Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Publication Date: September 24, 2024
Last Updated: September 24, 2024

Definitions and Calculators

3. Risk Calculators

 3.1. Cardiovascular Risk Indices

  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.
(2a, B-NR)
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Assessment

3.2 Functional Capacity Assessment

  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.
(2a, B-NR)
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3.3. Frailty

  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.
(2a, B-NR)
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3.4. Preoperative Biomarkers for Risk Stratification

  1. In patients with known CVD, or age ≥65 years, or age ≥45 years with symptoms suggestive of CVD undergoing elevated risk NCS, it is reasonable to measure B-type natriuretic peptide (BNP) or N-Terminal pro B-type natriuretic peptide (NT-proBNP) before surgery to supplement evaluation of perioperative risk.
(2a, B-NR)
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  1. In patients with known CVD, or age ≥65 years, or age ≥45 years with symptoms suggestive of CVD undergoing elevated-risk NCS, it may be reasonable to measure cardiac troponin (cTn) before surgery to supplement evaluation of perioperative risk.
(2b, B-NR)
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4. Preoperative Cardiovascular Diagnostic Testing

4.1. 12-Lead Electrocardiogram

  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 surgery, a preoperative resting 12-lead electrocardiogram (ECG) is reasonable to establish a preoperative baseline and guide perioperative management.
(2a, B-NR)

* Active symptoms and signs of CVD include chest pain, dyspnea, undiagnosed palpitations, tachycardia, syncope, or murmurs.

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  1. In patients undergoing NCS with a preoperative ECG exhibiting new abnormalities†, further evaluation is reasonable to refine assessment of cardiovascular risk.
(2a, B-NR)
† Abnormalities may include ST-segment elevation, ST depression, T-wave inversions, left ventricular (LV) hypertrophy, significant pathologic Q-waves, Mobitz type II or higher atrioventricular (AV) block, bundle branch block, QT prolongation, or AF.
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  1. For asymptomatic patients undergoing elevated-risk surgeries without known CVD, a preoperative resting 12-lead ECG may be considered to establish a baseline and guide perioperative management.
(2b, B-NR)
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  1. For asymptomatic patients undergoing low-risk surgical procedures, a routine preoperative resting 12-lead ECG is not recommended to improve outcomes.
(3 - No Benefit, B-NR)
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4.2. Assessment of Ventricular Function

4.2.1. Left Ventricular Function
  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.
(1, B-NR)
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  1. In patients with a known diagnosis of HF with worsening dyspnea or other change in clinical status undergoing NCS, preoperative assessment of LV function is reasonable to help guide perioperative management.
(2a, C-LD)
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  1. In asymptomatic and clinically stable patients undergoing NCS, routine preoperative evaluation of LV function is not recommended due to lack of benefit.
(3 - No Benefit, B-NR)
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4.3. Stress Testing

  1. For patients undergoing elevated-risk NCS with poor or unknown functional capacity and elevated risk for perioperative cardiovascular events based on a validated risk tool, stress testing may be considered to evaluate for inducible myocardial ischemia.
(2b, B-NR)
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  1. 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 Benefit, B-R)
* Poor functional capacity is considered <4 METS or a DASI score of ≤34.
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4.3.1. Modality Selection for Stress Testing

4.5. Coronary Computed Tomography Angiography

  1. For patients undergoing elevated-risk surgery with poor* or unknown functional capacity, and elevated risk for perioperative cardiovascular events based on a validated risk tool, coronary computed tomography angiography (CCTA) for the detection of high-risk coronary anatomy† may be considered.
(2b, B-NR)

* Poor functional capacity is considered <4 METS or a DASI score of ≤34.

† High-risk coronary anatomy is defined as patients with obstructive stenosis who have ≥50% left main stenosis or anatomically significant 3-vessel disease (≥70% stenosis).

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  1. 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 CCTA before NCS is not recommended due to lack of benefit.
(3 - No Benefit, B-NR)
* Poor functional capacity is considered <4 METS or a DASI score of ≤34.
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4.6. Invasive Coronary Angiography

  1. In patients undergoing NCS, routine preoperative invasive coronary angiography (ICA) is not recommended to improve perioperative outcomes.
(3 - No Benefit, C-LD)
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Management

6. Cardiovascular Comorbidities and Perioperative Management

6.1. Coronary Artery Disease

6.1.1. Coronary Revascularization
  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.
(1, C-LD)
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  1. In patients with CCD and hemodynamically significant left main coronary artery stenosis ≥50% who are planning elective NCS, coronary revascularization and deferral of surgery is reasonable to reduce perioperative cardiovascular events.
(2a, C-LD)
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  1. In patients with nonleft main CAD who are planned for NCS, routine preoperative coronary revascularization is not recommended to reduce perioperative cardiovascular events.*
(3 - No Benefit, B-R)

* Modified from the 2021 ACC/AHA/SCAI Coronary Revascularization Guideline.

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6.2. Hypertension and Perioperative Blood Pressure Management

Preoperative Blood Pressure Management

  1. In most* patients with HTN planned for elective NCS, it is reasonable to continue medical therapy for HTN throughout the perioperative period.†
(2a, C-LD)

* Caution is advised when continuing antihypertensive therapy in patients with low or low-normal perioperative BPs, older adults (≥65 years), and patients in whom the risk for perioperative hypotension is high based on an evaluation of the patient’s overall clinical status.
† Modified from the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA High Blood Pressure Guideline.”

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  1. In patients undergoing elective elevated-risk surgery who have cardiovascular risk factors for perioperative complications‡ and recent history of poorly controlled HTN (systolic blood pressure [SBP] ≥180 mm Hg or diastolic blood pressure [DBP] ≥110 mm Hg before the day of surgery), deferring surgery may be considered to reduce the risk of perioperative complications.†
(2b, C-LD)

† Modified from the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA High Blood Pressure Guideline.”

‡ One or more components of the RCRI: CAD, congestive heart failure, cerebrovascular accident, baseline serum creatinine >2.0 mg/dL, or preoperative insulin treatment.

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Intraoperative Blood Pressure Management

  1. In patients undergoing NCS, maintaining an intraoperative mean arterial pressure (MAP) ≥60 to 65 mm Hg or SBP ≥90 mm Hg is recommended to reduce the risk of myocardial injury.
(1, B-NR)
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Postoperative Blood Pressure Management
  1. In patients undergoing NCS, treatment of hypotension (MAP <60–65 or SBP <90 mm Hg) in the postoperative period is recommended to limit the risk of cardiovascular, cerebrovascular, renal events, and mortality.
(1, B-NR)
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  1. In patients with HTN undergoing NCS, it is recommended that preoperative antihypertensive medications be restarted as soon as clinically reasonable to avoid complications from postoperative HTN.
(1, C-EO)
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6.3. Heart Failure

  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.
(1, C-LD)

* Canagliflozin, dapagliflozin, and empagliflozin should be stopped ≥3 days and ertugliflozin ≥4 days before scheduled surgery.

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  1. In patients with compensated HF undergoing NCS, it is reasonable to continue GDMT (excluding SGLT2i) in the perioperative period, unless contraindicated, to reduce the risk of worsening HF.
(2a, C-LD)
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6.3.1. Hypertrophic Cardiomyopathy

  1. For patients with hypertrophic cardiomyopathy (HCM) undergoing NCS, factors that aggravate or trigger dynamic outflow obstructions (eg, positive inotropic agents, tachycardia, or reduced preload) are harmful and should be avoided to reduce the risk of hemodynamic instability.
(3 - Harm, C-LD)
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6.3.2. Pulmonary Hypertension

  1. In patients receiving stable doses of targeted medical therapies* for pulmonary arterial hypertension (PAH) undergoing NCS, it is recommended to continue these agents to reduce the risk for the development of perioperative MACE.
(1, C-LD)
* For example, nitric oxide pathway mediators, endothelin receptor antagonists, prostacyclin pathway agonists, or a combination of these.
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  1. In patients with severe† pulmonary hypertension (PH) undergoing elevated-risk NCS, referral to or consultation with a specialized PH center that can support risk assessment, optimization, and postoperative management (with consideration of intensive care after NCS) is reasonable to reduce perioperative cardiopulmonary complications.
(2a, C-LD)
† Severe PH is defined according to hemodynamics (severe precapillary PH component by right heart catheterization and echocardiography) and additional data derived from clinical assessment, exercise tests, and laboratory biomarkers. Hemodynamically, severe PH displays a mean pulmonary artery (PA) pressure >40 mm Hg, pulmonary vascular resistance >5 Wood units, or echocardiographic evidence of significant RV dysfunction (eg, RV-to-LV diastolic diameter ratio >0.8 or RV dysfunction that is graded as moderate or severe). Although all 5 World Symposium Pulmonary Hypertension group classifications display some degree of risk for developing severe PH, Group 1 (PAH), Group 3 (PH due to lung disease), and Group 4 (chronic thromboembolic PH) are at high risk for developing severe PH if left untreated and may be best managed and followed at a center with PH specialists.
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  1. In patients with severe† PH undergoing elevated-risk NCS, invasive hemodynamic monitoring is reasonable to guide intraoperative and postoperative care.
(2a, C-LD)
† Severe PH is defined according to hemodynamics (severe precapillary PH component by right heart catheterization and echocardiography) and additional data derived from clinical assessment, exercise tests, and laboratory biomarkers. Hemodynamically, severe PH displays a mean pulmonary artery (PA) pressure >40 mm Hg, pulmonary vascular resistance >5 Wood units, or echocardiographic evidence of significant RV dysfunction (eg, RV-to-LV diastolic diameter ratio >0.8 or RV dysfunction that is graded as moderate or severe). Although all 5 World Symposium Pulmonary Hypertension group classifications display some degree of risk for developing severe PH, Group 1 (PAH), Group 3 (PH due to lung disease), and Group 4 (chronic thromboembolic PH) are at high risk for developing severe PH if left untreated and may be best managed and followed at a center with PH specialists.
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  1. In patients with precapillary PH undergoing elevated-risk NCS, perioperative administration of short-acting inhaled pulmonary vasodilators (eg, nitric oxide, aerosolized prostacyclins) may be reasonable to reduce elevated RV afterload and prevent acute decompensated right HF.
(2b, C-EO)
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6.3.3. Adult Congenital Heart Disease

  1. In patients with intermediate- to elevated-risk congenital heart disease (CHD) lesions (Table 10) undergoing elective NCS, preoperative consultation with an adult congenital heart disease (ACHD) specialist is recommended before the surgery.*
(1, B-NR)
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6.3.4. Left Ventricular Assist Devices
  1. In patients with a left ventricular assist device (LVAD), coordination with the LVAD care team on the appropriate timing and perioperative considerations of elective NCS is recommended to mitigate the risk of perioperative MACE.
(1, C-EO)
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6.4. Valvular Heart Disease

6.4.1. Aortic Stenosis
  1. Patients with severe AS should be evaluated for the need for aortic valve intervention before elective NCS to reduce perioperative risk.*
(1, C-LD)
* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
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  1. In patients with suspected moderate or severe AS who are undergoing elevated-risk NCS, preoperative echocardiography is recommended before elective NCS to guide perioperative management.*
(1, C-EO)

* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”

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  1. In asymptomatic patients with moderate or severe AS and normal LV systolic function as assessed by echocardiography within the past year, it is reasonable to proceed with elective low-risk NCS.
(2a, C-LD)
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Figure 2. Management of Patients With Severe Aortic Stenosis Requiring Elective or Time-Sensitive Noncardiac Surgery

* Severe aortic stenosis: aortic valve area <1.0 cm2, mean aortic valve gradient ≥40 mm Hg, or peak aortic valve velocity Vmax ≥4.0 m/s.
† Symptoms of exertional dyspnea, angina, HF, syncope, or presyncope.
‡ Including elevated risk for hemodynamic instability, large volume shifts, or major bleeding.


AVR indicates aortic valve replacement; BAV, balloon aortic valvuloplasty; CAD, coronary artery disease; LVEF, left ventricular ejection fraction; NCS, noncardiac surgery; SAVR, surgical aortic valve replacement; and TAVI, transcatheter aortic valve implantation.


Modified from Sorrentino, et al. Copyright © 2022 BMJ Publishing Group. Limited by permission from BMJ Publishing Group Limited.

6.4.2. Mitral Stenosis

  1. Patients with severe mitral stenosis (MS) should be evaluated for the need for mitral valve (MV) intervention before elective NCS.
(1, B-NR)
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  1. In patients with severe MS who cannot undergo MV intervention before NCS, perioperative invasive hemodynamic monitoring is reasonable to guide management to reduce the risk of cardiovascular complications.
(2a, C-EO)
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  1. In patients with severe MS who cannot undergo MV intervention before NCS, perioperative heart-rate control (eg, beta blockers, calcium channel blockers [CCBs], ivabradine, digoxin) may be considered to prolong diastolic filling time and decrease perioperative cardiovascular complications.
(2b, C-LD)
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6.4.3. Chronic Aortic and Mitral Regurgitation
  1. In patients with suspected moderate or severe valvular regurgitation, preoperative echocardiography is recommended before elective NCS to guide perioperative management.*
(1, C-EO)
* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
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  1. In patients with VHD who meet indications for valvular intervention based on clinical presentation and severity of regurgitation, the need for valvular intervention should be considered before elective elevated-risk NCS to reduce perioperative risk.*
(1, C-EO)
* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
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  1. In asymptomatic patients with moderate or severe MR, normal LV systolic function, and estimated PA systolic pressure <50 mm Hg, it is reasonable to perform elective NCS.*
(2a, C-LD)

* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”

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  1. In asymptomatic patients with moderate or severe aortic regurgitation and normal LV systolic function (LVEF >55%), it is reasonable to perform elective NCS.*
(2a, C-LD)
* Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
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6.4.4. Previous Transcatheter Aortic Valve Implantation or Mitral Valve Transcatheter Edge-to-Edge Repair
  1. For patients who undergo successful transcatheter aortic valve implantation (TAVI), it is reasonable to perform NCS early* as clinically indicated.
(2a, B-NR)
* Evidence supports the safety of NCS within 30 days of TAVI, if indicated.
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  1. For patients who undergo MV TEER, it is reasonable to perform NCS after the successful MV intervention as clinically indicated.
(2a, C-EO)
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6.5. Atrial Fibrillation

Perioperative
  1. In patients with rapid AF identified in the setting of NCS, it is reasonable to treat potential underlying triggers contributing to AF and rapid ventricular response (eg, sepsis, anemia, pain).*
(2a, C-LD)

* Adapted from the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”

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  1. In patients with new-onset AF identified in the setting of NCS, initiation of postoperative anticoagulation therapy can be beneficial after considering the competing risks associated with thromboembolism and perioperative bleeding.*
(2a, C-LD)

* Adapted from the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”

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Post-discharge

  1. In patients with new-onset AF identified in the setting of NCS, outpatient follow-up for thromboembolic risk stratification and AF surveillance are recommended given a high risk of AF recurrence.*
(1, C-LD)
* Adapted from the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”
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6.6. Cardiovascular Implantable Electronic Devices

  1. Patients with cardiovascular implantable electronic devices (CIED) having elective NCS should have a management plan developed before surgery if electromagnetic interference (EMI) is anticipated, including identification of the type of CIED (eg, pacemaker, implantable cardioverter-defibrillator [ICD], implantable monitor), manufacturer, and model.
(1, B-NR)
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  1. Patients who are pacemaker-dependent having surgeries above the umbilicus with anticipated EMI should have the pacemaker reprogrammed or have a magnet placed on the generator to provide an asynchronous mode to avoid pacing inhibition.
(1, B-NR)
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  1. Pacemaker-dependent patients with a transvenous ICD undergoing surgery above the umbilicus with anticipated EMI should have the device reprogrammed*; if the patient is not pacemaker-dependent, then either reprogramming or a magnet placed on the generator can be used to inhibit tachytherapies or inappropriate shocks.
(1, B-NR)
* For pacemaker-dependent patients with an ICD, tachytherapies should be disabled and the device should be reprogrammed to an asynchronous mode to avoid pacing inhibition.
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  1. Patients who have a pacemaker or ICD reprogrammed to asynchronous pacing or have tachytherapies programmed off before surgery should have device functioning restored in the postoperative period before hospital discharge.
(1, B-NR)
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  1. Patients with leadless pacemakers who are pacemaker-dependent having surgeries with anticipated EMI above the umbilicus should have their pacemakers reprogrammed to an asynchronous mode.
(1, C-LD)
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  1. For patients with subcutaneous ICD having noncardiac or nonthoracic surgery with anticipated EMI above the groin, it is reasonable to reprogram the device or use a magnet to temporarily disable tachytherapies.
(2a, C-LD)
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6.7. Previous Stroke or Transient Ischemic Attack

  1. In patients with a history of stroke or transient ischemic attack, it is reasonable to delay elective NCS for ≥3 months after the most recent cerebrovascular event to reduce the incidence of recurrent stroke, MACE, or both.
(2a, B-NR)
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6.8. Obstructive Sleep Apnea

  1. In patients scheduled for NCS, obstructive sleep apnea (OSA) screening using validated questionnaires is reasonable to assess the risk of perioperative complications.
(2a, B-NR)
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7. Perioperative Medical Therapy

7.1. Statins

  1. In patients currently on statins and scheduled for NCS, continuation of statin therapy is recommended to reduce the risk of MACE.
(1, B-NR)
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  1. In statin-naïve adult patients who meet criteria for statin use based on ASCVD history or 10-year risk assessment and are scheduled for NCS, perioperative initiation of statin is recommended with intention of long-term use.
(1, B-R)
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7.2. Renin-Angiotensin-Aldosterone System Inhibitors

  1. In select* patients on chronic renin-angiotensin-aldosterone system inhibitors (RAASi) for HTN undergoing elevatedrisk NCS, omission 24 hours before surgery may be beneficial to limit intraoperative hypotension.
(2b, B-R)

* Patients with controlled BP and undergoing elevated-risk surgical procedures.

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  1. In patients on chronic RAASi for HFrEF, perioperative continuation is reasonable.†
(2a, C-EO)

† Modified from the “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.”

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7.4. Alpha-2 Receptor Agonists

  1. In patients undergoing NCS, initiation of low-dose clonidine perioperatively is not recommended to reduce cardiovascular risk.
(3 - No Benefit, B-R)
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7.5. Antiplatelet Therapy and Timing of Noncardiac Surgery in Patients With Coronary Artery Disease

  1. For patients with CAD undergoing elective NCS, management of perioperative antiplatelet therapy and timing of surgery should be determined by a multidisciplinary team with shared decision-making to weigh the risks of bleeding, thrombosis, and consequences of delayed surgery.
(1, B-NR)
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Timing of NCS After PCI
  1. In patients with recent coronary artery balloon angioplasty without stent placement, elective NCS should be delayed for a minimum of 14 days to minimize perioperative MACE.
(1, C-LD)
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  1. In patients with DES-PCI placed for ACS who require elective NCS with interruption of ≥1 antiplatelet agents, surgery should ideally be delayed ≥12 months to minimize perioperative MACE.
(1, B-NR)
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  1. In patients with DES-PCI placed for CCD who require elective NCS with interruption of ≥1 antiplatelet agents, it is reasonable to delay surgery for ≥6 months after PCI to minimize perioperative MACE.
(2a, B-NR)
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  1. In patients with DES-PCI who require time-sensitive NCS with interruption of ≥1 antiplatelet agents, NCS may be considered ≥3 months after PCI if the risk of delaying surgery outweighs the risk of MACE.
(2b, B-NR)
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  1. In patients with a recent (≤30 days) bare-metal stent (BMS) or DES-PCI, elective NCS requiring interruption of ≥1 antiplatelet agents is potentially harmful due to a high risk of stent thrombosis and ischemic complications.
(3 - Harm, B-NR)
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Perioperative Antiplatelet Management Post PCI
  1. In patients with prior PCI undergoing NCS, it is recommended to continue aspirin* (75–100 mg), if possible, to reduce the risk of cardiac events.
(1, B-R)

* Platelet adenosine diphosphate receptor (P2Y12) monotherapy may be considered if surgical bleeding risks are acceptable or if aspirin is not tolerated.

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  1. 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.
(1, B-NR)
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  1. In patients with prior PCI in whom OAC monotherapy must be discontinued before NCS, aspirin should be substituted when feasible in the perioperative period until OAC can be safely reinitiated.
(1, B-NR)
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  1. In select patients after PCI who have a high thrombotic risk, perioperative bridging with intravenous antiplatelet therapy may be considered <6 months after DES or <30 days after BMS if NCS cannot be deferred.
(2b, B-NR)
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Perioperative Antiplatelet Management in Patients Without Prior PCI

  1. In patients with CCD without prior PCI undergoing elective NCS, it may be reasonable to continue aspirin in selected patients when the risk of cardiac events outweighs the risk of bleeding.
(2b, B-R)
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  1. In patients with CAD but without prior PCI who are undergoing elective noncarotid NCS, routine initiation of aspirin is not beneficial.
(3 - No Benefit, B-R)
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7.6. Oral Anticoagulants

OAC Management
  1. For patients with CVD receiving OAC who require elective NCS, a multidisciplinary team-based approach to time-based* interruption is recommended to balance the competing risks of thromboembolism and perioperative bleeding (Tables 13 to 14).
(1, B-NR)

* Timing of preoperative interruption is based on patient-specific factors (eg, thrombotic risk, age, sex, body weight, renal clearance), surgical bleeding risk, and drug factors (eg, pharmacokinetics, dosing, drug interactions).

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OAC Bridging

  1. In patients with CVD and high thrombotic risk (Table 14) undergoing NCS where interruption of vitamin K antagonist (VKA) is required, preoperative bridging with parenteral heparin can be effective to reduce thromboembolic risk.
(2a, C-LD)
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  1. In most patients with CVD who are undergoing elective NCS where OAC interruption is warranted, routine periprocedural bridging is not recommended due to increased bleeding risk.
(3 - Harm, C-LD)
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OAC Resumption

  1. In patients with preoperative OAC interruption, resumption of OAC is reasonable after hemostasis is achieved.
(2a, C-LD)
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7.7. Perioperative Beta Blockers

  1. In patients on stable doses of beta blockers undergoing NCS, beta blockers should be continued through the perioperative period as appropriate based on the clinical circumstances.
(1, B-NR)
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  1. In patients scheduled for elective NCS who have a new indication for beta blockade, beta blockers may be initiated far enough before surgery (optimally >7 days) to permit assessments of tolerability and drug titration if needed.
(2b, B-NR)
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  1. 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 - Harm, B-R)
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7.8. Perioperative Management of Blood Glucose

  1. In patients with or at risk for diabetes who are scheduled for elective NCS, preoperative hemoglobin A1c (HbA1C) testing is reasonable if it has not been performed in ≤3 months.
(2a, B-NR)
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  1. In patients scheduled for NCS, SGLT2i should be discontinued 3 to 4 days* days before surgery to reduce the risk of perioperative metabolic acidosis.
(1, C-LD)

* Canagliflozin, dapagliflozin, and empagliflozin should be stopped ≥3 days and ertugliflozin ≥4 days before scheduled surgery.

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  1. In patients with diabetes or impaired glucose tolerance, continuation of metformin during the perioperative period is reasonable to maintain glycemic control.
(2a, C-LD)
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8. Anesthetic Considerations and Intraoperative Management

8.1. Choice of Anesthetic Technique and Agent

  1. In patients undergoing NCS, use of a volatile-based anesthetic agent or total intravenous anesthesia is reasonable for general anesthesia with no apparent difference in associated cardiovascular events (eg, MI, ischemia).
(2a, A)
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  1. In patients undergoing NCS where neuraxial is feasible, either neuraxial or general anesthesia is reasonable with no apparent difference in associated cardiovascular events.
(2a, B-R)
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8.2. Perioperative Pain Management

  1. For patients undergoing major abdominal surgery, the use of epidural analgesia for postoperative pain relief is reasonable to decrease the incidence of perioperative cardiac events.
(2a, B-R)
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  1. For patients with a hip fracture waiting for surgical repair, epidural analgesia may be considered to decrease the incidence of preoperative cardiac events.
(2b, B-R)
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8.3. Intraoperative Monitoring Techniques

8.3.1. Echocardiography
  1. In patients with unexplained hemodynamic instability undergoing NCS, the emergency use of perioperative TEE or FoCUS is reasonable to determine the cause if expertise is readily available.
(2a, C-LD)
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  1. In patients undergoing NCS without risk factors or procedural risks for significant hemodynamic compromise, the routine use of intraoperative TEE is not recommended to screen for cardiac abnormalities or to monitor for myocardial ischemia.
(3 - No Benefit, C-LD)
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8.3.2. Body Temperature
  1. In patients with CVD undergoing NCS, maintenance of normothermia is reasonable to avoid perioperative complications overall.
(2a, B-R)
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8.3.3. Temporary Mechanical Circulatory Support
  1. In patients with acute, severe hemodynamic instability and cardiopulmonary dysfunction undergoing urgent or emergency NCS, temporary MCS devices may be used preemptively or as rescue therapy.
(2b, C-LD)
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8.3.4. Pulmonary Artery Catheters

  1. In patients with CVD undergoing NCS, the use of PA catheterization may be considered when underlying medical conditions that significantly affect hemodynamics (eg, decompensated HF, severe valvular disease, combined shock states, pulmonary HTN) cannot be corrected before surgery.
(2b, C-LD)
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  1. In patients with CVD undergoing NCS, routine use of PA catheterization is not recommended to reduce morbidity or mortality.
(3 - No Benefit, A)
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8.4. Perioperative Anemia Management
  1. In patients having NCS with expected blood loss, tranexamic acid is reasonable to reduce intraoperative blood loss, reduce transfusions, and avoid anemia.
(2a, A)
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  1. In patients with iron deficiency anemia having elective NCS, iron therapy (either oral or intravenous) administered preoperatively is reasonable to reduce blood transfusions and to increase Hgb.
(2a, B-R)
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9. Perioperative Surveillance and Management of Myocardial Injury and Infarction

9.1. Myocardial Injury After Noncardiac Surgery Surveillance and Management

MINS Surveillance
  1. In patients with known CVD, symptoms of CVD, or age ≥65 years with cardiovascular risk factors undergoing elevated-risk NCS, it may be reasonable to measure cTn at 24 and 48 hours after surgery to identify myocardial injury.
(2b, B-NR)
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  1. In patients undergoing low-risk NCS, routine postoperative screening with cTn levels is not indicated without signs or symptoms suggestive of myocardial ischemia or MI.
(3 - No Benefit, B-NR)
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MINS Management
  1. In patients who develop MINS, especially in those not previously known to have excess cardiovascular risk, outpatient follow-up is reasonable for optimization of cardiovascular risk factors.
(2a, B-NR)
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  1. In patients who develop MINS, antithrombotic therapy may be considered to reduce thromboembolic events.
(2b, C-LD)
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9.2. Management of Postoperative ST-Segment-Elevation Myocardial Infarction/Non ST-Segment-Elevation Myocardial Infarction 

  1. Patients who develop STEMI after NCS should be considered for GDMT, including consideration of ICA, balancing bleeding and thrombotic risks with the severity of the clinical presentation.
(1, B-NR)
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  1. after NCS should receive medical therapy as recommended for patients with spontaneous MI but after consideration of postoperative bleeding risks and hemodynamic status.
(1, C-EO)
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  1. Patients who develop NSTEMI after NCS can be considered for ICA, balancing bleeding and thrombotic risks with the severity of clinical presentation.
(2a, C-LD)
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Recommendation Grading

Overview

Title

Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Authoring Organizations

American College of Cardiology

American Heart Association

Endorsing Organizations

American Society of Anesthesiologists

American Society of Echocardiography

American Society of Nuclear Cardiology

Heart Rhythm Society

Society for Cardiovascular Angiography and Interventions

Society for Vascular Medicine

Society of Cardiovascular Anesthesiologists

Society of Hospital Medicine

Publication Month/Year

September 24, 2024

Last Updated Month/Year

November 8, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery” provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

Target Patient Population

Patients being considered for cardiac surgery

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Prevention

Diseases/Conditions (MeSH)

D019990 - Perioperative Care, D002318 - Cardiovascular Diseases

Keywords

cardiovascular, perioperative care, anesthesia and analgesia

Supplemental Methodology Resources

Systematic Review Document

Methodology

Number of Source Documents
491
Literature Search Start Date
April 1, 2013
Literature Search End Date
July 1, 2014