Alpha-gal syndrome (AGS) is an acquired allergy characterized as a delayed hypersensitivity reaction to the galactose-alpha-1,3-galactose carbohydrate, which is present on mammalian meat. AGS can cause severe anaphylactic reactions and has been implicated in intraoperative reactions to medications or surgical products that are derived from mammalian meat. This narrative review will describe the current literature on alpha-gal etiology, epidemiology, and perioperative management. Additionally, our institution is present in Suffolk County, New York, US, a highly endemic area, and we share our centers’ recommendations for managing AGS patients from their initial preoperative presentation throughout the perioperative period. We propose a detailed pathway for detection, preparedness, and intraoperative management of AGS patients undergoing elective surgery as well as alternative management suggestions for AGS patients undergoing emergency surgery.

Perioperative myocardial ischemia and myocardial injury after noncardiac surgery (MINS) remain prevalent contributors to postoperative morbidity and mortality. Recent advances, including high-sensitivity biomarkers and updated 2024 American Heart Association/American College of Cardiology (AHA/ACC) guidelines, have modified the clinical approach to preoperative ischemic evaluation. This review intends to synthesize contemporary evidence and provide a framework for perioperative ischemic workup. A narrative review of the current literature and major society guidelines was conducted, focusing on perioperative risk stratification, functional capacity assessment, biomarker utilization, noninvasive and invasive diagnostic modalities, and perioperative medical optimization strategies. Contemporary perioperative evaluation favors a stepwise, risk-based approach that uses clinical risk indices, functional capacity, and selective diagnostic testing. Biomarkers such as natriuretic peptides and cardiac troponins enhance risk prediction and enable the detection of MINS, which is strongly associated with increased mortality. Evidence does not support routine preoperative stress testing or prophylactic coronary revascularization in stable patients. Guideline-directed medical therapy, including sustained statin use and attentive management of antiplatelet and beta-blocker therapy, remains central to risk mitigation. Modern perioperative ischemic workup prioritizes individualized, evidence-based evaluation over routine testing. Integration of biomarkers, structured risk assessment, and multidisciplinary management may improve outcomes, though additional research is needed to define optimal strategies for detecting and treating MINS.