AHA/ACC Update Guidelines on Cardiovascular Risk in Noncardiac Surgery

Annemarie Thompson, MD, MBA

Credit: American Heart Association

The American Heart Association (AHA) and American College of Cardiology (ACC) have released an updated joint guideline for the cardiovascular management of adults undergoing non-cardiac surgery, representing a decade of new data since the last guideline was published in 2014.¹

These updates, entitled the “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery,” illustrated the latest evidence for noncardiac surgery and the management of cardiovascular disease (CVD) risk factors before, during, and after surgery.

Recommendations were made for patients scheduled for noncardiac surgery from preoperative assessment through postoperative care, such as the appropriate use of cardiovascular testing and screening, management of cardiovascular conditions and risks, and the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for type 2 diabetes (T2D).

“Worldwide, there are approximately 300 million noncardiac surgeries each year, which underscores the need to summarize and interpret the evidence to assist clinicians in managing patients who present for surgery,” said Annemarie Thompson, MD, MBA, a professor of anesthesiology, medicine, and population health sciences at Duke University Medical Center, and the chair of the guideline writing group.² “This new guidelines is a comprehensive review of the latest research to help information clinicians who manage perioperative patients, with the ultimate goal of restoring health and minimizing cardiovascular complications.”

Similar to the 2014 report, the updated AHA/ACC guideline released a perioperative algorithm to guide care decisions before non-cardiac surgery. This included blood pressure management in the pre-, peri-, and post-operation periods, with tailored recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea, and previous stroke.

The AHA/ACC guidelines suggest health care professionals remain sensible and targeted when ordering screenings to determine cardiac risk before surgery. The guidelines recommended emergency-focused cardiac ultrasound for patients undergoing noncardiac surgery with unexplained hemodynamic instability if experts are available.

Further perioperative implications were placed on the role of newer medications for T2D, heart failure, and obesity management in these guidelines. In particular, SGLT2 inhibitors were urged to be discontinued 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis.

Glucagon-like polypeptide-1 (GLP-1) agonists for T2D or obesity are known to cause nausea and delayed stomach emptying, which could elevate the risk of pulmonary aspiration during anesthesia. Other organizations have recommended withholding GLP-1 agonists before noncardiac surgery to reduce this risk—the AHA/ACC indicated discontinuation and proper timing for doing so remain under investigation.

The AHA/ACC recommended it safe to halt blood thinners days before surgery, undergo surgery, and begin to take blood thinners in the postoperative period, even after hospital discharge. The organizations urged clinicians to refer to the recommendations for exceptions and modifications.

These recommendations called for additional research into myocardial injury after noncardiac surgery (MINS). Diagnosed by elevated cardiac troponin levels after surgery, MINS is found in approximately 1 in 5 noncardiac surgery patients. Although linked to worse short- and long-term events, there is little evidence of its cause and best strategies for prevention and management.

Guideline authors also insisted on an emphasis on atrial fibrillation (AF), which can occur during or after non-cardiac surgery. They noted individuals with newly diagnosed AF exhibit an increased stroke risk, recommending close follow-up to treat reversible causes of AF, and the need for rhythm control or blood thinners to prevent stroke.

“This guideline is written with the understanding that these and other cardiovascular risk factors and conditions can contribute to negative surgical outcomes if they are unrecognized or not optimized before surgery,” Thompson said.²

The guideline was developed in conjunction with and endorsed by seven other medical societies, including the American College of Surgeons, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society of Cardiovascular Anesthesiologists, the Society of Cardiovascular Computed Tomography, the Society of Cardiovascular Magnetic Resonance and the Society of Vascular Medicine.¹

“The US population is getting older and is living longer with chronic health conditions, including chronic heart and vascular diseases,” Thompson said.² “A multidisciplinary, team-based approach, including surgeons, primary care physicians, cardiologists, internal medicine doctors, and other medical specialists, is needed to optimize care for patients with cardiovascular conditions and risk factors before, during, and after surgery.”

References

1. _{Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online September 24, 2024. doi:10.1161/CIR.0000000000001285}
2. _{New guideline details how to manage CVD risk before, during & after Noncardiac Surgery. American Heart Association. September 24, 2024. Accessed September 25, 2024. https://newsroom.heart.org/news/new-guideline-details-how-to-manage-cvd-risk-before-during-after-noncardiac-surgery?preview=b490&preview_mode=True.}