Perioperative
Cardiovascular
Management:
An Update
Nicole M. Bhave, MD, FACC, FAHA, FASE
Clinical Professor, Cardiovascular Medicine
April 11, 2025
Disclosures
• No relevant relationships with industry
• I am married to an anesthesiologist
Objectives
Highlight what’s
new in the ACC/AHA
guidelines and
appropriate use
criteria
1
Foster
interdisciplinary
collaboration in
care of complex
patients
2
Reframe
perioperative
management as a
patient-centered
process
3
Case: an unfortunate surprise
• 65yoM with DM, HTN, and ESKD on HD x 3 years, interested
in living-donor kidney transplant
• Presented to Domino Farms for dobutamine stress test
• Felt poorly on dialysis and was sedentary
• Endorsed fatigue but no DOE or angina at low-level exertion
ECG
Workup and management
• Dobutamine stress test canceled
• My exam: JVP ~12 cm H2O above the right atrium, bibasilar rales, 2+
pitting edema to lower thighs
• Ultrafiltration intensified, with improvement in DOE
• AF already rate controlled with beta-blocker
• Regadenoson SPECT: fixed inferior and apical defects c/w prior MI;
no reversible ischemia; coronary angiography not pursued
• Underwent transplant with immediate urine production and
appropriate downward trend in Cr
• Quality of life greatly improved
The most important
component of the
preoperative evaluation
is the history and
physical examination.
-Kim Eagle, MD
2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM
Guideline for Perioperative Cardiovascular Management
for Noncardiac Surgery
A Report of the American Heart Association/American College of Cardiology Joint Committee
on Clinical Practice Guidelines
Developed in Collaboration With and Endorsed by the American College of Surgeons, American Society of Nuclear Cardiology, Hea rt Rhythm Society,
Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, Society of Cardiovascular Magneti c Resonance, and the
Society for Vascular Medicine
9
2024 Writing Committee Members*
Annemarie Thompson, MD, MBA, FAHA, Chair
Kirsten E. Fleischmann, MD, MPH, FACC, Vice-Chair
Nathaniel R. Smilowitz, MD, MS, FACC, Vice-Chair
Lisa de las Fuentes, MD, MS, FAHA, JC Liaison†
Debabrata Mukherjee, MD, MS, FACC, FAHA, JC Liaison‡
Niti R. Aggarwal, MD, FACC, FASNC
Faraz S. Ahmad, MD, MS, FACC, FAHA§
Robert B. “Skip” Allen, JD
S. Elissa Altin, MD, FACC, FSVM║
Andrew Auerbach, MD, MPH
Jeffrey S. Berger, MD, MS, FAHA, FACC
Benjamin Chow, MD, PhD, FACC, FASNC, MSCCT¶
Habib A. Dakik, MD, FACC
Eric L. Eisenstein, DBA
Marie Gerhard-Herman, MD, FACC, FAHA
Kamrouz Ghadimi, MD, MHSc, FAHA
Bessie Kachulis, MD#
Jacinthe Leclerc, RN, PhD, FAHA
Christopher S. Lee, PhD, RN, FAHA**
Tracy E. Macaulay, PharmD, FACC
Gail Mates, BS
Geno J. Merli, MD, FSVM
Purvi Parwani, MBBS, MPH, FACC††
Jeanne E. Poole, MD, FACC, FHRS‡‡
Michael W. Rich, MD, FACC
Kurt Ruetzler, MD, PhD, FAHA
Steven C. Stain, MD, FACS§§
BobbieJean Sweitzer, MD
Amy W. Talbot, MPH
Saraschandra Vallabhajosyula, MD, MSc, FAHA, FACC
John Whittle, MD
Kim Allan Williams, Sr., MD, MACC, FAHA, MASNC║║
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.
†Former ACC/AHA JCCPG member; current member during the writing effort. ‡ACC/AHA Joint Committee on Clinical Practice Guidelines. §AHA/ACC Joint Committee on Clinical Data Standards. ║Society for Vascular Medicine
representative. ¶Society of Cardiovascular Computed Tomography representative. #Society of Cardiovascular Anesthesiologists representative. **AHA/ACC Joint Committee on Performance Measures. ††Society for Cardiovascular
Magnetic Resonance representative. ‡‡Heart Rhythm Society representative. §§American College of Surgeons representative. ║║American Society of Nuclear Cardiology representative.
11
Top Take Home Messages
1. A stepwise approach to perioperative cardiac
assessment assists clinicians in determining when
surgery should proceed or when a pause for further
evaluation is warranted.
Figure 1. Stepwise
Approach to
Perioperative Cardiac
Assessment.
*Cardiovascular risk factors: HTN, smoking, high cholesterol,
diabetes, women age >65; men age >55; obesity; family
history of premature CAD.
†Determining elevated calculated risk depends on the
calculator used. Traditionally, RCRI >1 or a calculated risk of
MACE with any perioperative risk calculator >1% is used as a
threshold to identify patients at elevated risk.
§Abnormal biomarker thresholds: troponin >99th percentile
URL for the assay; BNP >92 ng/L, NT-proBNP ≥300 ng/L.
‡Conditions that pose additional risk for MACE.
║Noninvasive stress testing or CCTA suggestive of LM or
multivessel CAD.
Interactive version available at:
jacc.org/guidelines/perioperative-
cardiovascular-management/interactive
(Search: JACC periop tool)
https://www.jacc.org/guidelines/perioperative-cardiovascular-management/interactive
What risk calculator to use?
• Revised cardiac risk index (RCRI)
• 6 variables: ischemic heart disease, cerebrovascular disease, heart
failure, IDDM, SCr>2, intraperitoneal/intrathoracic/vascular case
• Predicts only cardiac complications
• Score of 2: ~10% risk at 30 days
• Available on MDCalc.com
• American College of Surgeons NSQIP
• 20 variables
• Predicts cardiac complications, infectious complications, VTE, etc.
• Available at Riskcalculator.facs.org
Not all risk is
cardiac…
18
Frailty
Recommendation for Frailty
Referenced studies that support the recommendations are summarized in the Online Data Supplement.
COR LOE Recommendation
2a B-NR
1.
In all patients ≥65 years of age and in those <64 years with perceived
frailty who are undergoing elevated-risk NCS, preoperative frailty
assessment using a validated tool can be useful for evaluating
perioperative risk and guiding management.
Duke Activity Status Index (DASI)
Activity: Can you…
Weight
take care of yourself (eg, eating, dressing, bathing, or using the toilet)?
2.75
walk indoors, such as around your house?
1.75
walk a block or 2 on level ground?
2.75
climb a flight of stairs or walk a hill?
5.5
run a short distance?
8
do light work around the house (eg, dusting, washing dishes)?
2.7
do moderate work around the house (eg, vacuuming, sweeping floors, carrying in
groceries)?
3.5
do heavy work around the house (eg, scrubbing floors, lifting or moving heavy furniture)?
8
do yardwork (eg, raking leaves, weeding, pushing a power mower)?
4.5
have sexual relations?
5.25
participate in moderate recreational activities (eg, golf, bowling, dancing, doubles tennis,
throwing a baseball or football)?
6
participate in strenuous sports (
eg, swimming, singles tennis, basketball, skiing)?
7.5
Score ≤34:
Increased
odds of
30-day death
or MI
Top Take Home Messages
2. Cardiovascular screening and treatment of patients
undergoing noncardiac surgery (NCS) should adhere to
the same indications as nonsurgical patients, carefully
timed to avoid delays in surgery and chosen in ways to
avoid overscreening and overtreatment.
21
Top Take Home Messages
3. Stress testing should be performed judiciously in
patients undergoing NCS, especially those at lower risk,
and only in patients in whom testing would be
appropriate independent of planned surgery.
Preoperative Biomarkers for Risk Stratification
Recommendations for Preoperative Biomarkers for Risk Stratification
Referenced studies that support the recommendations are summarized in the Online Data Supplement.
COR LOE Recommendations
2a B-NR
1.
In patients with known CVD, or age ≥65 years, or age ≥45 years with
symptoms suggestive of CVD undergoing elevated-risk NCS, it is
reasonable to measure B-type natriuretic peptide (BNP) or N-Terminal
pro B-type natriuretic peptide (NT-proBNP) before surgery to
supplement evaluation of perioperative risk.
2b B-NR
2.
In patients with known CVD, or age ≥65 years, or age ≥45 years with
symptoms suggestive of CVD undergoing elevated-risk NCS, it may be
reasonable to measure cardiac troponin (cTn) before surgery to
supplement evaluation of perioperative risk.
How should we
operationalize use of
preoperative biomarkers?
The jury is still out…
Who should
have an echo
or a stress
test before
surgery?
Preoperative AUC: overview
• First AUC document to address preoperative cardiac testing
• Multimodality document
• 182 clinical scenarios
• Known or suspected heart disease?
• Any prior cardiac testing?
• Functional status (<4 METs vs. ≥4 METs)
• Type of surgery
• Imaging less likely to be considered appropriate for asymptomatic,
functional patients and those having low-risk surgery
• Payors pay attention to AUC!
Asymptomatic,
functional
patients
Doherty et al., J Am Coll Cardiol. 2024
Patients with
symptoms or
poor functional
status
Doherty et al., J Am Coll Cardiol. 2024
Stress Testing
Recommendations for Stress Testing
Referenced studies that support the recommendations are summarized in the Online Data
Supplement.
COR LOE Recommendations
2b B-NR
1.
For patients undergoing elevated-
risk NCS with poor or unknown
functional capacity and elevated risk for perioperative
cardiovascular events based on a validated risk tool, stress testing
may be considered to evaluate for inducible myocardial ischemia.
3: No
benefit
B-R
2.
In patients who are at low risk for perioperative cardiovascular
events, have adequate* functional capacity with stable symptoms,
or who are undergoing low-risk procedures, routine stress testing
before NCS is not recommended due to lack of benefit.
*Poor functional capacity is considered <4 METS or a DASI score of ≤34.
31
Considerations and Contraindications
for Specific Stress Testing Modalities
Modality
Contraindication*
Vasodilator pharmacological
stress imaging
Significant arrhythmias (
eg, VT, second- or third-degree
atrioventricular block), significant hypotension (SBP <90 mm Hg),
known or suspected
bronchoconstrictive or bronchospastic disease
or recent use of dipyridamole or methylxanthines (
eg,
aminophylline, caffeine) within 12 h
Exercise stress testing (with or
without imaging)
Inability to exercise
Dobutamine stress
echocardiography
Critical aortic stenosis, hemodynamically significant LVOT
obstruction
Coronary CTA
• Greatest strength: high negative predictive value
• Order when you expect it to be normal!
• Coronary calcium can confound interpretation
• Equivocal results are common
• Contrast load: greater than for diagnostic cath
• Wait times are shorter than for PET or SPECT
34
Invasive Coronary Angiography
Recommendation for Invasive Coronary Angiography
COR LOE Recommendation
3: No
benefit
C-LD
1.
In patients undergoing NCS, routine preoperative invasive
coronary angiography (ICA) is not recommended to
improve perioperative outcomes.
Why not just cath all high-risk patients?
CARP Trial
• 5859 VA patients scheduled for major
elective vascular surgery (AAA repair or
lower extremity revascularization)
• All underwent coronary angiography
• Randomized to coronary
revascularization vs. no
revascularization
• Exclusion criteria: left main disease,
severe AS, severe LV dysfunction
Postop MI: 12% of revasc group,
14% of no-revasc group (P=0.37)
McFalls et al., NEJM 2004
ISCHEMIA-CKD: transplant post-hoc analysis
Herzog et al., J Am Coll Cardiol. 2021
If they need a stress test or a cath
for life, they should probably have
it before elective surgery.
If not, think twice before ordering.
Top Take Home Messages
4. Team-based care should be emphasized when
managing patients with complex anatomy or
unstable cardiovascular disease.
41
Top Take Home Messages
5. New therapies for management of diabetes, heart
failure, and obesity have significant perioperative
implications. SGLT2 inhibitors should be discontinued 3-4
days before surgery to minimize the risk of perioperative
ketoacidosis associated with their use.
What about other cardiac medications?
• Beta-blockers: continue (don’t start de novo)
• Statins: continue
• Most antihypertensives: continue
• ACEI, ARB, ARNI: consider 24-hr hold
STOP-or-NOT trial
More hypotension
in continuation
group:
54% vs. 41%,
risk ratio 1.31
Top Take Home Messages
6. Myocardial injury after NCS (MINS) is a newly
identified disease process that should not be
ignored because it portends real consequences
for affected patients.
Definition: >1 elevated troponin (>99th %ile)
of presumed ischemic origin
Beware: Not all myocardial injury is ischemic…
4th Universal Definition
of Myocardial
Infarction,
Thygesen et al.,
Circulation 2018
Is it plaque rupture or not??
• If higher suspicion for type II MI (supply-demand mismatch), start
with conservative management, correcting anemia, tachycardia,
hypotension; then consider coronary angiography only if patient
worsens clinically
• Warrants outpatient workup (cardiology visit, and vasodilator perfusion
study or coronary angiography)
• If high suspicion for type I MI (plaque rupture), consider urgent
coronary angiography
• Please consult us!
47
Myocardial Injury After Noncardiac Surgery:
Surveillance and Management
Recommendations for Myocardial Injury After Noncardiac Surgery
Referenced studies that support the recommendations are summarized in the Online Data
Supplement.
COR LOE Recommendations
MINS Surveillance
2b B-NR
1.
In patients with known CVD, symptoms of CVD, or age ≥65 years
with cardiovascular risk factors undergoing elevated-risk NCS, it
may be reasonable to measure cTn at 24 and 48 hours after surgery
to identify myocardial injury.
3: No
benefit
B-NR
2.
In patients undergoing low-risk NCS, routine postoperative
screening with cTn
levels is not indicated without signs or symptoms
suggestive of myocardial ischemia or MI.
Myocardial Injury After Noncardiac Surgery:
Surveillance and Management
MINS Management
2a B-NR
1. In patients who develop MINS, especially in those not previously
known to have excess cardiovascular risk, outpatient follow-
up is
reasonable for optimization of cardiovascular risk factors.
2b C-LD
2.
In patients who develop MINS, antithrombotic therapy may be
considered to reduce thromboembolic events.
Very controversial
49
Top Take Home Messages
7. Patients with newly diagnosed atrial fibrillation
identified during or after NCS have an increased risk of
stroke. These patients should be followed closely after
surgery to treat reversible causes of arrhythmia and to
assess the need for rhythm control and long-term
anticoagulation.
50
Atrial Fibrillation
Recommendations for Atrial Fibrillation
COR LOE Recommendations
Perioperative
2a C-LD
1. In patients with rapid AF identified in the setting of NCS, it is reasonable to
treat potential underlying triggers contributing to AF and rapid ventricular
response (eg, sepsis, anemia, pain).*
2a C-LD
2.
In patients with new-onset AF identified in the setting of NCS, initiation of
postoperative anticoagulation therapy can be beneficial after considering
the competing risks associated with thromboembolism and perioperative
bleeding.*
Post-discharge
1 C-LD
3.
In patients with new-onset AF identified in the setting of NCS, outpatient
follow-up for thromboembolic risk stratification and AF surveillance are
recommended given a high risk of AF recurrence.*
*Adapted from the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”
Atrial fibrillation tends
to come back.
Don’t assume it won’t.
Keep me informed.
Top Take Home Messages
8. Perioperative bridging of oral anticoagulant therapy
should be used selectively only in those patients at
highest risk for thrombotic complications and is not
recommended in the majority of cases.
56
High thromboembolic risk conditions
Risk
Category
Venous
Thromboembolism
Atrial Fibrillation
Mechanical Valve
Other Indications
High
Recent VTE
(<1
mo or <3 mo)
CHA
2
DS
2
-VASc ≥7
(or 5
-6 with recent
stroke or TIA)
AF with rheumatic
valvular heart disease
Mechanical mitral
valve
Caged ball or tilting
-
disk valve
Mechanical heart
valve in any position
with recent stroke or
TIA (<3 mo)
Recent
cardioembolic
stroke (<3
mo)‡
Active cancer
a/w
high VTE risk
LV thrombus
(within last 3
mo)
Severe
thrombophilia,
antiphospholipid
antibodies
For patients at high
thromboembolic risk, clear
documentation of the
perioperative anticoagulation
plan is critical.
BMS indicates bare-metal stent; DAPT, dual
antiplatelet therapy; DES, drug-eluting stent; NCS,
noncardiac surgery; and PCI, percutaneous coronary
intervention.
Figure 5. Optimal
Timing of Elective or
Time-Sensitive NCS
for Prior PCI
Requiring
Management of
DAPT.
61
Top Take Home Messages
9. In patients with unexplained hemodynamic instability and
when clinical expertise is available, emergency focused
cardiac ultrasound can be used for preoperative evaluation;
however, focused cardiac ultrasound (FoCUS) should not
replace comprehensive transthoracic echocardiography.
FoCUS: just the basics
Bringing it back to the patient
• Make the preoperative visit an opportunity
to educate about cardiac conditions and
risks of surgery
• Engage in shared decision-making
• Be transparent about workup,
interdisciplinary discussions, and areas of
uncertainty
• Emphasize importance of postoperative
follow up for new and existing
cardiovascular conditions
Thank you
Resources
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