the 2024 guideline includes a perioperative algorithm to guide health care professionals in care decisions for patients with cardiovascular conditions having noncardiac surgery.

The new guideline reviews blood pressure management before, during and after surgery, and highlights specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea and previous stroke.

Updated screening recommendations

The new guideline recommends that health care professionals be judicious and targeted about ordering screenings, such as stress testing, to determine cardiac risk prior to surgery.

The guideline also includes recommendations on using emergency-focused cardiac ultrasound for patients undergoing noncardiac surgery with unexplained hemodynamic instability (unstable blood pressure) if clinicians with expertise in cardiac ultrasound are readily available.

Focused cardiac ultrasound has emerged as a screening option since the last guideline; it can be performed in the operating room during surgery to help determine if heart problems are causing unstable blood pressure.

Considerations for medication management

Newer medications for type 2 diabetes, heart failure and obesity management have important perioperative implications, according to the 2024 guideline. SGLT2-inhibitors should be discontinued three to four days before surgery to minimize the risk of perioperative ketoacidosis, which is unbalanced pH levels in the blood that can negatively impact surgical outcomes.

Emerging data suggest that glucagon-like polypeptide-1 (GLP-1) agonists, medications that are used for managing type 2 diabetes and/or obesity, may cause delayed stomach emptying. In addition, nausea is a common side effect of GLP-1 agonists, and patients taking these medications may be at increased risk of pulmonary aspiration, or inhaling stomach content into their lungs, while under anesthesia.

Other organizations have recommended to withhold these medications prior to noncardiac surgery (for one week for patients on weekly doses and for one day for patients taking daily doses) to reduce the risk of pulmonary aspiration during surgery; however, the need for discontinuation and timing are an emerging area of investigation.

For patients who are taking blood thinners, the new guideline recommends that in most cases it is safe to stop blood thinners several days before surgery, proceed to surgery and then start taking blood thinners again after surgery, most commonly after hospital discharge. Clinicians are encouraged to refer to the guideline for exceptions and modifications.

Additional research needs identified

Myocardial injury after noncardiac surgery (MINS), or injury to the heart that occurs either during or shortly after noncardiac surgery, is diagnosed by elevated cardiac troponin levels after surgery. MINS occurs in about one in five noncardiac surgery patients. This newly identified condition is associated with worse short- and long-term outcomes for patients, yet little is known about what causes MINS, how to prevent it and how best to manage it.

In patients who develop MINS, outpatient follow-up is recommended to counsel patients on how to reduce their heart disease risk factors.

The new guideline emphasizes the importance of paying attention to an irregular heart rhythm known as atrial fibrillation (AFib), which may occur during or after noncardiac surgery.

Patients with newly diagnosed AFib have an increased risk of stroke, and guideline authors recommend closely following these patients after surgery to treat reversible causes of AFib and to consider the need for rhythm control and/or the use of blood thinners to prevent stroke. Ongoing studies are evaluating how to best manage AFib that occurs after surgery.

Thompson said, “The U.S. population is getting older and is living longer with chronic health conditions including chronic heart and vascular diseases. A multidisciplinary, team-based approach, including surgeons, primary care physicians, cardiologists, internal medicine doctors and other medical specialists, is needed to optimize care for patients with cardiovascular conditions and risk factors before, during and after surgery.”

This guideline was prepared by a volunteer writing group on behalf of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines, and developed with and endorsed by the American College of Surgeons, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society of Cardiovascular Anesthesiologists, the Society of Cardiovascular Computed Tomography, the Society of Cardiovascular Magnetic Resonance and the Society of Vascular Medicine.