New Guideline Improves Cardiovascular Care for Noncardiac Surgery Patients

A new guideline released jointly by the American Heart Association (AHA) and American College of Cardiology (ACC) provides updated recommendations for managing cardiovascular risk in patients undergoing noncardiac surgery. The 2024 guideline, which updates the previous 2014 version, incorporates a decade of new evidence to improve care before, during, and after surgery for patients with known or potential cardiovascular risk factors.

With approximately 300 million noncardiac surgeries performed worldwide each year, optimizing cardiovascular care for these patients is crucial. The guideline targets healthcare professionals across multiple disciplines who care for surgical patients requiring general or regional anesthesia.

Key updates in the guideline include more targeted recommendations for pre-operative cardiac screening tests, guidance on managing newer diabetes and obesity medications in the perioperative period, and strategies for addressing post-operative cardiovascular complications. The guideline emphasizes a multidisciplinary, team-based approach to care.

One significant change is more judicious use of pre-operative stress testing. The guideline recommends that healthcare professionals be more selective in ordering these tests, focusing on patients at higher cardiovascular risk. Additionally, the use of emergency-focused cardiac ultrasound is now recommended for patients with unexplained blood pressure instability during surgery, when clinicians with appropriate expertise are available.

The guideline also addresses management of newer medications like SGLT2 inhibitors for diabetes, recommending discontinuation 3-4 days before surgery to reduce complication risks. For patients on blood thinners, the guideline generally supports stopping these medications several days before surgery and restarting after discharge, with some exceptions noted.

Post-operative care recommendations include a new focus on myocardial injury after noncardiac surgery (MINS), a recently identified condition associated with worse outcomes. The guideline recommends follow-up for patients who develop MINS to address cardiovascular risk factors. Management of post-operative atrial fibrillation is also emphasized, given its association with increased stroke risk.

Dr. Annemarie Thompson, chair of the guideline writing group, stressed the importance of these updates given the aging population and increasing prevalence of chronic health conditions. "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," she said.

The comprehensive nature of this guideline, which was developed in collaboration with multiple medical societies, reflects the complexity of perioperative cardiovascular care. By providing evidence-based recommendations across the entire perioperative period, the guideline aims to improve outcomes for millions of surgical patients with cardiovascular risk factors.

As the population ages and lives longer with chronic conditions, implementing these guidelines will be crucial for healthcare systems to provide optimal care. The emphasis on targeted screening, careful medication management, and attentive post-operative care has the potential to significantly reduce cardiovascular complications and improve overall surgical outcomes.