How to manage heart and stroke risks before, during and after non-heart surgery
By American Heart Association News
For people having surgery unrelated to their hearts, new guidelines detail how to manage heart and stroke risks before, during and after surgery.
The guidelines, based on evidence accumulated over the past decade, address issues such as how to minimize testing to avoid unnecessary costs and delays in surgery and how to properly manage blood pressure and heart medications. They were issued Tuesday by the American Heart Association and American College of Cardiology. Seven other medical societies endorsed the new guidelines.
"There is a wealth of new evidence about how best to evaluate and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery," Dr. Annemarie Thompson, who led the guidelines writing group, said in a news release. Thompson is a professor of anesthesiology, medicine and population health sciences at Duke University School of Medicine in Durham, North Carolina.
"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," she said.
The updated guidelines, which target health professionals across disciplines, were written for patients scheduled for non-heart surgery from the time they're evaluated before surgery through postoperative care. They include recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, heart valve disease, pulmonary hypertension, obstructive sleep apnea and previous stroke. They replace older guidelines published in 2014.
"The U.S. population is getting older and is living longer with chronic health conditions, including chronic heart and vascular diseases," Thompson said. "A multidisciplinary, team-based approach" that includes surgeons, primary care physicians and specialists is needed to ensure optimal care for people with cardiovascular conditions and risk factors before, during and after surgery, she said.
The new guidelines cover the use of cardiovascular testing and screening, patient evaluations and assessments and the most recent evidence for how to manage cardiovascular conditions in people who need any surgery that requires general or regional anesthesia.
They also include recommendations for people taking new therapies to manage diabetes, heart failure and obesity. Specifically, the guidelines recommend that sodium-glucose cotransporter-2 (SGLT2) inhibitors be discontinued three to four days before surgery to minimize the risk of complications. The guidelines also include recommendations for discontinuing and resuming the use of blood thinners.
"From prior studies, conditions such as high blood pressure, Type 2 diabetes, age older than 55 in men and 65 in women, smoking and obesity are known risk factors that predispose patients to cardiovascular disease," Thompson said. "Others have a family history of premature coronary artery disease, which can also put them at increased risk. These guidelines are 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."
The updated guidelines also focus on the need for additional research in two areas.
One is a newly identified condition known as myocardial injury after noncardiac surgery, or MINS, which involves injury to the heart that occurs during or shortly after surgery. Little is known about what causes MINS or how to prevent or manage it.
More research is also needed to understand how to manage irregular heart rhythms that may occur during or after noncardiac surgery, which can increase the risk for stroke.