Top Things to Know: 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery
Prepared by Sally S. Wong, PhD, RD, CDN, FAHA, National Senior Director, Science & Medicine
- It has been nearly 10 years since the last Perioperative Guideline. This new Guideline incorporates new data, recommendations on assessments, and recommendations on management. Additionally, this Guideline will look for opportunities to visually represent state-of-the-art perioperative management to provide clarity and efficient referencing by healthcare professionals.
- This Perioperative Guideline provides a stepwise approach to perioperative cardiac assessment and guides clinicians to determine when surgery should proceed or when a pause is warranted for further evaluation.
- Cardiovascular screening and treatment among patients undergoing noncardiac surgery (NCS) should adhere to the same indications as would be applied in nonsurgical patients, timed carefully to avoid delays in surgery, and chosen in ways to avoid over-screening and over-treatment with limited benefit.
- For low-risk patients undergoing low-risk surgeries, less stress testing is preferred, with stress testing only appropriate when indicated in the non-perioperative period.
- A large emphasis was placed on team-based care when planning perioperative management for patients with complex anatomy or unstable CVD.
- New therapies for managing diabetes, heart failure, and obesity have significant perioperative considerations. Sodium-glucose co-transporter2 inhibitors (SGLT2-inhibitors) should be discontinued 3-4 days prior to surgery to minimize the risk of SGLT2i-associated perioperative ketoacidosis.
- Randomized, controlled trials to determine therapies and risk mitigation are ongoing for myocardial injury after NCS, which is a newly identified disease process that should not be ignored as it portends real consequences for affected patients.
- Patients with atrial fibrillation identified during or after NCS should be followed in the post-op and post-discharge period to treat reversible causes and to consider the need for rhythm control and long-term anticoagulation given the increased risk of stroke.
- Novel oral anticoagulants and warfarin have wide-ranging administration indications, which require individualized perioperative consideration and recommendations for discontinuation, bridging, and restarting in the postoperative period.
- Lastly, this guideline is intended to inform all clinicians involved in the care of patients being considered for noncardiac surgery. Preoperative evaluation encompasses the assessment of perioperative risk and determination of the need for additional cardiovascular testing through exercise, imaging, or biomarker assessment.
Citation
Thompson A, Fleischmann KE, Smilowitz NR, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, de las Fuentes L, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Mukherjee D; Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA Sr. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guidelinefor perioperative cardiovascular management for noncardiac surgery: a report of the American College ofCardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online September 24, 2024. doi: 10.1161/CIR.0000000000001285