New guidelines detail how to manage CVD risk before, during and after non-cardiac surgery

Highlights from the guidelines:

• Guidelines for the cardiovascular evaluation and management of patients before, during, and after noncardiac surgery, jointly developed by the American Heart Association and the American College of Cardiology, examine 10 years of new evidence and provide updates since the last guidelines in 2014.
• The updated guidelines cover patients scheduled for noncardiac surgery, from preoperative evaluation to postoperative care, and include recommendations on the appropriate use of cardiovascular testing and screening, management of cardiovascular disease and risk, and for patients taking sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) to treat type 2 diabetes.
• The guidelines were developed in collaboration with and endorsed by the American College of Surgeons, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society of Cardiovascular Anesthesiology, the Society of Cardiovascular Computed Tomography, the Society of Cardiovascular Magnetic Resonance, and the Society of Vascular Medicine.

Embargo until Tuesday, September 24, 2024 at 1pm CST/2pm EST

DALLAS and WASHINGTON, Sept. 24, 2024 — The 2024 guidelines for cardiovascular management of adults undergoing noncardiac surgery reflect updates and new evidence in the decade since the guidelines were last published in 2014. It was published today in the American Heart Association's flagship peer-reviewed journal. circulation And at the same time JackFlagship journal of the American College of Cardiology.

The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Perioperative Cardiovascular Management of Noncardiac Surgery Guideline presents the latest evidence regarding appropriate assessment of cardiovascular disease risk in patients scheduled for noncardiac surgery and management of cardiovascular disease risk factors before, during, and after noncardiac surgery. Recommendations address patient evaluation and diagnosis, the use of cardiovascular testing and screening, and evidence-based management of cardiovascular status and risk in these patients before, during, and after surgery.

“There is a wealth of emerging evidence about how to best assess and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery,” said AnnMarie Thompson, MD, MPH, FAHA, professor of anesthesiology, medicine and population health sciences at Duke University Medical Center in Durham, North Carolina, and chair of the guideline writing group.

“Approximately 300 million non-cardiac surgeries are performed annually worldwide, highlighting the need to summarize and interpret evidence to assist clinicians in the management of patients undergoing surgery,” Thompson said. “This new guideline is a comprehensive review of the latest research to inform clinicians managing patients in the perioperative period, with the ultimate goal of restoring health and minimizing cardiovascular complications.”

The guidelines are targeted to many disciplines of health care professionals who care for patients undergoing surgery requiring general or regional anesthesia and who have known or potential cardiovascular risk.

“Previous studies have shown that conditions such as high blood pressure, type 2 diabetes, age 55 or older for men and 65 or older for women, smoking and obesity are risk factors that predispose patients to cardiovascular disease. People with a family history of premature coronary artery disease are also at increased risk,” Thompson said. “The guidelines are based on the understanding that if these cardiovascular risk factors and conditions are not recognized or optimized before surgery, they may result in poor surgical outcomes.”

Perioperative management of cardiovascular disease

As in 2014, the 2024 guidelines include perioperative algorithms to guide health care professionals' care decisions for patients with cardiovascular disease undergoing noncardiac surgery. The new guidelines discuss blood pressure management before, during, and after surgery and highlight specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular disease, pulmonary hypertension, obstructive sleep apnea, and a history of stroke.

Updated Screening Recommendations

The new guidelines recommend that health care providers use careful, targeted testing, such as stress tests, to determine cardiac risk before surgery.

The guidelines also include a recommendation to use emergency cardiac ultrasound for patients undergoing noncardiac surgery with unexplained hemodynamic instability (unstable blood pressure) if a clinician with expertise in cardiac ultrasound is immediately available. Cardiac ultrasound has emerged as a screening option since the last guideline, and can be performed in the operating room during surgery to help determine whether a cardiac problem is causing unstable blood pressure.

Medication Administration Considerations

According to the 2024 guidelines, new drugs for type 2 diabetes, heart failure, and obesity management have important perioperative implications. SGLT2 inhibitors should be discontinued 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis, an imbalance in blood pH levels that can negatively impact surgical outcomes.

Emerging data suggest that glucagon-like polypeptide 1 (GLP-1) agonists, drugs used to manage type 2 diabetes and obesity, may slow gastric emptying. In addition, nausea is a common side effect of GLP-1 agonists, and patients taking these drugs may be at increased risk of pulmonary aspiration, i.e., inhalation of gastric contents into the lungs, during anesthesia. Other organizations recommend withholding these medications (for 1 week for patients taking them weekly or 1 day for patients taking them daily) before noncardiac surgery to reduce the risk of aspiration during surgery. However, the need and timing of discontinuation is an emerging area of ​​investigation.

The new guidelines recommend that for patients taking blood thinners, in most cases it is safe to stop taking the anticoagulants a few days before surgery, proceed to surgery, and then resume taking the anticoagulants after surgery, most commonly after discharge from the hospital. Clinicians are encouraged to refer to the guidelines for any exceptions or modifications.

Additional research needs were identified

Myocardial injury after noncardiac surgery (MINS), or cardiac injury occurring during or shortly after noncardiac surgery, is diagnosed by elevated cardiac troponin levels after surgery. MINS occurs in approximately one in five patients who undergo noncardiac surgery. 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 to best manage it. Outpatient follow-up is recommended for patients who develop MINS to counsel them on ways to reduce their risk factors for cardiac disease.

The new guidelines emphasize the importance of paying attention to an irregular heart rhythm called atrial fibrillation (AFib), which can occur during or after noncardiac surgery. Patients newly diagnosed with AFib are at high risk for stroke, and the guideline authors recommend closely monitoring these patients after surgery to treat reversible causes of AFib and consider the need for rhythm control and/or anticoagulant medications to prevent stroke. Ongoing studies are evaluating how to best manage AFib that occurs after surgery.

“The U.S. population is aging and people are living longer with chronic health conditions, including chronic cardiovascular disease,” said Thompson. “Optimizing care for patients with cardiovascular disease and risk factors before, during and after surgery requires a multidisciplinary, team-based approach that includes surgeons, primary care physicians, cardiologists, internists and other healthcare professionals.”

The 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 was developed in collaboration with and endorsed by the American College of Surgeons, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiology, Society of Cardiovascular Computed Tomography, Society of Cardiovascular Magnetic Resonance, and Society of Vascular Medicine.

Co-authors are co-vice chairs Kirsten E. Fleischmann, MD, MPH, FACC, and Nathaniel R. Smilowitz, MD, MS, FACC; Lisa de las Fuentes, MD, MS, FAHA; Debabrata Mukherjee, MD, MS, FACC, FAHA, MSCAI; Niti R. Agarwal, MD, FACC, FASNC; Faraz S. Ahmad, MD, MS, FACC, FAHA; Robert B. Allen, JD; S. Elissa Altin, MD, FACC, FSVMI; Andrew Auerbach, MD, MPH; Jeffrey S. Berger, MD, MS, FAHA, FACC; and Benjamin Chow, MD, Ph.D., FACC, FASNC, MSCCT. Habib A. Dakik, MD, FACC; Eric L. Eisenstein, DBA; Marie Gerhard Herman, MD, FACC, FAHA; Kamrouz Ghadimi, MD, MHSc, FAHA; Bessie Katulis, MD; Jacinto Leclerc, RN, PhD, FAHA; Christopher S. Lee, Ph.D., RN, FAHA; Tracy E. Macaulay, Ph.D., FACC; Gail Mates, BS; Geno J. Merli, MD, FSVM; Purvi Parwani, MBBS, MPH, FACC; Jeanne E. Poole, MD, FACC, FHRS; Michael W. Rich, MD, FACC; Kurt Ruetzler, MD, Ph.D., FAHA; Steven C. Stein, MD, FACS; Bobbie Jean Sweitzer, MD; Amy W. Talbot, MPH. Saraschandra Vallabhajosyula, MD, MS, FAHA, FACC; John Whittle, MD; and Kim Alan Williams Sr., MD, MACC, FAHA, MASNC. Author disclosures can be found in the manuscript.

The Society receives funding primarily from individuals. Foundations and corporations (including pharmaceutical companies, device manufacturers, and other businesses) also make donations and fund certain Society programs and events. The Society has strict policies to ensure that these relationships do not influence its scientific content. Revenues from pharmaceutical companies, biotechnology companies, device manufacturers, and health insurers, as well as financial information for the Society as a whole, are not disclosed. here.

Additional resources:

###

About the American Heart Association

The American Heart Association works tirelessly for a world where people live longer, healthier lives. We are committed to ensuring equitable health in all communities. Working with countless organizations and with the help of millions of volunteers, we fund innovative research, advocate for public health and share life-saving resources. The Dallas-based organization has been the leading source of health information for a century. As 2024 marks our 100th anniversary, we celebrate 100 years of rich history and achievements. As we move into our second century of bold discovery and impact, our vision is to advance the health and hope of all people, everywhere. Connect with Us heart.org, Facebook, X Or call 1-800-AHA-USA1.

About the American College of Cardiology
The American College of Cardiology (ACC) is a global leader in transforming cardiovascular care and improving heart health for all. As the preeminent source of specialty medical education for the entire cardiovascular care team since 1949, ACC certifies cardiovascular experts who meet rigorous qualifications in more than 140 countries and lead the way in shaping healthcare policies, standards and guidelines. Through our world-renowned JACC journals, NCDR registry, ACC accreditation services, global network of member sections, CardioSmart patient resources and more, the College is committed to enabling a world where science, knowledge and innovation optimize patient care and outcomes. For more information, visit Learn more Or follow @ACCinTouch.

For media inquiries: 214-706-1173

AHA: Amanda Ebert, [email protected]

ACC: Olivia Walther, email address

Public Inquiries: 1-800-AHA-USA1 (242-8721)

heart.org and Stroke.org