A Complete Approach: New Recommendations for CVD Risk Management Before, During, and After Non Cardiac 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 the American Heart Association’s flagship, peer-reviewed journal Circulation and simultaneously in JACC, the flagship the American College of Cardiology.
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.
“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 if clinicians with expertise in cardiac ultrasound are readily available.
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.
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.
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. In patients who develop MINS, outpatient follow-up is recommended to counsel patients on how to reduce their heart disease risk factors.
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.
Reference: Thompson, A., Fleischmann, K. E., Smilowitz, N. R., de las Fuentes, L., Mukherjee, D., Aggarwal, N. R., Ahmad, F. S., Allen, R. B., Altin, S. E., Auerbach, A., Berger, J. S., Chow, B., Dakik, H. A., Eisenstein, E. L., Gerhard-Herman, M., Ghadimi, K., Kachulis, B., Leclerc, J., Lee, C. S., Macaulay, T. E., Mates, G., Merli, G. J., Parwani, P., Poole, J. E., Rich, M. W., Ruetzler, K., Stain, S. C., Sweitzer, B., Talbot, A. W., Vallabhajosyula, S., Whittle, J., & Williams, K. A. (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
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