2024-Perioperative-CV-Management-Guideline-Slide-Set-gl

Guideline Overview

  • Title: 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery

  • Developed By: American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

  • Collaborators: Endorsed by multiple organizations including the American College of Surgeons, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society of Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine.

Surgical Timing and Risk Definitions

Surgical Timing Definitions

  • Emergency: Immediate threat to life/limb, requiring surgery within <2 hours

  • Urgent: Threat to life/limb, surgery needed within ≥2 to <24 hours with possible evaluation

  • Time-sensitive: Delay up to 3 months allowed for preoperative assessment

  • Elective: Surgery can be delayed for full evaluation and management

Surgical Risk Categories

  • Low Risk: MACE risk predicted <1%

  • Elevated Risk: MACE risk predicted ≥1%

Cardiovascular Risk Indices

Recommendations on Risk Indices

  • Recommendation 2a: Use of validated risk-prediction tools is beneficial for patients with known cardiovascular disease (CVD) before noncardiac surgery (NCS).

Key Cardiovascular Risk Calculators

  1. **Goldman Index of Cardiac Risk (1977)

  2. Revised Cardiac Risk Index (RCRI) (1999)

  3. Gupta NSQIP Risk Calculator for MI or Cardiac Arrest (MICA) (2011)

  4. ACS NSQIP Surgical Risk Calculator (2023)

  5. Surgical Outcome Risk Tool (2014)

  6. NSQIP Geriatric-Sensitive Perioperative Cardiac Risk Index (2017)

  7. AUB-HAS2 Cardiovascular Risk Index (2019)

Functional Capacity Assessment

  • Recommendation: Structured assessment like Duke Activity Status Index (DASI) to stratify risk of perioperative adverse events for elevated-risk NCS patients.

Duke Activity Status Index (DASI)

  • Scoring based on ability to perform specific activities. Score ranges from 0-58.2; higher scores indicate better functional status.

Frailty Assessment Recommendations

  • Recommendation: Preoperative frailty assessment for patients ≥65 years or <64 with perceived frailty undergoing elevated-risk NCS.

Frailty Assessment Tools

  • Physical Frailty Phenotype (Fried Phenotype): Assesses slowness, weight loss, exhaustion, weakness.

  • Edmonton Frail Scale: Evaluates multiple domains; higher scores indicate greater frailty.

Preoperative Biomarkers for Risk Stratification

  • Recommendation 1: Measure BNP or NT-proBNP before surgery for patients with CVD or high cardiovascular risk.

  • Recommendation 2: Cardiac troponin (cTn) measurement may be reasonable for patients at elevated risk prior to surgery.

Diagnostic Testing Recommendations

12-Lead Electrocardiogram (ECG)

  • Recommendation 2a: Preoperative ECG recommended for patients with known CVD or significant symptoms before elevated-risk surgery.

Left Ventricular Function Assessment

  • Recommendation 1: Evaluate LV function preoperatively in patients with new dyspnea or recent clinical changes.

Stress Testing Recommendations

  • For elevated-risk NCS with uncertain functional capacity, stress testing may help assess myocardial ischemia.

Stress Testing Modalities Considerations

  • Contraindications: Include significant arrhythmias and hypotension.

Coronary Computed Tomography Angiography (CCTA) Recommendations

  • Recommendation 1: May consider CCTA for patients with known elevated risk and poor functional capacity.

Cardiovascular Management of Hypertrophic Cardiomyopathy

  • Recommendation for HCM: Avoid medications that exacerbate obstruction; manage preload to avoid hemodynamic instability.

Recommendations for Heart Failure Management

  • In patients with heart failure (HF), withhold SGLT2 inhibitors before surgery to reduce metabolic acidosis risk.

Recommendations on Aortic Stenosis Preoperative Management

  • Patients must be evaluated for aortic valve intervention before elevated-risk NCS.

Recommendation for Managing Antiplatelet Therapy and OAC

  • For CAD: A multidisciplinary approach is necessary for managing antiplatelet therapy and timing of surgery.

Timing Recommendations

  • Surgery should be delayed post-PCI based on stent type and individual bleeding risk.

Conclusion

  • The guideline encompasses various aspects of perioperative cardiovascular management, integrating risk stratification, functional capacity assessment, specific testing recommendations, and personalized management based on individual patient characteristics.