JAMA Clinical Guidelines Synopsis
Perioperative Cardiovascular Medication Management for Noncardiac Surgery
David E. Winchester, Jeet J. Mehta, Jason T. Alexander
JAMA 2026;335;(19):1717-1718. doi:10.1001/jama.2026.0067
Guideline title 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery
Release date September 24, 2024
Prior version 2014
Developers and funding sources American Heart Association and American College of Cardiology
Target population Adult patients undergoing noncardiac surgery
Major recommendations
- For patients receiving statins, continuation of current therapy is recommended to reduce major adverse cardiovascular events (strength of recommendation [SR]: 1; quality of evidence [QOE]: B [nonrandomized trials {NR}]). Perioperative initiation of statin therapy is recommended for all patients with established or elevated atherosclerotic cardiovascular disease risk, with intention for long-term use (SR: 1; QOE: B [randomized trials {R}]).
- For patients with prior percutaneous coronary intervention (PCI) undergoing noncardiac surgery, continuation of aspirin is recommended (SR: 1; QOE: B [R]). For patients with coronary artery disease without prior PCI, perioperative initiation of aspirin is not recommended due to lack of benefit (SR: 3 [no benefit]; QOE: B [R]).
- For patients taking stable dosages of β-blockers, continuation of therapy based on clinical circumstances is recommended (SR: 1; QOE: B [NR]). Initiation of β-blockers on the day of surgery in patients without clinical need is not recommended due to increased risk of postoperative mortality (SR: 3 [harm]; QOE: B [R]).
- The sodium-glucose cotransporter 2 (SGLT-2) inhibitors canagliflozin, dapagliflozin, and empagliflozin should be discontinued 3 days prior to surgery, and ertugliflozin should be discontinued 4 days prior, to reduce the risk of perioperative metabolic acidosis (SR: 1; QOE: C [limited data]).
Summary of the Clinical Problem
An estimated 14 million inpatient and 19 million ambulatory operations are performed annually in the US, with many patients having cardiovascular risk factors or established cardiovascular disease.1 Herein, we focus on recommendations for perioperative management of medical therapies related to cardiovascular disease, including statins, antiplatelet agents, β-blockers, SGLT-2 inhibitors, and glucagon-like peptide 1 (GLP-1) agonists. These therapies were selected based on their frequent use, recommendation strength, and relevance to clinicians who care for patients undergoing noncardiac surgery (see the guideline1 for recommendations on α2-receptor agonists, renin-angiotensin-aldosterone system inhibitors, oral anticoagulants, and perioperative management of blood glucose).
Characteristics of the Guideline Source
The writing committee comprised a diverse array of clinicians, including cardiologists, internists, intensivists, surgeons, and pharmacists. The SR class (eTable in the Supplement) was rated 1 (most beneficial) to 3 (no benefit or harm) based on the balance of benefits and risks. The QOE was rated A to C, with A evidence supported by more than 1 high-quality randomized clinical trial (RCT), a meta-analysis of high-quality RCTs, or a single RCT with supporting information from high-quality registry studies; B evidence supported by moderate QOE; and C evidence representing limited data or expert opinion.1
Evidence Base
Of 103 guideline recommendations issued, 27 pertained to medical therapy with 11 class 1 recommendations, 11 with class 2, 2 with class 3 (no benefit), and 3 with class 3 (strong recommendations to avoid harm). Among the 11 class 1 recommendations, 2 were supported by RCT data, 7 by nonrandomized trial data, and 2 by limited evidence (eg, observational or registry studies).
For patients already taking statins, observational evidence demonstrates their safety and benefit in the perioperative period. In a cohort study of 780 591 patients undergoing major noncardiac surgery, 77 082 (9.9%) receiving lipid-lowering therapy (91% statins) had lower in-hospital mortality vs propensity score–matched patients not receiving lipid-lowering therapy (2.18% vs 3.15%; adjusted odds ratio, 0.62; 95% CI, 0.58-0.67).2 Perioperative initiation of statins is recommended for all patients with established atherosclerotic cardiovascular disease or elevated risk. Supporting evidence is derived from small RCTs and large observational cohorts. In a US observational study of veterans (N = 96 486) undergoing noncardiac surgery, statin use was associated with decreased 30-day all-cause mortality (1.8% with a statin vs 2.3% without; relative risk, 0.82; 95% CI, 0.79-0.86).3 However, a small trial of statin-naive patients (N = 648) with established or elevated risk of atherosclerotic cardiovascular disease randomly assigned to high-dose atorvastatin (80 mg) or placebo within 18 hours before surgery reported no reduction in mortality (4.3% with atorvastatin vs 4.1% with placebo; hazard ratio [HR], 1.14; 95% CI, 0.53-2.47; P = .74).4
For patients with coronary artery disease without prior PCI undergoing elective noncarotid, noncardiac surgery, aspirin initiation is not recommended due to lack of benefit and increased harm. An RCT of 10 010 patients at increased risk of vascular complications undergoing noncardiac surgery reported no difference in the composite outcome of death or nonfatal myocardial infarction (MI) at 30 days with aspirin (7.0%) vs placebo (7.1%) (HR, 0.99; 95% CI, 0.86-1.15; P = .92). However, major bleeding was more common with aspirin (230 [4.6%] vs 188 [3.8%]; HR, 1.23; 95% CI, 1.01-1.49; P = .04).5 A nonprespecified subgroup analysis of participants in an RCT of aspirin vs placebo showed benefit of initiating aspirin over placebo for those with prior PCI.6 Among 470 participants with prior PCI, mortality or nonfatal MI occurred in 14 (6.0%) of 234 receiving aspirin vs 27 (11.5%) of 236 receiving placebo (HR, 0.50; 95% CI, 0.26-0.95.6
Initiation of β-blockers during the perioperative period is not recommended due to increased risk of postoperative mortality. In an RCT of 8351 participants with or at risk of atherosclerotic disease undergoing noncardiac surgery, those who received extended-release metoprolol succinate had fewer MIs (176 [4.2%] vs 239 [5.7%]; HR, 0.73; 95% CI, 0.60-0.89; P = .002) but higher mortality (129 [3.1%] vs 97 [2.3%]; HR, 1.33; 95% CI, 1.03-1.74; P = .03) and increased risk of stroke (41 [1.0%] vs 19 [0.5%]; HR, 2.17; 95% CI, 1.26-3.74; P = .005).7 For patients taking long-term β-blockers, continuing therapy throughout the perioperative period is recommended. In a cohort study of 73 450 patients with a history of acute MI and no history of heart failure, discontinuation of β-blockers for more than 4 months following 1 year of therapy was associated with increased risk of acute coronary syndrome or death (HR, 1.22; 95% CI, 1.09-1.37).8
SGLT-2 inhibitors reduce major cardiovascular and kidney-related events in patients with diabetes, chronic kidney disease, and heart failure but are associated with increased risk of urinary tract infections, hypovolemia, and euglycemic diabetic ketoacidosis. Evidence of risk of euglycemic diabetic ketoacidosis in patients receiving SGLT-2 inhibitors who have undergone various noncardiac surgeries is limited to case reports and case series and is thus difficult to quantify. Until additional studies evaluating the benefits and harms of short-term discontinuation of SGLT-2 inhibitors are available, discontinuing canagliflozin, dapagliflozin, and empagliflozin 3 days prior to surgery and ertugliflozin 4 days prior to noncardiac surgery is recommended (SR class 1, QOE level C evidence) to reduce risk of perioperative euglycemic diabetic ketoacidosis.
GLP-1 agonists are associated with decreased gastric emptying and residual gastric residue. In a propensity score–matched case-control study of patients with diabetes, those receiving GLP-1 agonists were more likely to have gastric residue confirmed on esophagogastroduodenoscopy vs those not receiving GLP-1 agonists (11/205 vs 1/205; P = .004).9 In 2023, the American Society of Anesthesiologists recommended that weekly-dosed GLP-1 agonists should be withheld more than 1 week prior to noncardiac surgery and daily-dosed GLP-1 agonists should be withheld 1 day prior to noncardiac surgery due to a theoretical increased risk of pulmonary aspiration. A more recent consensus statement10 based on expert opinion suggested that GLP-1 therapies can be continued for some patients, but a shared decision-making approach is encouraged, and clinicians should confirm that patients are not in the escalation phase of dosing or taking a high dose, and that they have no symptoms of delayed gastric emptying, such as nausea, vomiting, or abdominal discomfort.
Discussion
Management of cardiovascular disease has changed substantially in the 10 years since the last guidelines on perioperative cardiovascular medication management for noncardiac surgery. However, many of the medical therapies responsible for advancements have not been evaluated by RCTs in the perioperative period, creating an incomplete assessment of benefits and harms.
Areas in Need of Future Study or Ongoing Research
Further study is needed for commonly prescribed medications that have no SR class 1 recommendations for preoperative management (such as calcium channel blockers, angiotensin-converting enzyme inhibitors, and other renin-angiotensin system inhibitors) and for increasingly prescribed medications, such as the neprilysin inhibitor/angiotensin receptor blocker sacubitril-valsartan, SGLT-2 inhibitors, and GLP-1 agonists. Additional study of perioperative glucose control in patients with diabetes is also warranted.
