A new clinical practice guideline provides updated recommendations on the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery, published in Circulation, offers evidence-based guidance from preoperative assessment through postoperative care.

Key updates and recommendations include:

• Stepwise Perioperative Cardiac Assessment: A stepwise approach to perioperative cardiac assessment is recommended to help clinicians determine when surgery should proceed or when further evaluation is necessary.
• Judicious Stress Testing: Preoperative stress testing should be performed judiciously, particularly in lower-risk patients, and only when it is appropriate independent of the planned surgery.
• Team-Based Care: Team-based care is emphasized for managing patients with complex anatomy or unstable cardiovascular disease.
• Sodium-Glucose Cotransporter-2 Inhibitors: New therapies for diabetes, heart failure, and obesity have significant perioperative implications. Sodium-glucose cotransporter-2 inhibitors should be discontinued 3-4 days before surgery to reduce the risk of perioperative ketoacidosis.
• Myocardial Injury After Noncardiac Surgery (MINS): MINS has been identified as an important condition requiring close monitoring and management.
• Selective Use of Anticoagulants: Perioperative bridging of oral anticoagulant therapy should be used selectively, reserved for patients at the highest risk of thrombotic complications.
• Focused Cardiac Ultrasound: In patients with unexplained hemodynamic instability, emergency-focused cardiac ultrasound can be used for perioperative evaluation when expertise is available.

Additional guidelines:

• Frailty Assessment: Frailty assessment is recommended in patients aged ≥65 years or those under 65 with perceived frailty. This should be done using validated tools to guide perioperative risk management. Frailty is associated with an increased risk for complications, including cardiac events, functional decline, and prolonged hospital stay.
• Functional Capacity Measurement: The Duke Activity Status Index (DASI) is recommended for estimating functional capacity in patients undergoing elevated-risk surgery. Functional capacity below 4 METs is linked to a higher risk of adverse perioperative cardiovascular events. Structured tools like DASI help identify patients who may benefit from additional cardiovascular testing before surgery.
• Preoperative Electrocardiogram (ECG): For patients with known cardiovascular risk factors, a 12-lead ECG is recommended preoperatively to establish a baseline and guide perioperative management. This applies particularly to those undergoing elevated-risk surgeries.
• Right Ventricular (RV) Function Assessment: Patients with valvular disease or pulmonary hypertension should be evaluated for RV function which is associated with perioperative cardiovascular risks. Echocardiography is recommended for assessing RV function where needed.

The guidelines also provide detailed recommendations on preoperative evaluation, including:

• Use of validated risk prediction tools to estimate perioperative major adverse cardiovascular event (MACE) risk.
• Assessment of functional capacity using structured tools like DASI.
• Preoperative measurement of natriuretic peptides and troponin in select higher-risk patients.
• Judicious use of preoperative stress testing, coronary computed tomography angiography (CCTA), and invasive coronary angiography.

In terms of perioperative management of cardiovascular conditions:

• Continuation of beta-blockers, statins, and most antihypertensive medications perioperatively in patients already taking them.
• Cautious management of patients with valvular heart disease, pulmonary hypertension, and adult congenital heart disease.
• Updated recommendations on perioperative antiplatelet and anticoagulation management.

Conflict of interest disclosures can be found in the full guidelines.