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American Heart AssociationCardiology2024advanced

Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Published by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines · ACC/AHA Class of Recommendation and Level of Evidence

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Summary

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Cardiovascular risk factors and disease are prevalent among adults undergoing noncardiac surgery, and perioperative cardiovascular complications are an important cause of morbidity and mortality. Each year, approximately 14.4 million inpatient and 19.2 million ambulatory surgeries are performed in the United States.

perioperative cardiovascular managementACC/AHAcardiologyguidelinesnoncardiac surgerySGLT2imyocardial injury after noncardiac surgeryatrial fibrillation

Key Takeaways

  • 1
    A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted.
  • 2
    Cardiovascular screening and treatment of patients undergoing noncardiac surgery should adhere to the same indications as nonsurgical patients.
  • 3
    Stress testing should be performed judiciously in patients undergoing noncardiac surgery, especially those at lower risk.
  • 4
    Team-based care should be emphasized when managing patients with complex anatomy or unstable cardiovascular disease.
  • 5
    New therapies for management of diabetes, heart failure, and obesity have significant perioperative implications. SGLT2i should be discontinued 3 to 4 days before surgery.
  • 6
    Myocardial injury after noncardiac surgery is a newly identified disease process that should not be ignored.
  • 7
    Patients with newly diagnosed atrial fibrillation identified during or after noncardiac surgery have an increased risk of stroke and should be followed closely.
  • 8
    Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications.
  • 9
    Emergency focused cardiac ultrasound can be used for perioperative evaluation in patients with unexplained hemodynamic instability.

What's New in This Version

This guideline supersedes the previously published '2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery', updating recommendations with new evidence and evidence-based management strategies.

Key Recommendations

3.1. Cardiovascular Risk Indices

  • rec_3.1_1

    In patients with known CVD being considered for NCS, a validated risk-prediction tool can be useful to estimate the risk of perioperative MACE.

    2aEvidence: B-NRRisk Assessment

3.2. Functional Capacity Assessment

  • rec_3.2_1

    In patients undergoing elevated-risk NCS, a structured assessment of functional capacity (such as the Duke Activity Status Index [DASI]) is reasonable to stratify the risk of perioperative adverse cardiovascular events.

    2aEvidence: B-NREvaluation

3.3. Frailty

  • rec_3.3_1

    In all patients ≥65 years of age and in those <64 years with perceived frailty who are undergoing elevated-risk NCS, preoperative frailty assessment using a validated tool can be useful for evaluating perioperative risk and guiding management.

    2aEvidence: B-NREvaluation

4.1. 12-Lead Electrocardiogram

  • rec_4.1_1

    For patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, other significant structural heart disease, or symptoms of CVD undergoing elevated-risk surgery, a preoperative resting 12-lead electrocardiogram (ECG) is reasonable to establish a preoperative baseline and guide perioperative management.

    2aEvidence: B-NRDiagnostic Testing

4.2.1. Left Ventricular Function

  • rec_4.2.1_1

    In patients undergoing NCS with new dyspnea, physical examination findings of HF, or suspected new/worsening ventricular dysfunction, it is recommended to perform preoperative evaluation of LV function to help guide perioperative management.

    1Evidence: B-NRDiagnostic Testing

4.3. Stress Testing

  • rec_4.3_2

    In patients who are at low risk for perioperative cardiovascular events, have adequate functional capacity with stable symptoms, or who are undergoing low-risk procedures, routine stress testing before NCS is not recommended due to lack of benefit.

    3: No benefitEvidence: B-RDiagnostic Testing

6.1.1. Coronary Revascularization

  • rec_6.1.1_1

    In patients with ACS being considered for elective NCS, coronary revascularization as appropriate and deferral of surgery is recommended to reduce perioperative cardiovascular events.

    1Evidence: C-LDManagement

6.3. Heart Failure

  • rec_6.3_1

    In patients with HF undergoing elective NCS, sodium-glucose cotransporter-2 inhibitors (SGLT2i) should be withheld for 3 to 4 days before surgery when feasible to reduce the risk of perioperative metabolic acidosis.

    1Evidence: C-LDMedication Management

7.5. Antiplatelet Therapy and Timing of Noncardiac Surgery in Patients With Coronary Artery Disease

  • rec_7.5_8

    In patients with CAD who require time-sensitive NCS within 30 days of PCI with BMS or <3 months of PCI with DES, DAPT should be continued unless the risk of bleeding outweighs the benefit of the prevention of stent thrombosis.

    1Evidence: B-NRMedication Management

7.7. Perioperative Beta Blockers

  • rec_7.7_3

    In patients undergoing NCS and with no immediate need for beta blockers, beta blockers should not be initiated on the day of surgery due to increased risk for postoperative mortality.

    3: HarmEvidence: B-RMedication Management

Scope & Objectives

Clinical Topic

Perioperative Cardiovascular Management

Objectives

Provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

Target Patient Population

Adult patients (≥18 years of age) being considered for noncardiac surgery.

Diagnostic Criteria

Myocardial injury after noncardiac surgery (MINS) diagnosis requires >1 elevated cTn (>99th percentile of the upper reference limit) of presumed ischemic origin.

Target Providers

SurgeonsAnesthesiologistsIntensivistsPrimary cliniciansCardiologistsConsultants

Patient Criteria & Setting

Therapeutic Area

Cardiovascular Disease

Guideline Scope

EvaluationManagementRisk Assessment

Inclusion Criteria

  • Adult patient (≥18 years of age)
  • Considered for noncardiac surgery

Care Settings

Ambulatory surgery centerOutpatient surgeryInpatient surgeryPerioperative care

Special Populations

Liver and Kidney TransplantationObesity and Bariatric SurgeryAdult Congenital Heart DiseaseFrail patientsHeart Transplantation RecipientsLeft Ventricular Assist Devices (LVAD) patients

Evidence Grading

System: ACC/AHA Class of Recommendation and Level of Evidence

Evidence Levels

Level AHigh-quality evidence from more than 1 RCT, meta-analyses of high-quality RCTs, or 1 or more RCTs corroborated by high-quality registry studies.
Level B-RModerate-quality evidence from 1 or more randomized controlled trials (RCTs) or meta-analyses of moderate-quality RCTs.
Level B-NRModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies.
Level C-EOConsensus of expert opinion based on clinical experience.
Level C-LDRandomized or nonrandomized observational or registry studies with limitations of design or execution, or physiological/mechanistic studies in human subjects.

Recommendation Strength

Class 1STRONG recommendation. Benefit >>> Risk. Intervention is recommended, indicated, useful, effective, or beneficial.
Class 2aMODERATE recommendation. Benefit >> Risk. Intervention is reasonable or can be useful/effective/beneficial.
Class 2bWEAK recommendation. Benefit ≥ Risk. Intervention may/might be reasonable or considered.
Class 3: HarmSTRONG. Risk > Benefit. Intervention is potentially harmful and should not be performed.
Class 3: No BenefitMODERATE. Benefit = Risk. Intervention is not recommended.

Safety & Contraindications

Contraindications

  • Vasodilator stress testing: significant arrhythmias, significant hypotension, or known/suspected bronchoconstrictive disease
  • Dobutamine stress echocardiography: critical aortic stenosis, hemodynamically significant LVOT obstruction

Monitoring Guidance

Intraoperative monitoring techniques are described, including targeted guidance on echocardiography, body temperature maintenance, temporary mechanical circulatory support, and pulmonary artery catheters.

Authors & Contributors

Annemarie ThompsonKirsten E. FleischmannNathaniel R. SmilowitzLisa de las FuentesDebabrata MukherjeeNiti R. AggarwalFaraz S. Ahmad

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Perioperative MedicineCardiovascular Risk AssessmentNoncardiac SurgeryPreoperative EvaluationMyocardial Injury (MINS)