ACC/AHA releases guidelines to reduce cardiac risk presurgery

Updated recommendations suggest patients should not stop statins before surgery.

Patients with heart disease should take special precautions before undergoing any surgery to reduce the risk for a cardiac event, according to updated joint guidelines from the American College of Cardiology and American Heart Association.

The “ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery” an update from 2002, are published in Circulation.

According to the recommendations, patients should not stop taking cholesterol-lowering drugs before surgery.

“In the past we had to go on indefinite evidence, but now there are a number of studies published to help us direct best practices,” said, Lee A. Fleisher, MD, chair of the guideline writing committee, in a press release.“Statin use wasn’t even addressed in the previous guidelines. New trials have shown us that patients should continue taking them.”

Other key recommendations

In addition, patients do not need to undergo percutaneous coronary intervention or CABG prior to having noncardiac surgery.

“Several trials now show that in people without symptomatic heart disease, fixing the heart first doesn't make much of a difference in how well they do in surgery,” Fleisher said.

For those patients undergoing a nonurgent, noncardiac surgery who do require an artery-opening procedure prior to that surgery, the guidelines recommend angioplasty with a bare metal stent followed by four to six weeks of antiplatelet therapy.

Due to the risks for excessive bleeding common to any surgery, patients were previously advised to stop taking their antiplatelet therapy prior to surgery. In the guideline update, they are now recommended to stop therapy for urgent and noncardiac surgery that necessitates it, but to continue aspirin therapy if possible and restart the antiplatelet therapy as soon as possible.

“We now know that the antiplatelet medication is very important after stent placement, and we advocate stopping it for as little time as possible,” Fleisher said.

The guidelines also recommend that patients undergo evaluation and treatment before noncardiac surgery only for acute problems, such as unstable angina, decompensated HF, arrhythmias or severe heart valve disease. If the noncardiac surgery is an emergency, heart testing should be bypassed and the patient should enter surgery promptly.

“In general, indications for further cardiac testing and treatments are the same as in the nonoperative setting, but their timing is dependent on several factors,” according to the guidelines. — Judith Rusk

I think they’re driving at doing less evaluations. Whether that’s appropriate or not I don’t know. Guidelines are guidelines and one still needs to decide based on all the layers involved.

— George Vetrovec, MD
Member, Interventional Cardiology, Cardiology Today Editorial Board

For more information:

• Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. Published ahead of print Sept. 27, 2007;10.1161/CIRCULATIONAHA.107.185699.