David E. Winchester, MD, MS¹; Jeet J. Mehta, MD¹; Jason T. Alexander, MD²

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).

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

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

LEGGI TUTTO https://jamanetwork.com/journals/jama/fullarticle/2846882?guestAccessKey=c391ca7b-434b-4013-9c71-7b612f9655f5&utm_medium=email&utm_source=postup_jn&utm_campaign=article_alert-jama&utm_content=olf-tfl_&utm_term=033126#250889180:~:text=doi%3A%2010.1001/jama.2026.0067