An Updated Approach to Perioperative Management of Patients Undergoing Noncardiac Surgery: Cleared for Take-Off?

Summary

The new guideline for evaluating surgical patients for cardiovascular risk promotes a multidisciplinary approach that can help improve patient outcomes.

The perioperative period has long been recognized as a vulnerable time for enhanced cardiovascular risk, likely due to physical and emotional stress, increased inflammation and thrombosis, fluid volume shifts and blood loss, and hemodynamic instability. Thus, cardiovascular complications may occur during or shortly after procedures, leading to prolonged hospitalizations and increased morbidity and mortality.

“Can you please clear this patient to undergo noncardiac surgery?” This is a request cardiologists often receive and never look forward to. It’s not that cardiologists aren’t happy to evaluate patients and assess risk. Rather, the word “clearance” is inappropriate and should be removed from the lexicon of clinicians evaluating patients undergoing noncardiac surgeries, as the term “medically cleared” may imply the patient is free of risks.

Healthcare practitioners should not be tasked with “clearing” patients. Rather, their role is to assess the cardiovascular risk of the patient relative to the procedure being performed—acknowledging that there is no such thing as “no risk”—by evaluating symptoms, testing when appropriate, and counseling patients in a shared-decision fashion that will lead to a safer perioperative period.

The updated 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery addresses key issues in assessing and managing patients undergoing any type of noncardiac surgery.¹ The practice guideline, co-published by the American College of Cardiology and the American Heart Association, brings together the collective available evidence and makes recommendations to guide clinicians and help ensure the best possible clinical outcomes. Given the high prevalence of cardiovascular disease, an aging population with rising comorbidities, and the growing number of surgical and nonsurgical procedures performed, the updated perioperative guideline is an important aid in the management of potentially complex care situations.

Cardiovascular medicine has evolved significantly over the past few decades, with evidence-based guidelines that outline opportunities to improve morbidity and mortality and guide clinical care. While cardiovascular care has become increasingly complex—with the addition of numerous medications, diagnostics, procedures, and surgeries—the approach of speaking with the patient to elicit symptoms, understand the social determinants of health, and explore the wishes of the patient and family remains at the forefront. 

Improving Perioperative Cardiovascular Assessment

Unfortunately, perioperative consultation and testing continue to be overused and not well-understood. The likely forces contributing to this include fee-for-service models, concern for litigation, and a lack of familiarity with the guidelines.

There is room for improvement to reduce the burden and cost associated with perioperative cardiovascular assessment:

• In asymptomatic patients, low-risk procedures (e.g., cataract operations and endoscopy) do not require cardiovascular assessment; unless, of course, the patient has active or unstable symptoms.
• Cardiovascular testing, with the exception of electrocardiography, should not typically be ordered unless the patient is symptomatic or has a change in cardiovascular status. Practitioners should adhere to the same indications as nonsurgical patients and should be careful when ordering tests as screening tools. Inappropriate cardiovascular testing does not improve morbidity or mortality.
• There is no such thing as a “risk-free” perioperative state for any patient, and patients and their practitioners need to understand and accept this. Risk often depends on the type of surgery being performed and the patient’s comorbidities.
• Proper communication and documentation are, as in all encounters, incredibly important. It is critical to bring in the entire care team with transparent, timely communication.
• Clinicians need to take the time to listen to and examine their patients, assess for any new or changed symptoms, and adhere to well-established guidelines.

Key Points of the 2024 Guideline

The following strategies can assist in the perioperative evaluation and management of patients undergoing noncardiac surgery:

• Participate in interdisciplinary team-based care to enhance communication and shared decision-making among the care team and the patient/family. It may be beneficial to request that the cardiologist who performed the preoperative evaluation also manage the patient during the post-operative hospitalization. This continuity of care could facilitate more timely diagnosis and management should any changes in the patient’s condition or cardiovascular events arise. 
• Provide virtual or in-person screening and perioperative planning to improve patient satisfaction and streamline care. This benefits practitioners by providing opportunities to gather more information and benefits patients by providing input on their health status with recommendations to mitigate risks.
• Quantify patient risk with a risk calculator, of which there are many. Although there is no perfect tool, nothing is as essential as speaking with the patient to assess symptoms and medical history.
• Evaluate functional capacity as an important predictor of cardiovascular risk.
• Assess biomarkers (e.g., troponin and brain natriuretic peptides) as an adjunctive tool only in appropriate patients at specific time points. Random biomarker assessment is not indicated.
• Perform diagnostic testing (e.g., electrocardiography, cardiac computed tomography, echocardiography, stress testing, and cardiac catheterization) only during the perioperative period if there are clear indications. Over-testing remains a substantial problem, can lead to inappropriate, costly procedures, and may potentially harm patients.
• Employ basic hemodynamic monitoring, especially blood pressure and heart rate; invasive hemodynamics are rarely required.
• Reinforce continuing stable medications during the perioperative state, with a few exceptions, such as sodium-glucose cotransporter-2 inhibitors. It is often ill-advised to start new medications just prior to surgery.
• Refer patients with complex adult congenital heart disease to specialists familiar with these conditions when possible.
• Evaluate stenotic valve lesions before surgery; patients with regurgitant valve lesions typically tolerate surgery well.
• Address unstable cardiac rhythms prior to surgery.
• Conduct a perioperative risk assessment for patients undergoing moderate to high cardiovascular risk procedures/surgeries. Most low-risk procedures do not require cardiovascular risk assessment; unless, of course, patients are symptomatic.
• Follow a guideline-driven approach with appropriate documentation of clinical decision-making to best serve patients and reduce medico-legal risk. If the surgeon disagrees with the evaluation recommendations, the surgeon must document the reasons for choosing a different plan.
• Address the evaluation of perioperative patients similarly to the evaluation of all patients and utilize diagnostic testing and therapies accordingly. Testing for testing’s sake is not the antidote.

Caring for patients undergoing surgery may be challenging, especially when complicated procedures are performed on complicated patients. Thankfully, the updated guideline provides further recommendations and evidence for best practices. Like all guidelines, however, the recommendations are not rules; instead, they are helpful reminders about best practices and thoughtful approaches to specific situations. The most effective approach involves using all of the available information and maintaining communication with patients and their families to make well-informed decisions with clarity and transparency.

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