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Published by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines · ACC/AHA Class of Recommendation and Level of Evidence
Cardiovascular risk factors and disease are prevalent among adults undergoing noncardiac surgery, and perioperative cardiovascular complications are an important cause of morbidity and mortality. Each year, approximately 14.4 million inpatient and 19.2 million ambulatory surgeries are performed in the United States.
Key Takeaways
This guideline supersedes the previously published '2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery', updating recommendations with new evidence and evidence-based management strategies.
In patients with known CVD being considered for NCS, a validated risk-prediction tool can be useful to estimate the risk of perioperative MACE.
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.
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.
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-risk surgery, a preoperative resting 12-lead electrocardiogram (ECG) is reasonable to establish a preoperative baseline and guide perioperative management.
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.
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.
In patients with ACS being considered for elective NCS, coronary revascularization as appropriate and deferral of surgery is recommended to reduce perioperative cardiovascular events.
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.
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.
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.
Clinical Topic
Perioperative Cardiovascular Management
Objectives
Provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.
Target Patient Population
Adult patients (≥18 years of age) being considered for noncardiac surgery.
Diagnostic Criteria
Myocardial injury after noncardiac surgery (MINS) diagnosis requires >1 elevated cTn (>99th percentile of the upper reference limit) of presumed ischemic origin.
Target Providers
Therapeutic Area
Cardiovascular DiseaseGuideline Scope
Inclusion Criteria
Care Settings
Special Populations
System: ACC/AHA Class of Recommendation and Level of Evidence
Evidence Levels
Recommendation Strength
Contraindications
Monitoring Guidance
Intraoperative monitoring techniques are described, including targeted guidance on echocardiography, body temperature maintenance, temporary mechanical circulatory support, and pulmonary artery catheters.
Difficulty
advanced
Learning Paths