How to manage the cardiovascular health of patients during noncardiac surgeries
Cardiovascular complications occur in approximately 1 of every 33 admissions for a noncardiac surgery. That amounts to more than 400,000 cardiovascular complications per year.
These statistics led to the creation of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery, a new guidance from several leading U.S. medical societies.[1]
The new document, published in JACC, represents an update to previous recommendations. It includes new clinical evidence that has been added since the last update in 2024. The American Heart Association, American College Cardiology and Heart Rhythm Society were just some of the groups behind its development. The goal is to help guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgeries in an effort to reduce or mitigate the consequences of any complications.
The authors of this guidance shared a step-by-step approach to perioperative cardiac assessments that should assist in determining when surgery should proceed or when a pause for further evaluation is warranted. It encourages stress testing to be performed judiciously in patients undergoing noncardiac surgery, especially those at lower risk, and only in patients in whom testing would be appropriate independent of the planned surgery. The authors said this testing should be done in a way that avoids overtreatment.
In addition, the group noted, a team-based approach should be used when managing patients with complex anatomy or unstable cardiovascular disease.
Highlights from the new guidance
One key takeaways in the document is the fact that new therapies for the management of diabetes, heart failure and obesity may have significant perioperative implications. The document states that sodium-glucose cotransporter 2 (SGLT2) inhibitors should be discontinued three or four days before surgery, for example, to minimize the risk of perioperative ketoacidosis associated with their use.
Myocardial injury after noncardiac surgery is also a newly identified disease process where attention should be paid to avoid serious consequences.
Patients with newly diagnosed atrial fibrillation (AFib) identified during or after noncardiac surgery will face an increased stoke risk, and these patients should be followed closely after surgery. Attempts should be made to treat reversible causes of AFib and to assess the need for rhythm control and long-term anticoagulation.
The authors also said the perioperative bridging of oral anticoagulant therapy should be used selectively only in patients at highest risk for thrombotic complications. It is not recommended in the majority of surgical cases.
In patients with unexplained hemodynamic instability and when clinical expertise is available, it is suggested an emergency focused cardiac ultrasound be used for perioperative evaluation. However, the authors added that a focused cardiac ultrasound exam should not replace a comprehensive transthoracic echocardiography.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]