CVD

Olivia C. Welter, PharmD

In November 2024, the Journal of the American College of Cardiology published a multisociety guideline on perioperative cardiovascular management for noncardiac surgery (NCS). It reflects advancements in evidence-based medicine and updates recommendations from the 2014 version of the guideline, including addressing new medical conditions, new medication classes, and new approaches to risk assessment.

Risk assessment

The guideline authors recommend that clinicians use a validated cardiac risk-prediction tool when estimating the risk of perioperative major adverse cardiac events. Such tools include the Revised Cardiac Risk Index, National Surgical Quality Improvement Program risk calculators, Surgical Outcome Risk Tool, and AUB-HAS2 Cardiovascular Risk Index.

The guideline authors note that functional capacity is an important predictor of adverse cardiovascular event risk. Clinicians can assess a patient’s functional capacity by using a self-reporting instrument such as the Duke Activity Status Index. The patient’s responses give providers a better picture of whether a patient can manage standard tasks such as bathing, climbing stairs, and doing work around the house, and how their score may affect their surgery. Clinicians may also opt to conduct stress testing before surgery for patients with elevated risk for perioperative cardiac events. However, the guideline does not recommend routine stress testing for all patients due to lack of benefit. Clinicians should only consider stress testing for patients in whom testing would be appropriate independent of planned surgery.

Preoperative considerations

Prior to NCS, clinicians should thoroughly review a patient’s medication regimen. The guideline authors recognize that new therapies for management of diabetes, heart failure, and obesity can have significant perioperative implications. SGLT-2 inhibitors have been associated with metabolic acidosis and euglycemic ketoacidosis in the perioperative period, which can lead to serious complications, including death. Patients with heart failure undergoing NCS withhold their SGLT-2 inhibitors doses for 3 to 4 days prior to surgery to mitigate risk of complications such as metabolic acidosis.

The guideline experts also address patients who take chronic renin-angiotensin-aldosterone system inhibitors (RAASi), recommending that patients taking RAASi for hypertension omit any doses for 24 hours prior to surgery, and patients taking RAASi for heart failure with reduced ejection fraction continue therapy as normal.

Patients on stable doses of b-blockers should continue their therapeutic regimen during the perioperative period. However, patients who have a new indication for b-blockade should begin b-blocker therapy more than 7 days before the surgery to allow for assessments of tolerability and drug titration if needed. Additionally, clinicians should avoid initiating b-blockers on the day of surgery when there is no immediate need because it can increase the risk for postoperative mortality.

Some patients may require additional preoperative consultations or assessments to ensure they can safely proceed with surgery while minimizing risk for adverse effects. The guideline recommends that patients with intermediate to elevated risk congenital heart disease (CHD) consult with a CHD specialist prior to the surgery and that patients with aortic stenosis or suspected valvular regurgitation should receive preoperative echocardiography to guide perioperative management. Patients with a history of cardiac transplant may also benefit from a preoperative assessment performed in collaboration with the transplant team. Overall, a stepwise approach to cardiac assessment can help determine when surgery can proceed or when it should be delayed for further evaluation.

Anticoagulation

The guideline recommends a multidisciplinary team-based approach to balance competing risks of thromboembolism and perioperative bleeding for patients receiving oral anticoagulants prior to surgery.

Due to increased bleeding risk, the guideline recommends that clinicians selectively use perioperative bridging of oral anticoagulant therapy in patients at highest risk for thrombotic complications. The guideline also states that patients who have their anticoagulation interrupted perioperatively may reasonably resume therapy once hemostasis is achieved.

According to the guideline, patients diagnosed with AFib during or after surgery are at higher risk for stroke and may benefit from postoperative anticoagulation therapy. Clinicians should closely follow these patients after surgery to treat any reversible causes of arrhythmia and assess the need for long-term anticoagulation and rhythm control.  ■