The ACC and the American Heart Association have released a new, updated guideline for minimizing the risk of cardiovascular complications before, during and after a patient undergoes non-cardiac surgery. The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery," was published Aug. 1 in the Journal of the American College of Cardiology, and was accompanied by a systematic review of the guideline on perioperative beta blockade in non-cardiac surgery.

The updated guideline was based on a thorough evidence review that analyzed randomized controlled trials, case series, systematic reviews, cohort studies and registries. It puts particular emphasis on preoperative evaluation, offering recommendations on when clinical testing – such as 12-lead ECG, assessment of left ventricular function, coronary angiography and stress testing – may be warranted. Additionally proposed is a new testing algorithm that incorporates a risk calculator while continuing to emphasize that stable patients undergoing low-risk surgery or practice good exercise tolerance rarely need further cardiac studies.

Among its various other recommendations, the guideline recommends that beta blockers should be continued in patients undergoing non-cardiac surgery who have been on the drugs chronically. Also noted is that it may be reasonable to begin perioperative beta blockers for patients with intermediate or high risk myocardial ischemia, or for patients with three or more Revised Cardiac Risk Index risk factors such as heart failure, coronary artery disease, renal insufficiency, diabetes mellitus, or even cerebrovascular accident. Regardless, initiation of therapy should be long enough in advance to assess the safety and tolerability of any beta blocker before surgery.

These recommendations for perioperative beta blocker use were based on the results of the accompanied systematic review of 17 studies that found that "perioperative beta blockade started within one day or less before non-cardiac surgery prevents nonfatal myocardial infarction but increases risk of stroke, mortality, hypotension and bradycardia." The authors of the review note that moving forward, additional multicenter random control trials are needed to address the knowledge gap of insufficient data on beta blockade started two or more days prior to surgery.

Further recommendations in the updated guideline address elective non-cardiac surgery, which should be delayed 14 days after balloon angioplasty, 30 days after bare-metal stent implantation, and optimally 365 days after drug-eluting stent implantation. Coronary artery bypass graft surgery should only be performed if it would be indicated independent of a non-cardiac surgery.

Also analyzed is dual antiplatelet therapy, with the writing committee recommending that its management be determined by a committee of the patient, and his or her surgeon, anesthesiologist, and cardiologist to weigh the relative risk of bleeding versus prevention of stent thrombosis. In patients that have received coronary stents and must undergo a surgical procedure that mandates the discontinuation of P2Y₁₂ platelet receptor inhibitor therapy, it is recommended that the patient continue with aspirin and restart P2Y₁₂ as soon as possible.

The writing committee notes that moving forward, "future research on perioperative evaluation and management span the spectrum from randomized controlled trials to regional and national registries to focus on patient outcomes." They add that "future research will also need to understand how information regarding perioperative risk is incorporated into patient decision-making."

In a related editorial comment, Jeffrey Anderson, MD, FACC, et al. note, "the clinical practice guidelines on cardiovascular care in the perioperative period represents a fresh and objective review of old and new evidence in this important clinical arena." They add that, "Clinicians will find the recommendations in these revised clinical practice guidelines useful in their daily work and can be reassured that the recommendations have been vetted thoroughly by the most rigorous scientific process. Furthermore, the recommendations in both documents are fundamentally aligned, so that cardiovascular clinicians worldwide may deliver optimal, standardized care."

Keywords: Exercise Tolerance, Stroke, Myocardial Infarction, Ventricular Function, Left, Drug-Eluting Stents, Hypotension, Risk Factors, Perioperative Period, Electrocardiography, Registries, Renal Insufficiency, Coronary Angiography, Metals, Thrombosis, Heart Failure, Bradycardia, Coronary Artery Bypass, Cardiac Surgical Procedures, Diabetes Mellitus, Exercise Test

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