Updated AHA/ACA Guideline on Managing CVD Risk With Noncardiac Surgery
On September 24, the American Heart Association and American College of Cardiology simultaneously published an updated joint guideline in Circulation and JACC addressing cardiovascular evaluation and management of patients before, during, and after noncardiac surgery.
The 2024 guideline, now updated a decade later, is endorsed by the American College of Surgeons, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society of Cardiovascular Magnetic Resonance, and Society of Vascular Medicine.
These updates are intended for patients of noncardiac surgery, from preoperative evaluation through postoperative care, including the appropriate use of cardiovascular testing and screening, management of cardiovascular conditions, and recommendations for those who are taking sodium-glucose cotransporter 2 (SGLT2) inhibitors for type 2 diabetes.
“There is a wealth of new evidence about how to best evaluate and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery,” said Chair of the guideline writing group Annemarie Thompson, MD, MBA, FAHA, of Duke University Medical Center in North Carolina. The guideline targets the many disciplines of health care providers caring for people who are undergoing surgery that requires general or regional anesthesia and who have known or potential cardiovascular risks.
Some of the new key guideline points include the following:
As did the 2014 guideline, the 2024 guideline includes a perioperative algorithm to guide care decisions for patients with cardiovascular conditions undergoing noncardiac surgery. The new guidelines, in addition, include points on blood pressure management before, during, and after surgery. Specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea, and previous stroke are also included in the 2024 update.
The guideline update also includes recommendations on using emergency-focused cardiac ultrasound in patients undergoing noncardiac surgery with unexplained hemodynamic instability. This screening option can be performed in the operating room during surgery to help determine if heart problems are causing unstable blood pressure.
According to the 2024 guideline, SGLT2 inhibitors should be discontinued three to four days before surgery to minimize the risk for perioperative ketoacidosis, which can negatively affect surgical outcomes. Glucagon-like peptide 1 (GLP-1) inhibitors used for managing type 2 diabetes and/or obesity may cause delayed stomach emptying, which may put patients at increased risk for pulmonary aspiration while under anesthesia; discontinuation and timing of GLP-1 inhibitors prior to surgery are emerging areas of investigation. The new guideline also states that in most cases, it is safe to stop blood thinners several days before surgery and restart upon hospital discharge, but clinicians are encouraged to refer to the guideline for exceptions and modifications.
Myocardial injury after noncardiac surgery is diagnosed based on elevated cardiac troponin levels after surgery. However, little is known about this newly identified condition, how to prevent it, and how to best manage it. Outpatient follow-up is recommended to council patients on how to reduce their heart disease risk factor.
Paying attention to whether atrial fibrillation occurs during or after noncardiac surgery is imperative, and the guideline prompts clinicians to closely follow these patients to treat reversible causes on atrial fibrillation and consider the need for rhythm control or the use of blood thinners.
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