Periop cardiovascular guideline updated, calls for avoiding overscreening
The American College of Cardiology, American Heart Association, and other societies released new recommendations on evaluating and managing cardiovascular risk in patients undergoing noncardiac surgery.
A group of cardiovascular societies recently updated their guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery.
The guideline represents an update of the guideline put out in 2014 by the American College of Cardiology and American Heart Association. It was also developed and endorsed by the American College of Surgeons, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and Society for Vascular Medicine. The guideline was published on Sept. 24 by Circulation and JACC.
The new guideline calls for a stepwise approach and notes that screening and treatment of surgical patients should proceed like that in nonsurgical patients, avoiding overscreening and overtreatment. Specifically, preoperative stress testing should be performed judiciously, only in patients in whom it would be appropriate independent of planned surgery, the guideline says.
The guideline notes that new therapies for diabetes, heart failure, and obesity have significant perioperative implications. Specifically, sodium-glucose cotransporter-2 inhibitors should be discontinued three to four days before surgery to minimize the risk of perioperative ketoacidosis. Oral anticoagulants should be bridged perioperatively only in those patients at highest risk for thrombotic complications; this practice is not recommended in the majority of cases.
The guideline also addresses myocardial injury after noncardiac surgery, describing it as “a newly identified disease process that should not be ignored because it portends real consequences for affected patients.” Similarly, patients with atrial fibrillation that is diagnosed in the perioperative period “should be followed closely after surgery to treat reversible causes of arrhythmia and to assess the need for rhythm control and long-term anticoagulation,” the guideline said.
It also notes that emergency focused cardiac ultrasound can be used for perioperative evaluation of patients with unexplained hemodynamic instability when clinical expertise is available, but ultrasound should not replace comprehensive transthoracic echocardiography.