In this high-yield, clinically focused session, Steven L. Cohn, MD, MACP, FRCP, SFHM, professor emeritus at the University of Miami Miller School of Medicine in Miami, one of the leading experts in perioperative medicine, discussed the new American College of Cardiology/American Heart Association guidelines on perioperative cardiovascular management relevant to hospitalist practice.
Our role in this process is not to “clear” patients for surgery, but to estimate the risks and benefits of surgery, guide medical decisions, and facilitate informed decision making between the surgeons, anesthesiologists, and—most importantly—the patient. Similar to previous perioperative guidelines, there is a stepwise, algorithmic approach.
These guidelines include a change in defining surgical timelines. Emergency surgery is now defined as needing surgery within two hours, urgent surgery is six to 24 hours, time-sensitive surgery is up to three months, and elective surgery can now be delayed indefinitely. As with previous guidelines, emergency surgery should proceed to the operating room without further evaluation. For patients requiring urgent or time-sensitive surgery, clinicians are advised to evaluate for active cardiac conditions, defined as acute coronary syndrome, unstable cardiac arrhythmias, or decompensated heart failure. These conditions are high risk and warrant postponing surgery to allow for management of the acute cardiac issue, and perhaps a multidisciplinary discussion about surgical deferral, alternative nonsurgical management, or palliative treatment.
The overall perioperative cardiac risk should be estimated based on both the risk of the surgery itself and patient-specific risk factors. A validated risk prediction tool can be useful for estimating the risk of major adverse cardiovascular events. It is important to understand the limitations of major cardiac risk calculators, including how they were derived, to ensure accurate estimations. Ultimately, the history and physical exam remain the most important parts of the process. Risk calculators are tools to assist in decision making, but we are responsible for using our best clinical judgment.
The next section of the algorithm includes a new category: potential risk modifiers. These are significant factors that are not included in most risk calculators but represent disease processes that may increase risk and require additional evaluation or testing. Examples include severe pulmonary hypertension, history of coronary artery bypass graft, severe valvular heart disease, and frailty.
Functional capacity is another important part of the algorithm. The algorithm recommends assessing either whether a patient can perform at least 4 METs of activity or using the Duke Activity Status Index (DASI). A 2018 study of preoperative assessment methods (the METS study) found that clinician assessment of self-reported exercise capacity did not predict postoperative complications. In contrast, the Duke Activity Status Index score was associated with postoperative complications. A cutoff score greater than 34 predicted low risk; however, more recently, some experts have suggested that a cutoff of 25 might better balance the risks of complications with the burden of unnecessary testing.
Another new step in the algorithm is the use of cardiac biomarkers for risk stratification. This applies to patients with known cardiovascular disease, those over age 65, and patients over 45 with symptoms suggestive of cardiovascular disease. The guidelines offer a Class 2a recommendation for N-terminal prohormone of brain natriuretic peptide testing or a Class 2b recommendation for troponin. The European Society of Cardiology, which has previously recommended biomarker testing, prefers troponin over N-terminal prohormone of brain natriuretic peptide. If cardiac biomarkers are normal, the patient is considered low-risk, and no further cardiac testing is warranted. If biomarkers are elevated, a multidisciplinary team should discuss the risks and benefits of further cardiac evaluation. Postoperative troponin monitoring can also be considered in high-risk patients.
Cardiac stress testing should not be routinely performed as part of the perioperative evaluation. It may be considered in patients with poor or unknown functional status who are undergoing high-risk surgery and have a high predicted risk of major adverse cardiac events. Even then, stress testing should only be performed if the results will influence management. Coronary CT angiography is mentioned in the guidelines as an alternative with similar indications, but it may overestimate risk and is more often used in non-surgical settings. Coronary angiography should be reserved for patients with clear indications, such as acute coronary syndrome or significant ischemia, as it would be in a non-surgical setting.
Prophylactic coronary intervention has not been shown to improve perioperative outcomes. Coronary artery bypass graft and percutaneous coronary intervention carry their own risks. After these interventions, the risks of stent thrombosis (if dual antiplatelet therapy [DAPT] is interrupted), increased bleeding (if DAPT is continued), and the consequences of surgical delay must be carefully weighed. The current guideline recommends delaying elective surgeries for 12 months after PCI with drug-eluting stents placed for acute coronary syndrome or complex anatomy. A delay of 6 months is reasonable for patients with chronic coronary disease. Time-sensitive surgeries can proceed after three months if the risk of surgical delay outweighs the risk of major adverse cardiovascular events.
The guidelines also address perioperative medication management. Aspirin used for primary prevention should be held perioperatively, but it is often reasonable to continue it in patients taking it for secondary prevention. Patients with a history of stent placement should continue aspirin, and DAPT should be continued in patients with recent stents if possible. If surgery necessitates stopping DAPT, prasugrel should be held for seven days, clopidogrel for five days, and ticagrelor for three days prior to surgery. Beta-blockers should be continued in patients already taking them. If beta-blockers are newly indicated, they should be initiated at least seven days prior to surgery and not started on the day of surgery. Statins should be continued in all patients, and those with an indication for statin therapy should be started on them prior to surgery. For patients taking an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker for hypertension, consider holding it 24 hours before surgery if blood pressure is well controlled. However, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers should be continued if prescribed as part of goal-directed medical therapy for heart failure with reduced ejection fraction.
In summary, hospitalists play a central role in perioperative risk assessment, not to “clear” patients for surgery, but to weigh risks and benefits, identify high-risk features, and guide decision making. These updated guidelines offer a structured approach, but clinical judgment remains key. Effective perioperative planning requires an understanding of risk tools, awareness of important clinical nuances, and a consistent focus on patient values to support collaborative surgical decision making.
Key Takeaways
- Screen and treat cardiac disease as you would in the non-surgical setting.
- Use stress testing judiciously; reserve it for patients who would warrant testing independently of surgery.
- Manage cardiac medications thoughtfully, balancing surgical timing, bleeding risk, and cardiac benefit.
Dr. Miller is an associate professor of medicine and vice-section chief of hospital medicine at the University of New Mexico in Albuquerque, N.M.