In 2014, the American College of Cardiology and American Heart Association (ACC/AHA) released an updated guideline on perioperative cardiovascular evaluation and management of patients undergoing non-cardiac surgery. The guideline—published jointly in the Journal of the American College of Cardiology and Circulation—discusses several important treatment considerations for this patient population.
Addressing β-Blocker Use
According to the guideline, β-blockers should be continued in patients undergoing surgery if they have been taking these medications chronically. For patients with intermediate- or high-risk myocardial ischemia after a previous surgery, it may be reasonable to begin perioperative β-blockade. For those with three or more risk factors (eg, diabetes, heart failure, or coronary artery disease), the guidelines say it may reasonable to begin β-blockers before surgery. In patients with no risk factors, starting β-blockers in the perioperative setting provides unknown benefit, especially if long-term β-blockade is not indicated.
“The guidelines reaffirm that stopping β-blockers in the perioperative period can be harmful,” says Lee A. Fleisher, MD, who chaired the ACC/AHA writing committee. “Our evidence-review committee examined all of the literature to better define how these drugs should be used.” Some recommendations for using these drugs were also downgraded. For example, β-blockers can be given to high-risk patients, but this was downgraded from a class IIa recommendation to class IIb due to weak evidence.
Other Important Changes
The ACC/AHA recommendations have not changed much regarding the use of statins in the perioperative setting. Most data supporting the use of statins in this setting are taken from observational studies. Some evidence suggests that statins should not be withdrawn and might be reasonable to use for patients undergoing non-cardiac surgery. Perioperative statin use is deemed reasonable in patients undergoing vascular surgery and may be considered in patients with indications for these drugs if they are undergoing higher-risk procedures.
“The guidelines also recommend using the Revised Cardiac Risk Index as the primary tool for assessing cardiac risk and the American College of Surgeons’ National Surgical Quality Improvement Program Surgical Risk Calculator to estimate the likelihood of unfavorable outcomes after surgery,” Dr. Fleisher says. “In addition, there is new guidance on the timing of elective non-cardiac surgery.” Elective non-cardiac surgery should be delayed 14 days after balloon angioplasty and bare-metal-stent implantation. These surgeries surgery should be delayed 1 year following the implantation of a drug-eluting stent, but may be considered after 6 months if the risk of further delay is greater than risks of ischemia and stent thrombosis.
“Perioperative care of patients undergoing non-cardiac surgery is a team sport,” says Dr. Fleisher. “All physicians involved in the care of these patients should review the guidelines and consider the recommendations. This may help improve outcomes and better inform decision making.”
Readings & Resources (click to view)
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Aug 1 [Epub ahead of print]. Available at: http://circ.ahajournals.org/content/early/2014/07/31/CIR.0000000000000105.long.
Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA guidelines on noncardiac surgery: cardiovascular assessment and management. Eur Heart J. 2014 Aug 1 [Epub ahead of print]. Available at: http://eurheartj.oxfordjournals.org/content/early/2014/07/28/eurheartj.ehu282.full.pdf+html.
Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 2011;58:2432-2446.