The American Heart Association (AHA) and American College of Cardiology (ACC) have jointly released new guidelines for cardiovascular management of adults undergoing noncardiac surgery, providing critical updates to recommendations last issued in 2014. Published simultaneously in the journals Circulation and JACC, the 2024 guideline synthesizes a decade of new evidence to guide clinicians in assessing and managing cardiovascular risk for the approximately 300 million noncardiac surgeries performed worldwide each year.
The updated guideline aims to optimize care and minimize cardiovascular complications for patients with known or potential cardiovascular risk factors undergoing surgery requiring general or regional anesthesia. It provides evidence-based recommendations on patient evaluations, appropriate use of cardiovascular testing and screening, and management of specific cardiovascular conditions before, during, and after noncardiac surgery.
Key updates in the 2024 guideline include more judicious recommendations for preoperative cardiac stress testing, guidance on using emergency-focused cardiac ultrasound during surgery, and new considerations for managing diabetes medications like SGLT2 inhibitors in the perioperative period. The guideline also addresses emerging issues like myocardial injury after noncardiac surgery (MINS) and postoperative atrial fibrillation.
Dr. Annemarie Thompson, chair of the guideline writing group, emphasized the importance of these updates given the aging population and increasing prevalence of chronic cardiovascular conditions. "This new guideline is a comprehensive review of the latest research to help inform clinicians who manage perioperative patients, with the ultimate goal of restoring health and minimizing cardiovascular complications," Thompson stated.
The guideline recommends a multidisciplinary, team-based approach to perioperative cardiovascular care, involving surgeons, primary care physicians, cardiologists, and other specialists. It provides detailed recommendations for managing specific conditions like hypertension, coronary artery disease, valvular heart disease, and obstructive sleep apnea in the surgical setting.
Notably, the guideline advises discontinuing SGLT2 inhibitors 3-4 days before surgery to reduce the risk of ketoacidosis. It also highlights potential concerns with GLP-1 agonists delaying gastric emptying, which may increase aspiration risk during anesthesia. For patients on blood thinners, the guideline generally recommends stopping these medications several days before surgery and restarting after discharge, with some exceptions.
The updated recommendations have significant implications for perioperative care. By providing evidence-based guidance on cardiovascular risk assessment and management, the guideline aims to improve surgical outcomes and reduce complications for millions of patients undergoing noncardiac procedures each year. Healthcare providers across multiple specialties will need to familiarize themselves with these updates to optimize care coordination and patient safety.
As the population ages and chronic cardiovascular conditions become more prevalent, adhering to these guidelines will be increasingly crucial for minimizing surgical risks. The emphasis on judicious use of preoperative testing may also help reduce unnecessary procedures and healthcare costs. At the same time, the guideline highlights areas needing further research, such as optimal management of newly identified conditions like MINS.
The comprehensive nature of this update, addressing everything from preoperative evaluation to postoperative follow-up, underscores the complexity of perioperative cardiovascular care. As medical knowledge and treatments continue to advance, regular updates to such guidelines will remain essential for ensuring the best possible outcomes for surgical patients with cardiovascular risk factors.
