New guidelines on perioperative evaluation and management

Cardiology experts released new guidelines on perioperative care of patients undergoing noncardiac surgery last week.

The updated guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) include recommendations on risk factors and timing to consider before surgery, preoperative tests, perioperative medication management, and postoperative surveillance for myocardial infarction.

The guideline writers separately commissioned a systematic review on which to base their perioperative beta-blocker recommendations. They concluded that beta-blockers should be continued in patients who have been on the drugs chronically and that it may be reasonable to begin them before surgery for patients with intermediate- or high-risk myocardial ischemia or 3 or more Revised Cardiac Risk Index risk factors. Initiation of therapy, however, should be far enough in advance to assess safety and tolerability, definitely not the day of surgery, and preferably more than 1 day before.

Other drugs addressed under the perioperative therapy recommendations include statins, alpha-2 agonists, angiotensin-converting enzyme inhibitors, and antiplatelet agents (including a treatment algorithm for patients with coronary stents). The guidelines also include a new algorithm to guide preoperative testing, addressing such methods as 12-lead electrocardiography, assessment of left ventricular function, coronary angiography, and stress testing.

Finally, the guidelines conclude with advice on surveillance for perioperative myocardial infarction, recommending troponin measurement and electrocardiography if a patient has signs or symptoms suggestive of myocardial ischemia or infarction. However, the usefulness of these tools in high-risk patients with no signs or symptoms is uncertain, and routine postoperative screening is not useful, the guideline concluded.

The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery was published by the Journal of the American College of Cardiology and Circulation ±html on Aug. 1.

The June issue of ACP Internist offered guidance on perioperative medication management.