Today, the American College of Cardiology (ACC) and the American Heart Association (AHA) Joint Committee on Clinical Practice Guidelines have released an updated guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. This guideline supersedes the previous 2014 version and incorporates new evidence to provide clinicians with consolidated guidance.

Clinicians are advised to familiarize themselves with this updated guideline, as it includes evidence-based management strategies for cardiovascular disease and associated medical conditions. These strategies encompass pharmacological therapies, perioperative monitoring, and the use of devices to optimize patient outcomes during noncardiac surgeries.

The recommendations listed in this guideline are, whenever possible, evidence based. An initial extensive evidence review—which included literature derived from research within selected databases relevant to this guideline—was conducted from August 2022 to March 2023. 

The guideline has been developed to assist clinicians in implementing an evidence-based, expert-informed approach to the perioperative cardiovascular management of patients being considered for noncardiac surgery (NCS). Optimal outcomes are achieved through effective communication among all relevant parties, including the surgeon, anesthesiologist, intensivist, primary clinician, consultants, and most importantly, the patient.

The primary objective of perioperative evaluation and management is to promote patient engagement and facilitate shared decision-making by providing clear and comprehensible information on perioperative cardiovascular risk, as well as recommendations for risk mitigation and management. While this guideline primarily focuses on the perioperative care of patients referred for elevated-risk NCS, it is important to note that extensive preoperative testing is not supported by evidence for patients undergoing low-risk surgeries. Additional cardiovascular testing rarely leads to improved patient outcomes.

In this discussion, we will delve into the key takeaways and insights surrounding the guideline’s recommendations for perioperative cardiovascular evaluation and management for noncardiac surgery. Please note that this list does not encompass all major points. For a complete list of recommendations, refer to the full text guideline located here on the ACC website.

Key Takeaways and Recommendations:

Risk Calculators:

Preoperative cardiovascular risk assessment plays an important role in predicting the likelihood of adverse outcomes during surgery.

  • Risk calculators serve as valuable tools that can complement or even replace the assessment of surgery-related factors (such as anesthesia type and surgery type) and patient-related factors (such as physical activity and physical examination). When used together, they provide a comprehensive evaluation of the potential risk of cardiovascular complications. It is important to note that there is a significant variability in the predicted risk of cardiovascular complications when different risk-prediction tools are employed.

Stress Testing:

Stress testing should be used judiciously in patients undergoing NCS, particularly those at lower risk. Testing should only be performed in patients for whom it would be appropriate regardless of planned surgery.

  • The presence of reversible myocardial ischemia on a preoperative stress test is associated with increased risk for perioperative cardiac events. However, the positive predictive value of an abnormal test is modest, and it is not clear that an abnormal test provides incremental prognostic value beyond standard risk assessment tools (eg, RCRI) or biomarkers (eg, natriuretic peptides). 
  • Testing is also expensive and may lead to unnecessary downstream testing or delays in performing the indicated surgery.  

Multidisciplinary Care Models: 

Collaborative, team-based care is essential when managing patients with complex cardiovascular conditions or unstable anatomy. This approach ensures that patients receive comprehensive and coordinated care.

  • Multidisciplinary care models are becoming more prevalent in the management of complex conditions and care pathways in perioperative medicine. These team-based care models encompass the pre-, intra-, and post-hospital phases of care, playing a crucial role in the care delivery system. They not only enhance efficiency of care but also have the potential to improve overall clinical outcomes and align with patient-centered care objectives, such as facilitating recovery at home.
  • While there is limited data demonstrating the direct impact of interdisciplinary models on the quality and outcomes of perioperative cardiac care, they serve as the foundational framework necessary for achieving meaningful improvements in quality and outcomes. By fostering collaboration among healthcare professionals from various disciplines, these models pave the way for more comprehensive and integrated patient care, ultimately leading to better overall results in perioperative medicine.

Myocardial Injury After NCS

Myocardial injury following NCS is a newly recognized condition that should not be underestimated, as it can have severe implications for patients affected by it.

  • Elderly patients undergoing NCS face an elevated risk of various cardiac and noncardiac complications, such as myocardial injury and infarction, atrial fibrillation (AF), acute kidney injury, and delirium. 
  • Perioperative myocardial injury occurs in around 20% of NCS patients and presents a range of clinical manifestations, from asymptomatic myocardial injury to clear postoperative myocardial infarction (MI), characterized by ischemic symptoms or ECG changes, pathologic Q-waves, or evidence of myocardial tissue loss on imaging.

Atrial Fibrillation During or After NCS

Patients who develop AF during or after neurosurgical procedures are at an elevated risk of stroke. It is imperative that these patients receive vigilant monitoring post-surgery to identify and address any reversible causes of arrhythmia, as well as to assess the necessity for long-term anticoagulation therapy.

The occurrence of new-onset perioperative/postoperative AF (POAF) following neurosurgical procedures is not uncommon, with the incidence varying depending on the specific type of surgery and patient demographics. POAF can manifest as either asymptomatic or symptomatic, potentially leading to hemodynamic instability.

We appreciate your participation in our Guidelines Spotlight on Perioperative Cardiovascular Evaluations and Management for Noncardiac Surgery. These guidelines are continuously evolving to enhance patient care and outcomes. We value your thoughts and feedback and look forward to our next spotlight.

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