Perioperative Cardiovascular Management

Statin Therapy

The American Heart Association recommends continuing all statins perioperatively without interruption in patients already taking them to reduce major adverse cardiac events (MACE) 1
The American College of Cardiology recommends initiating statins in statin-naïve patients who meet criteria based on ASCVD history or 10-year risk assessment, with intention for long-term use beyond the perioperative period 1
Large cohort data demonstrates that 9.9% of patients receiving perioperative lipid-lowering therapy had lower surgical mortality compared to those without such therapy 1
In vascular surgery, atorvastatin 20 mg daily initiated 30 days preoperatively reduced the composite endpoint of cardiac death, nonfatal MI, stroke, and unstable angina from 26% to 8% at 6 months (P=0.031) 1

The American Heart Association recommends continuing beta-blockers in patients already taking them, as withdrawal increases 1-year mortality dramatically (HR: 2.7) and postoperative discontinuation carries 50% mortality versus 1.5% with continuation 2
The American College of Cardiology does not recommend routinely initiating beta-blockers in beta-blocker-naïve patients, particularly within 1 day of surgery 3, 4
Meta-analyses show that beta-blockers reduce nonfatal MI (RR: 0.69) but increase nonfatal stroke (RR: 1.76), hypotension (RR: 1.47), bradycardia (RR: 2.61), and all-cause mortality (RR: 1.30) when started ≤1 day before surgery 3

The American Heart Association recommends considering omitting RAAS inhibitors 24 hours before elevated-risk surgery in patients with controlled hypertension to limit intraoperative hypotension (Class IIb, Level B-R) 1
The American College of Cardiology recommends continuing RAAS inhibitors perioperatively in patients taking them for heart failure with reduced ejection fraction (HFrEF) (Class IIa, Level C-EO) 1
Meta-analysis of 6,022 patients showed more intraoperative hypotension with continuation but no difference in MACE 1

The American College of Cardiology recommends continuing aspirin perioperatively for secondary prevention unless bleeding risk is extremely high (e.g., intracranial surgery) 6
The American College of Cardiology recommends maintaining dual antiplatelet therapy in patients with recent coronary stents 6
Elective surgery should be delayed: ≥14 days after balloon angioplasty, ≥30 days (4-6 weeks) after bare-metal stent, ≥6-12 months after drug-eluting stent 6

The American College of Cardiology does not recommend routine prophylactic coronary revascularization before noncardiac surgery in stable coronary artery disease (Class III, Level B) 6
Revascularization should only occur for standard indications, such as significant left main coronary artery stenosis, 3-vessel disease, or high-risk unstable angina or acute MI 6

The American Heart Association recommends measuring troponin and obtaining ECG when signs or symptoms of ischemia, MI, or arrhythmia are present (Class I) 7
Routine postoperative screening with troponin or ECG in asymptomatic high-risk patients has uncertain benefit (Class IIb) 7
The American Heart Association does not recommend performing routine screening in unselected patients without symptoms (Class III) 7