New guideline for cardiovascular management in noncardiac surgery released
The American Heart Association and American College of Cardiology have jointly published an updated guideline for managing cardiovascular risks in patients undergoing noncardiac surgery, reflecting a decade of new evidence since the last update in 2014.
Noncardiac surgery and cardiovascular risk
With approximately 300 million noncardiac surgeries performed worldwide each year, the need for comprehensive guidance on managing perioperative cardiovascular risk is crucial. The ‘2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery’, published simultaneously in Circulation [1] and JACC on 24 September 2024, aims to address this need.
The guideline provides evidence-based recommendations for healthcare professionals involved in the care of patients with known or potential cardiovascular risk factors undergoing surgery requiring general or regional anaesthesia. It covers the entire perioperative period, from preoperative evaluation through to postoperative care.
Key updates and recommendations
One of the significant updates in the guideline is the approach to preoperative screening. The document emphasises judicious use of cardiac stress testing, encouraging healthcare professionals to be more targeted in their screening approach. This shift aims to reduce unnecessary and costly testing whilst ensuring appropriate risk assessment.
The guideline also introduces recommendations for the use of emergency-focused cardiac ultrasound during surgery. This technique can be employed to investigate unexplained haemodynamic instability in the operating room, provided that clinicians with the necessary expertise are available.
Medication management
The 2024 guideline addresses the perioperative management of newer medications used for treating type 2 diabetes, heart failure, and obesity. Notably, it recommends discontinuing sodium-glucose cotransporter-2 (SGLT2) inhibitors three to four days before surgery to minimise the risk of perioperative ketoacidosis.
The document also highlights emerging concerns regarding glucagon-like polypeptide-1 (GLP-1) agonists, which are used for managing type 2 diabetes and obesity. These medications may cause delayed gastric emptying and increase the risk of pulmonary aspiration during anaesthesia. While the guideline acknowledges recommendations from other organisations to withhold these medications prior to surgery, it notes that this is an area requiring further investigation.
For patients on anticoagulant therapy, the guideline generally recommends discontinuing these medications several days before surgery and resuming them after discharge. However, clinicians are advised to consult the full document for specific exceptions and modifications to this approach.
Emerging areas of focus
The guideline draws attention to myocardial injury after noncardiac surgery (MINS), a recently identified condition occurring in about 20% of noncardiac surgery patients. MINS is associated with poorer short- and long-term outcomes, but its causes, prevention, and optimal management remain unclear. The guideline recommends outpatient follow-up for patients who develop MINS to counsel them on reducing cardiovascular risk factors.
Another area of emphasis is the management of postoperative atrial fibrillation (AF). Patients who develop new-onset AF during or after surgery have an increased risk of stroke. The guideline recommends close monitoring of these patients postoperatively to address reversible causes of AF and consider the need for rhythm control and anticoagulation therapy.
Multidisciplinary approach
Dr Annemarie Thompson, Chair of the guideline writing group and professor at Duke University Medical Center, emphasised the importance of a team-based approach to perioperative care. “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 optimise care for patients with cardiovascular conditions and risk factors before, during and after surgery,” she said.
Implications for practice
This comprehensive update to the perioperative cardiovascular management guideline reflects the evolving understanding of cardiovascular risks associated with noncardiac surgery. By incorporating a decade of new evidence, it provides healthcare professionals with up-to-date, evidence-based recommendations to optimise patient care and minimise cardiovascular complications in the perioperative period.
The guideline’s emphasis on targeted screening, judicious use of preoperative testing, and careful medication management aligns with the broader trend in medicine towards more personalised and cost-effective care. As the population ages and the prevalence of chronic cardiovascular conditions increases, this guideline will serve as a valuable resource for the multidisciplinary teams involved in perioperative care.
Reference:
- Thompson, A., Fleischmann, K. E., Smilowitz, N. R., et. al. (2024). 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. https://doi.org/10.1161/CIR.0000000000001285
