Rapid Clinical Updates: The Latest Hot Topics in Perioperative Medicine-Slides

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This clinical update, presented by Drs. Smita Kalra and Kurt Pfeifer and moderated by Dr. Andrew Dunn, highlights key advances in perioperative medicine focusing on cardiovascular risk assessment and management before and after noncardiac surgery, based on the 2024 AHA/ACC guidelines.<br /><br />The rising complexity and age of surgical patients have increased the role of hospitalists in perioperative care, with evidence supporting medical co-management to improve outcomes. Cardiac complications contribute to about 25% of postoperative morbidity and mortality, but a comprehensive evaluation of all organ systems remains essential.<br /><br />A systematic approach to preoperative cardiac evaluation includes assessing surgical urgency (emergent, urgent, elective) and identifying cardiovascular red flags such as unstable heart failure, severe valvular disease, uncontrolled arrhythmias, significant hypertension, recent stroke, or recent coronary interventions, which may alter timing or necessitate multidisciplinary discussion.<br /><br />For nonurgent cases, evaluation extends beyond ischemic heart disease to include heart failure, valvular disease, pulmonary hypertension, and arrhythmias. Coronary disease is important but often less critical; new options like biomarkers (BNP/NT-proBNP and troponins) and coronary CT angiography (CCTA) help improve risk stratification. BNP is particularly valuable for identifying low-risk patients due to its high negative predictive value.<br /><br />Postoperative myocardial injury (MINS), defined by elevated troponin within 30 days post-surgery without non-cardiac causes, is common yet under-recognized. MINS carries a significant increase in 30-day mortality risk. High-risk patients, including those over 65 with cardiovascular risk factors undergoing elevated-risk surgery, may benefit from troponin surveillance at 24 and 48 hours post-op.<br /><br />Management of MINS involves ruling out myocardial infarction using ECG and echocardiography, optimizing medical therapy (aspirin, statins), and addressing nonischemic contributors such as anemia, AKI, sepsis, or pulmonary embolism. Referral to cardiology is advised when indicated. For perioperative myocardial infarction, balance between ischemic and bleeding risks guides invasive coronary evaluation and treatment.<br /><br />In summary, the 2024 AHA/ACC guidelines provide a structured framework for perioperative cardiovascular risk management with emphasis on individualized care, biomarker use, and recognition and management of MINS to improve patient outcomes.

Keywords

perioperative medicine

cardiovascular risk assessment

noncardiac surgery

2024 AHA/ACC guidelines

perioperative cardiac evaluation

biomarkers BNP NT-proBNP troponins

postoperative myocardial injury (MINS)

cardiac complications

medical co-management

perioperative myocardial infarction management