Guideline update addresses CV evaluation, management for patients undergoing noncardiac surgery

The American College of Cardiology and the American Heart Association released a guideline update for reducing the risk for CV complications in patients undergoing noncardiac surgery.

The “Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery” was drafted by a writing committee composed of general and subspecialty cardiologists, anesthesiologists, a surgeon, a hospitalist and a patient representative. The document addresses care administered before, during and after noncardiac surgery.

Topics covered in the guideline include recommendations for analysis of clinical risk factors, management of perioperative cardiac testing and preoperative evaluation, perioperative therapy, anesthetic use and intraoperative management, and surveillance and management of perioperative MI.

Update needed

The update follows an evidence review conducted by the guideline committee in April, which analyzed randomized controlled trials, registries, case series, cohort studies and systematic reviews. An independent evidence review committee also evaluated evidence related to perioperative treatment with beta-blockers, whose analysis was consistent with or without evidence from the controversial DECREASE trials; however, removing the DECREASE trials decreased the magnitude of benefit of beta-blocker therapy, according to the release.

“Given the recent publication of several large-scale trials, including POISE II, and new risk calculators, as well as the controversy regarding the use of beta-blockers related to the DECREASE trials, the writing committee felt it was necessary to re-evaluate all of the data on CV care for the patient undergoing noncardiac surgery,” Lee Fleisher, MD, chair of the writing committee and chair of the anesthesiology and critical care department at Perelman School of Medicine at University of Pennsylvania, said in the release.

Care before, during, after surgery

The guideline discusses care provided before, during and after noncardiac surgery.

The authors provide specific recommendations on when clinical testing, including 12-lead ECG, left ventricular function assessment, coronary angiography and stress testing, is warranted. The guideline also advocates the use of validated risk-prediction tools to determine perioperative risk for major adverse cardiac events in this patient population, but notes that further testing is not necessary for patients considered at low risk for these events.

The document also presents a new testing algorithm that incorporates a risk calculator and stresses the lack of a need for further cardiac study among stable patients undergoing low-risk surgery or among those with high exercise tolerance, according to the release.

Beta-blocker therapy

Beta-blocker therapy is recommended for patients undergoing chronic surgery who have been chronic users of the drugs. In addition, perioperative beta-blocker therapy may be reasonable in patients with intermediate- or high-risk myocardial ischemia or those with at least three risk factors from the Revised Cardiac Risk Index. However, according to the guideline, treatment should be initiated long enough in advance — at least 1 day — to assess safety and tolerability before surgery, according to the release.

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Dual antiplatelet therapy

The recommendations also focus on the management of dual antiplatelet therapy. According to the guideline, management of DAPT within 4 to 6 weeks of stent implantation should be established through consensus between the patient, cardiologist, surgeon and anesthesiologist, with an attempt to balance the benefits of stent thrombosis prevention with the potential risk for bleeding. Neither the initiation nor continuation of aspirin therapy is recommended for patients who have received coronary stents and must undergo noncardiac surgery.

Among patients with coronary stents who require discontinuation of P2Y12 platelet receptor inhibitor therapy, it is recommended that aspirin therapy be continued, if possible, and reinitiation of P2Y12 therapy should occur as soon as possible after noncardiac surgery, according to the release.

Elective surgery delay

The authors noted that data related to the delaying of elective noncardiac are is “evolving,” but the guideline contains recommendations for a 14-day delay after balloon angioplasty, 30-day delay after bare-metal stent implantation and 1-year delay after drug-eluting stent implantation. The guideline contains a new class IIb recommendation that acknowledges elective surgery more than 180 days after DES implantation may be considered if the risks of delaying surgery outweigh the risks for a cardiac event. CABG is recommended only if it would be indicated independent of noncardiac surgery, according to the release.

Future research

Future research should include both randomized trials and regional and national registries, with a focus on patient outcomes, according to the guideline. Specifically, the authors called for further evaluation of the benefit of new imaging modalities for preoperative screening, as well as assessment of the optimal timing of perioperative beta-blocker therapy, along with ideal type, dose and titration protocol.

The importance of a “perioperative team approach” is also stressed to implement these recommendations.

“The perioperative team is intended to engage clinicians with appropriate expertise; enhance communication of the benefits, risks and alternatives; and include the patient’s preferences, values and goals,” the authors wrote. “Future research will also need to understand how information regarding perioperative risk is incorporated into patient decision-making.”

For more information:

Fleisher LA. J Am Coll Cardiol. 2014;doi:10.1016/j.jacc.2014.07.945.

Fleisher LA. Circulation. 2014;doi:10.1161/CIR.0000000000000105.

Disclosure: See the full guideline for a list of the authors’ relevant financial disclosures.