Managing Cardiovascular Risk in Noncardiac Surgery: Comprehensive Guidelines and Strategies
The 2024 guideline for cardiovascular management of adults undergoing noncardiac surgery has been released by the American Heart Association (AHA) and the American College of Cardiology (ACC). This updated guideline reflects a decade of new evidence since the last release in 2014 and aims to provide comprehensive recommendations for assessing and managing cardiovascular risk in patients scheduled for noncardiac surgery.
Guideline Highlights
The joint guideline addresses cardiovascular evaluation and management of patients before, during, and after noncardiac surgery. It reviews a decade of new evidence and provides updates on appropriate use of cardiovascular testing and screening, management of cardiovascular conditions and risks, and recommendations for patients taking sodium-glucose cotransporter-2 inhibitors (SGLT2-inhibitors) for Type 2 diabetes.
Collaboration and Endorsements
The guideline was developed in collaboration with and endorsed by various medical organizations including the American College of Surgeons, the American Society of Nuclear Cardiology, the Heart Rhythm Society, and others. This collaborative effort ensures that the recommendations are supported by a diverse group of experts in the field.
Key Recommendations
The 2024 guideline emphasizes the importance of assessing cardiovascular disease risk in patients undergoing noncardiac surgery. It provides guidance on patient evaluations, appropriate use of cardiovascular testing, and evidence-based management of cardiovascular conditions and risks before, during, and after surgery.
One important aspect highlighted in the guideline is the management of blood pressure before, during, and after surgery. Specific recommendations are provided for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea, and previous stroke.
Screening Recommendations
The new guideline recommends judicious and targeted ordering of screenings, such as stress testing, to determine cardiac risk prior to surgery. Additionally, the use of emergency-focused cardiac ultrasound is recommended for patients undergoing noncardiac surgery with unexplained hemodynamic instability, if clinicians with expertise in cardiac ultrasound are readily available.
Medication Management
The guideline addresses the perioperative implications of newer medications for Type 2 diabetes, heart failure, and obesity management. It recommends discontinuing SGLT2-inhibitors three to four days before surgery to minimize the risk of perioperative ketoacidosis. The guideline also discusses the potential risks associated with glucagon-like polypeptide-1 agonists and the need for careful medication management before surgery.
Research Needs
The guideline identifies the need for further research on myocardial injury after noncardiac surgery (MINS) and the management of atrial fibrillation (AFib) that may occur during or after surgery. These areas require ongoing studies to determine the best approaches to prevent and manage these conditions in surgical patients.
Conclusion
In conclusion, the 2024 guideline for managing cardiovascular risk in noncardiac surgery provides a comprehensive overview of the latest evidence and recommendations for clinicians caring for patients undergoing surgery. By following these guidelines, healthcare professionals can optimize care for patients with cardiovascular conditions and risk factors, ultimately improving outcomes and reducing complications associated with noncardiac surgery.
