There are approximately 300 million noncardiac surgeries performed worldwide each year, highlighting the importance of summarizing and interpreting evidence to help clinicians manage patients undergoing surgery. The American Heart Association (AHA, Dallas, TX, USA) and the American College of Cardiology (ACC, Washington, DC, USA) have now released an updated joint guideline on cardiovascular evaluation and management for patients before, during, and after noncardiac surgery. This guideline reviews a decade of new evidence and provides updates since the previous version was released in 2014.

Published in the AHA’s flagship, peer-reviewed journal Circulation and simultaneously in JACC, the flagship journal of the ACC, the “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery” presents the latest evidence for assessing and managing cardiovascular disease risk in patients scheduled for noncardiac surgery. It addresses patient evaluations, cardiovascular testing, screening, and evidence-based management of cardiovascular conditions before, during, and after surgery. The guideline is aimed at healthcare professionals from multiple disciplines who care for patients undergoing surgeries requiring general or regional anesthesia and who may have known or potential cardiovascular risks.

As in the 2014 guideline, the 2024 update includes a perioperative algorithm to guide healthcare professionals in making care decisions for patients with cardiovascular conditions who are undergoing noncardiac surgery. It reviews blood pressure management and includes specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea, and those with a history of stroke. The new guideline advises a targeted approach when ordering screenings, such as stress tests, to assess cardiac risk before surgery. Additionally, it recommends the use of emergency-focused cardiac ultrasound for patients with unexplained hemodynamic instability during noncardiac surgery, provided clinicians skilled in cardiac ultrasound are available. This ultrasound technology, which has become a screening option since the last guideline, can be used during surgery to determine whether heart problems are causing unstable blood pressure.

The 2024 guideline also highlights newer medications for Type 2 diabetes, heart failure, and obesity management that have significant perioperative implications. For example, SGLT2 inhibitors should be discontinued three to four days before surgery to reduce the risk of perioperative ketoacidosis, which can negatively impact surgical outcomes. Additionally, emerging data suggest that glucagon-like polypeptide-1 (GLP-1) agonists, used to manage Type 2 diabetes and obesity, may delay stomach emptying and increase the risk of pulmonary aspiration during anesthesia due to their side effect of nausea. Other medical organizations have recommended withholding GLP-1 agonists before noncardiac surgery—one week for patients on weekly doses and one day for those on daily doses—to mitigate this risk, though further research is needed to refine these recommendations. For patients taking blood thinners, the guideline suggests that, in most cases, it is safe to stop the medication several days before surgery and restart it after surgery, typically after hospital discharge. Exceptions and modifications to this recommendation are also outlined in the guideline.

Another focus of the new guideline is myocardial injury after noncardiac surgery (MINS), which refers to heart damage occurring during or shortly after noncardiac surgery. MINS, diagnosed by elevated cardiac troponin levels, affects roughly one in five patients and is associated with worse short- and long-term outcomes. While the causes and management strategies for MINS remain unclear, the guideline recommends outpatient follow-up for patients who develop this condition to reduce heart disease risk factors. Additionally, the guideline emphasizes the need to monitor atrial fibrillation (AFib), an irregular heart rhythm that can develop during or after noncardiac surgery. Patients newly diagnosed with AFib are at an increased risk of stroke, and the guideline advises close monitoring of these patients after surgery, addressing reversible causes of AFib and considering rhythm control or the use of blood thinners to prevent stroke. Ongoing studies are investigating the best ways to manage AFib that occurs postoperatively.

“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. “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.” 

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