New Guideline Provides Comprehensive Update on Cardiovascular Management for Noncardiac Surgery

The American Heart Association and American College of Cardiology have released a new guideline for managing cardiovascular risks in patients undergoing noncardiac surgery, providing clinicians with updated evidence-based recommendations for the first time in a decade. The comprehensive guideline, published simultaneously in the journals Circulation and JACC, aims to improve patient outcomes by addressing cardiovascular evaluation and management before, during, and after noncardiac surgical procedures.

With approximately 300 million noncardiac surgeries performed worldwide each year, the guideline serves as a crucial resource for healthcare professionals across multiple disciplines. It offers detailed guidance on patient assessment, appropriate use of cardiovascular testing, and management of various cardiovascular conditions and risk factors throughout the perioperative period.

Key updates in the 2024 guideline include recommendations on blood pressure management, specific guidance for patients with conditions such as coronary artery disease and hypertrophic cardiomyopathy, and considerations for newer medications used to treat diabetes and obesity. The guideline also addresses emerging issues such as myocardial injury after noncardiac surgery (MINS) and postoperative atrial fibrillation, highlighting areas where further research is needed.

One significant change from the 2014 guideline is a more judicious approach to preoperative cardiac stress testing. The new recommendations emphasize targeted screening rather than routine testing for all patients. Additionally, the guideline introduces the use of emergency-focused cardiac ultrasound during surgery for patients with unexplained hemodynamic instability, provided that clinicians with appropriate expertise are available.

The guideline also provides important updates on medication management. It recommends discontinuing SGLT2 inhibitors, a class of diabetes medications, three to four days before surgery to reduce the risk of ketoacidosis. The guideline also notes potential concerns with GLP-1 agonists, used for diabetes and obesity management, regarding delayed stomach emptying and increased risk of pulmonary aspiration during anesthesia.

For patients on blood thinners, the guideline generally recommends stopping these medications several days before surgery and resuming them after discharge, with specific exceptions noted in the full document. This approach aims to balance the risks of bleeding during surgery with the need for anticoagulation.

The comprehensive nature of the guideline underscores the complexity of managing cardiovascular risks in surgical patients, particularly as the population ages and lives longer with chronic health conditions. Dr. Annemarie Thompson, chair of the guideline writing group, emphasized the importance of a multidisciplinary, team-based approach to optimize care for these patients.

This updated guideline represents a collaborative effort among multiple medical societies, including the American College of Surgeons, the American Society of Nuclear Cardiology, and the Heart Rhythm Society, among others. Its recommendations are based on a thorough review of the latest research and expert consensus, providing a valuable resource for clinicians involved in perioperative care.

As medical knowledge continues to evolve, this guideline serves as a critical tool for improving patient outcomes and reducing cardiovascular complications associated with noncardiac surgery. Healthcare professionals across various specialties are encouraged to familiarize themselves with these updated recommendations to ensure the best possible care for their surgical patients with cardiovascular risk factors.