Highlights from the American College of Cardiology and American Heart Association 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery

Abstract

Increasing noncardiac surgery volumes globally combined with the growing prevalence of cardiovascular risk factors continues to pose a challenge for anesthesiologists caring for patients in the perioperative period. Forty-five percent of all patients >45 years old have multiple cardiovascular risk factors, with cardiovascular complications reported in three percent of surgical admissions. In 2024, the American College of Cardiology and the American Heart Association, in collaboration with several subspecialty societies, updated the 2014 guidelines on the management of cardiovascular diseases in the perioperative period for patients undergoing noncardiac surgery. Some of the topics covered include perioperative risk calculators, guidelines for diagnostic testing, perioperative considerations for cardiovascular comorbidities, management of medical therapies, and anesthetic/intraoperative management strategies. Since the guidelines are broad and detailed, this article highlights essential recommendations that are especially relevant to the busy perioperative physician.

APPROXIMATELY 313 MILLION surgeries are performed annually worldwide.¹ The prevalence of cardiovascular risk factors is increasing, with ≥2 risk factors reported in 45% of surgical inpatients ≥45 years of age.² Perioperative cardiovascular complications have been reported in 3% of surgical admissions and are associated with higher medical costs, prolonged inpatient hospitalizations, and increased mortality.³ Recently, the American College of Cardiology (ACC) and the American Heart Association (AHA) undertook the task of updating guidelines to assist physicians in optimizing the cardiovascular health of their patients in the perioperative period. They have compiled evidence-based care into a report titled the “2024 ACC/AHA Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.”⁴ The last edition of this guideline was published in 2014, so this new document incorporates ten years of new data. This article highlights and summarizes the key points that are the most relevant for the busy perioperative physician including perioperative risk calculators, preoperative cardiac testing, perioperative management of cardiac comorbidities, management of medical therapies, and anesthetic considerations for patients undergoing noncardiac surgery (NCS).

Shared Decision-Making with Teams-Based Care and Quality of Life Factors

Multidisciplinary care models often serve as the framework for creating pathways that standardize cardiac care practices or the coordination of pain control and rehabilitation to speed recovery. Although there is limited data demonstrating that these models improve perioperative cardiac care or outcomes, available evidence suggests they are associated with increased patient satisfaction. While the guideline does not make specific recommendations, the authors note that shared decision-making and discussing patients’ goals and priorities regarding quality of life may guide perioperative planning and have also been associated with greater patient satisfaction.⁴

Risk Calculators

Cardiovascular Risk Indices

For patients with known cardiovascular disease, a validated risk-prediction tool can be useful to estimate the risk of perioperative major adverse cardiac events (MACE) associated with NCS (Class IIa). Commonly used cardiovascular risk scores are described in Table 1. While the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator may provide the best predictive discrimination, the Revised Cardiac Risk Index and the AUB (American University of Beirut)-HAS2 scores are easily calculated with moderate predictive discrimination. Individual model performance may vary because of differences in surgical populations and data is lacking to support the use of one risk index over another.⁴

Table 1.

Selected Risk Scores and Calculators x

	RCRI (1999)	Gupta NSQIP Risk Calculator for Perioperative MICA (2011)	American College of Surgeons NSQIP Surgical Risk Calculator (2023)	Surgical Outcome RiskTool (2017)	AUB-HAS2 Cardiovascular Risk Index (2019)
Criteria	Ischemic heart disease Cerebrovascular disease History of HF Insulin therapy for diabetes Serum creatinine ≥ 2.0 mg/dL Planned high-risk procedure (intraperitoneal, intrathoracic, or vascular surgery) (1 point for each criterion)	Age ASA class Preoperative function Creatinine Procedure type	Age group Sex ASA class Functional status Emergency case Steroid use for a chronic condition Ascites within 30 d preoperatively System sepsis within 48h preoperatively Ventilator dependent Disseminated cancer Diabetes Hypertension requiring medication Previous cardiac event HF in 30 preoperatively Dyspnea Current smoker within 1 y History of COPD Dialysis Acute renal failure BMI class CPT-specific linear risk	Age group ASA class Urgency of surgery Specialty Severity of surgery Cancer	Age ≥ 75 years History of heart disease Symptoms of angina/dyspnea Hemoglobin <12 mg/dL Vascular surgery Emergency surgery
Score Range	Class I: RCRI 0 (lowest risk) Class II: RCRI 1 Class III: RCRI 2 Class IV: RCRI 3+ (highest risk)	0%−100% (0% lowest risk, 100% highest risk)	0%−100% (0% lowest risk, 100% highest risk)	0%−100% (0% lowest risk, 100% highest risk)	CVRI Score 0 (lowest risk) CVRI Score 1 CVRI Score 2 CVRI Score 3 CVRI Score >3 (highest risk)
Threshold Denoting Elevated Risk	RCRI > 1	> 1%	> 1%		CVRI Score ≥ 2
Outcome	MI, pulmonary edema, ventricular fibrillation, complete heart block, cardiac death	Intraoperative/postoperative MI or cardiac arrest within 30d	Cardiac arrest, MI, all-cause mortality within 30d	30-d mortality	Death, MI, or stroke at 30d

Adapted with permission from Thompson A, et al.

Abbreviations: ASA, American Society of Anesthesiologists; AUB, American University of Beirut; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CPT, current procedural terminology; CVRI, Coronary Vascular Resistance Index; HF, heart failure; MI, myocardial infarction; MICA, MI and cardiac arrest; NCEPOD, National Confidential Enquiry into Patient Outcome and Death; NSQIP, National Surgical Quality Improvement Program; RCRI, Revised Cardiac Risk Index; ROC, receiver operating characteristic.

Functional Capacity Assessment

Functional capacity is an important predictor of adverse cardiovascular events for patients undergoing NCS. Although it is often assessed by asking patients if they can climb 2 flights of stairs (an activity commonly associated with >4 metabolic equivalents), the guideline suggests that a structured assessment of functional capacity (such as the Duke Activity Status Index) is reasonable to stratify the risk of perioperative adverse cardiovascular events (Class IIa) (Table 2). An objective assessment of functional capacity can be provided by exercise stress testing and should be considered if the information obtained would alter management.⁴

Table 2.

Duke Activity Status Index (DASI).

Activity: Can you …	Points
take care of yourself (eg, eating, dressing, bathing, or using the toilet)?	2.75
walk indoors, such as around your house?	1.75
walk a block or 2 on level ground?	2.75
climb a flight of stairs or walk a hill?	5.5
run a short distance?	8
do light work around the house (eg, dusting, washing dishes)?	2.7
do moderate work around the house (eg, vacuuming, sweeping floors, carrying in groceries)?	3.5
do heavy work around the house (eg, scrubbing floors, lifting or moving heavy furniture)?	8
do yardwork (eg, raking leaves, weeding, pushing a power mower)?	4.5
have sexual relations?	5.25
participate in moderate recreational activities (eg, golf, bowling, dancing, doubles tennis, throwing a baseball or football)?	6
participate in strenuous sports (eg, swimming, singles tennis, basketball, skiing)?	7.5

The DASI is obtained by summing the points of all performed activities (range 0–58.2). Higher scores correspond with higher functional status.

Frailty

Frailty is a syndrome characterized by increased vulnerability to stressors and is an independent risk factor for adverse outcomes after NCS, regardless of age. It has a weighted prevalence of 10.7% among community-dwelling individuals 65 years and older and is twice as common in women as in men.⁵ The following recommendations are new to this edition of the guideline. Preoperative frailty assessment using a validated tool may be useful to evaluate risk and guide management in patients ≥65 years or those <64 years with perceived frailty who are undergoing elevated-risk NCS (Class IIa).⁴ Although no specific tool is recommended, the guideline briefly discusses screening instruments such as the FRAIL scale and the Edmonton Frail Scale and other tools such as the Deficit Accumulation Index that can be used with electronic medical records. A frailty assessment may facilitate a more nuanced discussion of the potential benefits and risks of proceeding with surgery with patients and their families. It may also identify patients who could potentially benefit from prehabilitation before NCS.⁴

Preoperative Biomarkers

Biomarkers such as cardiac troponin and B-type natriuretic peptide are inexpensive and widely available. Although there is no data to show that the use of preoperative biomarkers to guide management is associated with improved perioperative cardiovascular outcomes, the guideline suggests their use is reasonable to supplement evaluation of perioperative risk in patients with known cardiovascular disease, age ≥65 years, or age ≥45 years with symptoms of cardiovascular disease undergoing elevated risk NCS (Class IIa).

The guideline authors cite retrospective cohort studies indicating an association of elevated BNP or NT-proBNP with increased perioperative mortality to justify their recommendations, but acknowledge that no definitive, externally validated cut-off thresholds have been identified.⁴ Additionally, emerging evidence from a separate large retrospective cohort study suggests that adding preoperative NT-proBNP to self-reported functional status did not improve predictive accuracy of major adverse cardiovascular events.⁶ Given the lack of specific biomarker cut-off thresholds to improve risk stratification, it is uncertain how these biomarkers could be systematically included in pre-operative optimization algorithms or shared decision-making models at this time. We look forward to additional evidence evaluating the potential utility of biomarkers and how the distinct incorporation of biomarker strategies may improve patient outcomes. Until this data is available, the potential value of a preoperative biomarker assessment should be balanced against the risk that results lead to further testing and care delays, especially for more urgent procedures.⁴

Preoperative Cardiovascular Diagnostic Testing

12-Lead Electrocardiogram

A preoperative resting 12-lead electrocardiogram (ECG) rarely contributes prognostic information beyond what is offered by risk assessment tools. However, in patients with known risk factors such as coronary artery disease (CAD), arrhythmia, peripheral arterial disease, cerebrovascular disease, structural heart disease, or symptoms suggesting cardiovascular disease, a preoperative ECG may help establish a preoperative baseline and guide management (Class IIa). Findings such as a second-degree Mobitz type II or higher atrioventricular block, new atrial fibrillation or atrial fibrillation associated with rapid ventricular response, and prolonged QT interval may inform preoperative evaluation and anesthetic planning. The guideline specifically notes that incidental findings of Q waves or a bundle branch block in an otherwise asymptomatic patient should not lead to invasive evaluation and treatment for coronary disease, reinforcing the limited utility of preoperative ECGs. In asymptomatic patients undergoing low-risk surgical procedures, a routine preoperative ECG is not recommended to improve outcomes (Class III).⁴

Although screening ECG is relatively inexpensive, there is ample evidence that routine preoperative screening ECG in low-risk patients undergoing low-risk surgery has little impact on patient outcomes, and avoiding both the cost of the test and the possible cascade of care that can result from it is desirable.

Ventricular Function

Left ventricular systolic and diastolic dysfunction are both associated with perioperative MACE in NCS. In patients presenting for NCS with new dyspnea, physical examination findings consistent with heart failure, or suspected worsening ventricular dysfunction, an evaluation of left ventricular function is recommended (Class I) to identify patients who may benefit from the initiation of guideline-directed medical therapy (GDMT). No specific modality is noted in the guideline; however, presumably transthoracic echocardiography (TTE) is suitable, or FoCUS can be helpful to stratify patients’ ventricular function. Similarly, in patients with known heart failure with a change in clinical status, preoperative evaluation of left ventricular function may help guide management by adjusting GDMT prior to surgery (Class IIa). However, in asymptomatic and clinically stable patients, no routine preoperative evaluation of left ventricular function is recommended (Class III).⁴

Reduced right ventricular function can be present in patients with pressure overload pathology (such as pulmonary hypertension, valvular disease, or left heart dysfunction) or volume overload pathology (such as intracardiac shunts and congenital heart disease). Reduced right ventricular function may also be present due to cardiomyopathy or ischemic heart disease. Although this disease is associated with adverse cardiovascular outcomes, routine assessment of right ventricular function in asymptomatic and clinically stable patients is not recommended. Patients with mitral regurgitation, tricuspid regurgitation, and pulmonary hypertension may reasonably undergo preoperative evaluation of right ventricular function with TTE or cardiac magnetic resonance imaging.

Stress Testing

Because preoperative revascularization for patients without high-risk features has not been shown to reduce perioperative MACE,⁷ the goal of preoperative stress testing should not be to identify all undiagnosed CAD. Rather, the goal should be to identify patients with left main disease or severe multivessel disease with reduced left ventricular ejection fraction as these patients have been excluded from studies of preoperative revascularization and represent a subpopulation where revascularization may improve clinical outcomes. The guideline makes a Class IIb recommendation that stress testing may be considered in patients undergoing elevated-risk NCS with poor or unknown functional capacity and where a validated risk tool suggests elevated perioperative risk. Owing to a lack of benefit, stress testing is not recommended for low-risk procedures, patients at low risk of perioperative MACE, and patients with good functional capacity and stable cardiac symptoms (Class III).

Exercise-based testing modalities are generally preferred over pharmacological stress testing if the patient can participate. In general, while positive test results have only moderate predictive value for perioperative cardiovascular events, negative results reliably correlate with a lower risk of perioperative events.⁴

Cardiopulmonary Exercise Testing

Cardiopulmonary exercise testing measures the physiologic response to exercise and provides an objective measure of functional capacity. Compared to other measures of functional capacity, such as a 6-minute walk test, cardiopulmonary exercise testing may provide additional physiologic data that could support its use in high-risk patients with reduced functional capacity undergoing high-risk surgery.⁴

Coronary Computed Tomography Angiography

Although coronary computed tomography angiography (CCTA) has grown in popularity as a modality to exclude atherosclerotic plaque and obstructive CAD, its role in preoperative evaluation is not clear, particularly because preoperative revascularization has not been shown to improve postoperative outcomes. A prospective randomized trial evaluated CCTA versus functional testing as a screening test in symptomatic patients with suspected CAD and found no difference in clinical outcomes after a median of 2 years of follow-up.⁸ CCTA may be considered to exclude high-risk coronary anatomy in patients at elevated risk of cardiovascular complications (Class IIb).⁴ Similar to stress testing, CCTA is not recommended in patients with low risk of perioperative complications, undergoing low risk procedures, or with stable cardiac symptoms and good functional capacity (Class III).

Invasive Coronary Angiography

Routine invasive coronary angiography is not recommended for the preoperative evaluation of patients undergoing NCS, for reasons outlined here earlier (Class III).⁴

Approach to Perioperative Cardiac Testing

Fig. 1 describes a stepwise approach to perioperative risk stratification to assist in determining when surgery should proceed or be delayed for further evaluation is warranted. First, patients presenting for emergency surgery should proceed directly to surgery without additional cardiac testing. The authors argue that using an anesthesiologist-performed point-of-care ultrasound to grossly assess cardiac and valvular function should be considered if it would change perioperative management without significantly delaying surgery. Second, patients presenting for elective surgery with active acute cardiac conditions, such as acute coronary syndromes, unstable arrhythmias, or decompensated heart failure, require deferral of surgery and management and stabilization of the acute cardiac condition before proceeding.

Fig 1.

Stepwise approach to perioperative risk stratification. NCS, noncardiac surgery; CABG, coronary artery bypass grafting; CIED, cardiac implantable electronic device; ICD, implantable cardioverter-defibrillator; ECG, electrocardiogram; CVD, cardiovascular disease; GDMT, guideline-directed management and therapy; DASI, Duke Activity Status Index, METs, metabolic equivalents; BNP, B-type natriuretic peptide; NT-proBNP, N-terminal pro b-type natriuretic peptide; CCTA, coronary computed tomography angiography. Adapted with permission from Thompson, A. et al.

Third, the ACC/AHA guideline identifies several “risk-modifying” conditions (specifically severe valvular heart disease, pulmonary hypertension, certain congenital heart disease, coronary artery disease previously managed with revascularization, recent stroke, presence of a cardiac implantable electronic device, and frailty). Patients without these major risk modifiers should use a risk calculator for adverse cardiovascular events (Class IIa). Those with low calculated risk and no risk modifiers should proceed with surgery. Individuals with elevated risk and no risk modifiers should be considered for further testing including a 12-lead ECG (Class IIb). Patients with a risk modifier should be discussed during a multidisciplinary team meeting on the timing of NCS, as well as preoperative testing including an ECG (Class IIa) and echocardiography for suspected valvular or ventricular dysfunction (ClassI/IIa). Patients with poor or unknown functional capacity from either of these groups may warrant additional testing, including biomarkers, but only if it will impact perioperative care and decision-making. Overall, cardiac screening and treatment of patients undergoing NCS should follow the same indications as for nonsurgical patients to minimize surgical delays, over-screening, and overtreatment.⁴

Cardiovascular Comorbidities and Perioperative Management

Coronary Artery Disease

Coronary artery disease (CAD) is a prevalent risk factor in patients undergoing NCS and is associated with increased perioperative MACE.² Patients with a history of myocardial infarction (MI) have a 3.5 fold risk of perioperative MACE while patients with a history of coronary stenting have two times the risk compared to those without.^2,9 Time between coronary revascularization and NCS was found to be inversely proportional to MACE risk.¹⁰ Patients with acute coronary syndrome (ACS) benefit from coronary revascularization prior to NCS to reduce perioperative MACE (Class I).¹¹ Coronary revascularization is reasonable in patients with chronic coronary disease and left main disease ≥50% who are planning elective NCS to reduce perioperative MACE (Class IIa). Revascularization is not recommended to reduce perioperative cardiovascular events in patients with non-left main CAD (Class III).^7,12

Hypertension and Perioperative Blood Pressure Management

Twenty-five percent of patients undergoing major NCS have hypertension, which may lead to delays in elective NCS.¹³ Uncontrolled hypertension is associated with increased risk of perioperative complications, including cardiovascular and cerebrovascular events and bleeding.¹⁴ An optimal systolic blood pressure (SBP) goal has not been determined for all patients. Induction of anesthesia may result in labile blood pressure and heart rate in patients with uncontrolled hypertension. In a meta-analysis of 30 observational studies, patients with a preoperative diagnosis of hypertension had a 3% increase in cardiovascular complications. Similarly, a single-center retrospective analysis of participants undergoing NCS demonstrated an association between preinduction SBP of > 160 mmHg and a composite for morbidity and mortality in individuals with at least one component of the RCRI.¹⁵ In patients without an RCRI risk factor, there is no significant evidence of increased risk for perioperative complications if BP <180/110 (Class IIb). Given the weaker evidence, it is prudent that the decision on surgical timing be made as part of a multidisciplinary team with attention to patient-specific risk factors and time sensitivity of the intended surgical procedure.

Intraoperative hypotension is associated with significant potential harms, including myocardial injury, acute kidney injury, and mortality.¹⁶ This is best demonstrated in those with MAP <65 mmHg or SBP <90 mmHg lasting 15 minutes.¹⁶ Maintaining MAP ≥60 to 65 mmHg or SBP ≥90 at a minimum is recommended to decrease the chance of myocardial injury (Class I). POISE-3 investigators found that patients randomized to hypertension-avoidance (MAP>60 mmHg) as compared to hypotension-avoidance (MAP>80 mmHg) had no difference in major vascular events at 30 days (MINS, stroke, cardiac arrest). While no difference was found in this study, due to significant limitations including potential bias, further investigation is needed, and optimal MAP goals should be determined based on individual patient history and risk factors.¹⁷

Heart Failure

Heart failure increases patient risk for perioperative complications.¹⁸ One study in patients undergoing NCS showed that patients with a diagnosis of heart failure had a 67% higher adjusted odds of 90-day mortality compared to patients without heart failure.¹⁸ Optimization of heart failure before elevated risk surgery is associated with decreased risk of perioperative complications.¹⁸ Patients with compensated heart failure should continue goal-directed medical therapy, excluding sodium-glucose cotransporter-2 inhibitors (SGLT2i) in the perioperative period (Class IIa). SGLT2i medications should be held for 3 to 4 days when possible to reduce the risk of perioperative ketoacidosis (Class I). Notably, newer evidence after the release of the current guideline has demonstrated that continued use of SGLT2i in patients undergoing emergency surgery was not associated with more frequent episodes of diabetic ketoacidosis compared to patients not using SGLT2i.¹⁹

Hypertrophic cardiomyopathy is found in 1 in 500 people in the United States. This may lead to dynamic left ventricular outflow obstruction in the setting of decreased preload and afterload and tachycardia during anesthesia. Inotropes and diuresis should be avoided in these patients with vasopressors as the preferred agent for BP support (Class III).²⁰

Patients with pulmonary hypertension (PH) have a higher risk of perioperative MACE regardless of subtype, compared to patients without PH. Optimization and risk stratification of these patients include preoperative echocardiogram and right heart catheterization.²¹ It is recommended to continue targeted medical therapy for PH in patients on stable therapy perioperatively (Class I).

Adult congenital heart disease (ACHD) encompasses a wide range of phenotypes that require individual assessment of baseline risk. In patients with intermediate to elevated risk lesions undergoing elective surgery, consultation with an ACHD specialist is recommended (Class I). Intermediate risk lesions include unrepaired moderate-large shunts (including repaired ACHD with residual shunt), obstructive left- and right-sided lesions, Ebstein anomaly and anomalous coronary artery depending on origin. Elevated risk lesions include single ventricle patients, unrepaired or palliated cyanotic ACHD, double outlet right ventricle, pulmonary atresia, truncus arteriosus, and Transposition of the Great Arteries. For further classification of ACHD patients into low, intermediate, and elevated risk categories, please refer to Table 10 in the original guideline document.²²

The presence of a left ventricular assist device (LVAD) increases the risk of perioperative MACE, and special consideration is needed to determine the optimal timing of elective NCS. Coordination with an LVAD care team or coordinator for elective NCS is recommended (Class I).²³ Similarly, heart transplant recipients have increased risk of perioperative complications and benefit from preoperative assessment by the transplant team.²⁴ Perioperative considerations include attention to the immunosuppression regimen, potential for denervation of the transplanted heart and careful consideration of transfusion to decrease risk of HLA allosensitization or cytomegalovirus infection.²⁴

Valvular Heart Disease

Patients with severe aortic stenosis (AS) benefit from aortic valve intervention prior to elective NCS to reduce perioperative risk (Class I). In individuals with suspected moderate or severe AS planning for elevated risk NCS, a preoperative echocardiogram should be done to guide perioperative management (Class I). In patients who have asymptomatic moderate to severe AS with normal left ventricular systolic function, it is reasonable to proceed with low risk NCS (Class IIa), while those with symptomatic severe AS or asymptomatic severe AS and decreased left ventricular systolic function should be evaluated for aortic valve intervention before elective NCS. For patients for whom aortic valve intervention is recommended, a team-based patient-centered approach should be used to determine the repair modality (transcatheter v open surgical AVR).

Similarly, patients with severe mitral stenosis should be evaluated for potential mitral valve intervention before elective NCS (Class I). Patients with suspected moderate to severe aortic or mitral regurgitation benefit from preoperative echocardiogram prior to elective NCS to guide perioperative care (Class I). The need for valvular intervention before elective elevated-risk NCS should be considered to reduce perioperative risk (Class I). Patients with asymptomatic moderate or severe mitral regurgitation, with normal left ventricular systolic function and pulmonary artery systolic pressures <50 mmHg, can proceed with elective NCS (Class IIa). For asymptomatic moderate or severe aortic regurgitation with normal left ventricular systolic function, it is also reasonable to proceed with elective NCS (Class IIa).⁴

Patients who undergo successful transcatheter aortic valve implantation or mitral transcatheter edge-to-edge repair may proceed with NCS within 30 days if clinically indicated (Class 2a).²⁵ For readers seeking more detailed management recommendations for those with valvular heart disease, please refer to the “2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease.”²⁵

Atrial Fibrillation and Cardiovascular Implantable Electronic Devices

New-onset atrial fibrillation (AF) identified during NCS requires outpatient follow-up for surveillance and thromboembolic risk stratification (Class I). Patients with preexisting AF have an increased perioperative risk of all-cause mortality within 30 days of surgery compared to those without preexisting AF. Patients with preexisting AF and inadequate rate control (HR >100) should be medically optimized prior to surgery.²⁶ Patients with cardiovascular implantable electronic devices (CIED) require a recent interrogation (within 12 months for a pacemaker and within 6 months for an implantable cardioverter-defibrillator) and management plan before elective NCS if electromagnetic interference is anticipated (Class I). Patients who are pacemaker dependent with a planned procedure above the umbilicus should have their pacemaker reprogrammed or have a magnet placed to provide asynchronous pacing (Class I). For those with subcutaneous implantable cardioverter-defibrillator devices, it is reasonable to reprogram the device or use a magnet to disable tachytherapies if the surgery is above the groin (as opposed to above the umbilicus for other device types) (Class IIa).²⁷ We invite readers to explore other published guidelines for additional details on the management of CIEDs.^28,29

Previous Stroke and Obstructive Sleep Apnea

Patients with a previous stroke or transient ischemic attack have an elevated risk of recurrent stroke, but there is insufficient data on the optimal time to delay elective NCS. Delaying elective NCS for ≥3 months is reasonable to decrease the risk of recurrent stroke or MACE (Class IIa). Obstructive sleep apnea is associated with increased perioperative complications. Screening before elective NCS using validated questionnaires to predict perioperative risk is reasonable.³⁰ The recommendations from this section are summarized in Table 3.

Table 3.

Key Take-Home Messages from the Section on Perioperative Management of Cardiovascular Comorbidities

Subject	Important Recommendations
Coronary artery disease	In Patients with ACS for elective NCS, coronary revascularization and deferral of surgery is appropriate to reduce perioperative cardiovascular events.
Blood pressure	Maintaining an intraoperative MAP ≥60 to 65 mmHg or SBP ≥90 mmHg is recommended to reduce the risk of myocardial injury.
	Treatment of hypotension (MAP <60–65 or SBP <90 mm Hg) in the postoperative period is recommended to limit the risk of cardiovascular, cerebrovascular, renal events, and mortality.
	Preoperative antihypertensive medications should be restarted as soon as clinically reasonable to avoid complications from postoperative HTN.
Heart failure	SGLT2i should be withheld for 3 to 4 days before elective NCS when feasible to reduce the risk of perioperative metabolic acidosis.
Pulmonary hypertension	In patients receiving stable doses of targeted medical therapies for pulmonary arterial hypertension, continue these agents to reduce the risk for the development of perioperative MACE.
ACHD	In patients with intermediate- to elevated-risk congenital heart disease lesions undergoing elective NCS, preoperative consultation with an ACHD specialist is recommended.
LVADs	In LVAD patients, coordination with the LVAD coordination team on timing and perioperative considerations of elective NCS is recommended to reduce the risk of perioperative MACE.
Aortic stenosis	Patients with symptomatic severe AS or asymptomatic severe AS with LVEF <50% should be evaluated for potential aortic valve intervention before elective NCS to reduce perioperative risk.
	In patients with moderate to severe AS, preoperative echocardiography is recommended to guide perioperative management of elevated-risk NCS.
Mitral stenosis	Patients with severe mitral stenosis should be evaluated for the potential mitral valve intervention prior to elective NCS.
Chronic valvular regurgitation	In patients with suspected moderate or severe valvular regurgitation, preoperative echocardiography is recommended to guide perioperative management.
	In patients who meet indications for valvular intervention, this should be considered before elective elevated-risk NCS to reduce perioperative adverse events.
CIED	Patients with CIEDs having elective NCS should have a management plan developed before surgery if EMI is anticipated.
	Patients who are pacemaker-dependent having surgeries above the umbilicus with anticipated EMI should have the pacemaker reprogrammed or have a magnet placed on the generator to provide an asynchronous mode. An exception is for subcutaneous ICDs, where the threshold for intervention is above the groin (instead of umbilicus).
	Patients who have a pacemaker or ICD reprogrammed before surgery should have device functioning restored in the postoperative period before hospital discharge.

Abbreviations: ACS, acute coronary syndrome; NCS, noncardiac surgery; MAP, mean arterial pressure; SBP, systolic blood pressure; HTN, hypertension; SGLTi, sodium-glucose cotransporter-2 inhibitors; HTN, hypertension; MACE, major adverse cardiac events; ACHD, adult congenital heart disease; LVAD, left ventricular assist device; AS, aortic stenosis; LVEF, left ventricular ejection fraction; CIED, cardiac implantable electronic device; EMI, electromagnetic interference; ICD, implantable cardioverter-defibrillator.

Perioperative Medical Therapy

The 2024 guideline includes several updates and changes from the previous 2014 edition. Regarding statin therapy, the recommendation to continue statins for patients who are already taking them remains unchanged (Class I). However, the guideline now recommends initiating statins in the perioperative period based on atherosclerotic cardiovascular disease history or a 10-year risk assessment, with the intention of long-term use (Class I).³¹ The guideline does not provide specifics on whether this should be initiated by the proceduralist, anesthesiologist, or primary care provider.

For renin-angiotensin-aldosterone system inhibitors (RAASi), continuation of chronic RAASi therapy is now recommended only for patients with heart failure with reduced ejection fraction (HFrEF) (Class IIa).³² In patients with controlled blood pressure undergoing elevated risk surgery, discontinuing RAASi therapy 24 hours before surgery is suggested to limit intraoperative hypotension (Class IIb).³³ While there are no formal recommendations regarding calcium channel blockers (CCBs), continuing their use during the perioperative period is reasonable. Clinicians should be aware that dihydropyridines may cause intraoperative hypotension, and non-dihydropyridines may cause bradycardia.³⁴ The initiation of α₂-agonists is still not recommended (Class III – no benefit).³⁵

Updates to antiplatelet therapy and oral anticoagulant (OAC) management are significant in the new guideline. For the timing of NCS, a minimum of a 14-day interval is still recommended for elective NCS following coronary artery balloon angioplasty without stent placement (Class I). The guideline makes several recommendations for patients with a recent percutaneous coronary intervention (PCI), treated with dual antiplatelet therapy (DAPT), and scheduled for elective NCS requiring DAPT interruption. If a PCI is performed, the recommended waiting period depends on the indication for PCI. For ACS, elective NCS should be delayed by 12 months (Class I). For chronic CAD, a 6-month delay is recommended (Class IIa). For time-sensitive surgery, NCS may be performed 3 months after PCI (Class IIb). This is a change from the previous recommendation of waiting 6 months. Elective NCS should not be performed within 30 days of bare-metal stent (BMS) or drug-eluting stent (DES) placement.⁴

For antiplatelet therapy, the recommendations differ based on whether a patient has had a prior PCI. For those with prior PCI, continuation of aspirin is recommended during NCS (Class I). Dual antiplatelet therapy should be continued for patients with recent BMS-PCI (within 30 days) or DES-PCI (within 3 months). Bridging with intravenous antiplatelet therapy should be considered for patients at high thrombotic risk who require urgent NCS (Class IIb). For patients without prior PCI, continuation of aspirin is reasonable if the risk of cardiac events outweighs the risk of bleeding (Class IIb). However, routine initiation of aspirin in this population is not beneficial (Class III).⁴

Management of oral anticoagulants (OACs) has undergone significant revisions, as the 2014 guideline lacked formal recommendations in this category. OAC management should involve a multidisciplinary team, with time-based interruption guided by the assessment of perioperative thromboembolic and bleeding risk (Class I). Perioperative bridging therapy with parenteral heparin is recommended for patients at high thrombotic risk requiring interruption of vitamin K antagonists (Class IIa).³⁶ Bridging is not recommended for patients requiring interruption of OAC for NCS due to the increased risk of bleeding (Class III). OAC therapy should be resumed once hemostasis is achieved postoperatively (Class IIa).³⁶ The guideline also now provides detailed recommendations for the timing of OAC interruption along with appropriate reversal agents for emergency situations, which were previously unavailable. Generally, for high bleeding risk procedures, vitamin K antagonists should be withheld for at least 5 days prior, factor Xa inhibitors and dabigatran should be held for at least 2 days prior. In the case of renal impairment, OACs need to be held further in advance to account for decreased renal clearance. While the 4-factor prothrombin complex concentrate can be used as a universal reversal agent for all OACs, andexanet alfa can be used specifically for factor Xa inhibitors, and indarucizumab can be used specifically for direct thrombin inhibitors.

β-Blocker recommendations remain largely unchanged. Continuation of chronic β-blocker therapy is still recommended. For new indications, β-blockers should now be initiated at least 7 days prior to surgery, as opposed to the previous recommendation of at least 1 day.³⁷

New blood glucose management recommendations suggest that obtaining hemoglobin A1c preoperatively is reasonable if it has not been performed within the prior 3 months (Class IIa).³⁸ Continuation of metformin is reasonable to maintain glycemic control, as the risk of acidosis is relatively low (Class IIa).^39,40 These recommendations are summarized in Table 4.

Table 4.

Perioperative Medical Therapy

Medication Class	Recommendation	Class of Recommendation
Statins	Continuation statin for those on chronic statin therapy	1
	For statin naive patients undergoing NCS, initiation of statin is recommended based on ASCVD history or 10-year risk of assessment with intent of long-term use	1
Renin-angiotensin-aldosterone system inhibitors	Hold RAASi in patients with controlled BP and undergoing elevated-risk surgical procedures 24 hours prior to surgery to limit intraoperative hypotension	2b
	In patients with HFrEF, continue chronic RAASi	2a
Alpha 2 receptor agonist	Initiation of low-dose clonidine is not recommended	3: No benefit
Beta blockers	Continue chronic stable beta blocker therapy	1
	If new beta blocker therapy is indicated, initiate therapy at least 7 days prior to NCS	2b
	Beta blocker without immediate need should not be initiated on the day of surgery	3: Harm
Oral anticoagulant	In patients with CVD and high thrombotic risk where vitamin K antagonist interruption is needed, preoperative bridging therapy with heparin can be effective in reducing thrombotic risk	2a
	If OAC interruption is warranted, routine periprocedural bridging is not recommended	3: Harm
	Resume OAC after hemostasis is achieved	2a
Diabetes medications	Discontinue SGLT2i 3 to 4 days prior to surgery	1
	Continue metformin	2a
Antiplatelet therapy	Continue aspirin(75–100 mg) in patients with prior PCI	1
	Continue DAPT in patients who need time-sensitive NCS within 30 days of BMS-PCI or 3 months of DES-PCI unless bleeding risk is significant	1
	Substitute aspirin when feasible in patients for whom OAC monotherapy needs to be discontinued	1
	Intravenous antiplatelet bridging therapy may be considered <6 months for DES, or <30 days for BMS in those who are at high thrombotic risk	2b
	Continue aspirin in those without PCI when risk of cardiac events outweighs risk of bleeding	2b

Abbreviations: NCS, noncardiac surgery; ASCVD, atherosclerotic cardiovascular disease; RAASi, renin-angiotensin-aldosterone system inhibitors; HFrEF, heart failure with reduced ejection fraction; CCB, calcium channel blocker; CVD, cardiovascular disease; OAC, oral anticoagulants; SGLTI, sodium-glucose cotransporter-2 inhibitors; PCI, percutaneous coronary intervention; DAPT, dual anti-platelet therapy; BMS; bare metal stent; DES, drug-eluting stent.

Anesthetic Considerations, Intraoperative Management, and Postoperative Surveillance

In terms of anesthetic considerations, for patients undergoing NCS, there is no significant difference in cardiovascular events between intravenous and volatile anesthetic techniques, making either approach reasonable (Class IIa). Neuraxial anesthesia is also a reasonable option when feasible (Class IIa).⁴¹ Epidural analgesia is considered reasonable for postoperative pain control after major abdominal surgery (Class IIa) or pre-operative pain control for hip fractures (Class IIa) to reduce the incidence of perioperative cardiac events.⁴²

While the emergency use of transesophageal echocardiography (TEE) or focused cardiac ultrasound (FoCUS) is reasonable for unexplained hemodynamic instability (Class IIa), routine TEE is not recommended for screening cardiac abnormalities (Class III). Despite carrying a high class of recommendation, no controlled studies have been performed demonstrating the efficacy of either emergency TEE or FoCUS in the perioperative setting; these recommendations are extrapolated from “rescue” settings using TEE/FoCUS. However, outcomes from counterfactual scenarios where ultrasound is not available remains largely unknown and thus, the definitive benefit to this approach remains uncertain. Similar recommendations exist for the use of pulmonary artery catheters; they can be considered (Class IIB) in patients with critical cardiac issues that may alter hemodynamics but should not be used routinely in patients with CVD (Class III), recommendations that are unchanged from the previous guideline. The only cited study updating PAC use in the 2024 guideline is a non-perioperative retrospective registry study using propensity matching in patients with acute heart failure requiring inotropic support, suggesting a potential benefit in patients with a PAC; this study however suffers from its retrospective design with a high likelihood of residual confounding, and the results are not consistent with larger retrospective databases as well as randomized trial data showing no clinical benefits to PAC placement in dedicated high-risk non-cardiac surgery populations.^43–45 Given these limitations, the current low class of recommendation (Class IIB) seems reasonable. Temporary mechanical circulatory devices may be used in cases of severe hemodynamic instability or cardiopulmonary dysfunction for urgent or emergent surgical cases (Class IIb).⁴⁶

The new guideline introduces recommendations for perioperative anemia management. Tranexamic acid is recommended in NCS with anticipated significant blood loss to reduce transfusion requirements and prevent anemia (Class IIa). In the preoperative phase, iron therapy for iron-deficiency anemia is considered reasonable (Class IIa).^47,48

Updates to myocardial injury and infarction surveillance and management have also been made. For patients with known cardiovascular disease (CVD), symptoms of CVD, or risk factors for CVD, measurement of cardiac troponin (cTn) should be considered within 24 to 48 hours postoperatively to identify myocardial injury (Class IIb). Routine cTn screening is still not recommended for patients undergoing low-risk NCS or those without signs or symptoms of myocardial ischemia. New myocardial injury after noncardiac surgery (MINS) management strategies include outpatient follow-up and initiating antithrombotic therapy for those who develop MINS (Class I).⁴⁹ For postoperative STEMI or NSTEMI, goal-directed medical therapy should be considered, and invasive coronary angiography may be appropriate for patients with NSTEMI, taking into account the risk of postoperative bleeding and thrombosis as well as hemodynamic status. These recommendations are summarized in Table 5.

Table 5.

Key Recommendations from the Section on Anesthetic Considerations and Intraoperative Management.

	New Recommendations	Class of Recommendation
Choice of anesthetic technique	Use of volatile or total intravenous anesthesia is reasonable without difference in cardiovascular events.	2a
	Neuraxial anesthesia (when feasible) or general anesthesia is reasonable without difference in cardiovascular events	2a
Pain management	Use of epidural analgesia is reasonable to decrease perioperative cardiac events in major abdominal surgery	2a
	Epidural analgesia may be considered for preoperative pain control for patients with hip fracture	2b
Echocardiography	TEE or FOCUS is reasonable for emergency assessment of unexplained hemodynamic instability	2a
	Routine TEE use for assessment of cardiac abnormalities is not recommended	3: No Benefit
Temporary mechanical circulatory support	MCS may be used for severe hemodynamic instability and cardiopulmonary dysfunction undergoing urgent or emergent NCS	2b
Pulmonary artery catheters	PAC may be used if hemodynamically unstable medical conditions cannot be corrected prior to surgery	2b
	Routine use of PAC is not recommended	3: No Benefits
Perioperative anemia management	TXA use is reasonable with in surgeries with elevated expected blood loss	2a
	Iron therapy is reasonable as preoperative management for iron deficiency anemia	2a
Myocardial injury and infarction management	Obtaining cTn within 24 to 48 hours post-operation is reasonable to identify myocardial injury in patients with history or symptoms of CVD	2b

Abbreviations: TEE, transesophageal echocardiography; FOCUS, focused cardiac ultrasound; MCS, mechanical circulatory support; PAC, pulmonary artery catheterization; TXA, tranexamic acid; cTn, cardiac troponin; CVD, cardiovascular therapy.

Special Populations

Liver and Kidney Transplantation

Although patients with end-stage liver and kidney disease have a high prevalence of cardiovascular conditions, at least for kidney transplantation, recent studies suggest more frequent invasive or noninvasive preoperative screening for coronary artery disease is not associated with improved outcomes.⁵⁰

Obesity and Bariatric Surgery

Bariatric surgery has been associated with significant health benefits; however, it is not without risks. Careful attention to the history and cardiovascular risk factors during preoperative evaluation is recommended. In addition, patients with obesity are being prescribed GLP-1 inhibitors with increasing frequency. Although a standard preoperative holding period was originally recommended, recent multi-society clinical practice guidance suggests using a shared decision-making model that incorporates elements such as risk of delayed gastric emptying and the GLP-1 inhibitor dose in order to balance the metabolic need for the GLP-1 inhibitor with individual patient risk.⁵¹ In patients without elevated risk of delayed gastric emptying and aspiration, GLP-1 inhibitors can be continued preoperatively (Class Ia).

Conclusions and Future Directions

While the guideline authors are to be commended for perusing, analyzing, and thoughtfully processing ten years of major clinical advances in the field, readers need to recognize that the field of presurgical optimization continues to evolve, even after the ink on this guideline has dried. Two prime examples of changing guidance have already emerged: guidance regarding GLP-1 agonists and SGLT2 inhibitors. While not making a formal recommendation, the current guideline does comment that GLP-1 agonists should be held for as long as 1 week before surgery, as they may delay gastric emptying and increase aspiration risk.⁴ While true at the time of publication, recent retrospective studies assessing patients undergoing both elective and emergency surgeries found patients taking GLP-1 agonists were at no higher aspiration risk compared to those who were not; these data have already resulted in updated guidance from the ASA and other societies suggesting GLP-1 agonists may be continued perioperatively in patients without elevated aspiration risk.^52–54 Similarly, the 2024 ACA/AHA guideline offers a Class I recommend withholding SGLT-2 inhibitors for 3 to 4 days prior to surgery, based upon case report/case series level of evidence (LOE: C-Limited Data). However, recent larger and higher quality retrospective data (LOE: B-Non-randomized) suggest that patients taking SGLT2i undergoing emergency surgery (who were presumably unable to hold their SGLT2i medications) were at no higher risk of developing ketoacidosis after surgery compared to patients who were not taking SGLT2i medications.⁵⁵ While no fault of the guideline authors, it is crucial to recognize this guideline is not a living document with forms of automatic updates; instead, the readers will need to exert continued vigilance as evidence continues to change and separate guidelines are written from other societies superseding this document.

Despite these limitations, the guideline identifies several key knowledge gaps that should be addressed in future research. These include research on multidisciplinary care models; comparisons of risk indices; perioperative management of blood pressure, atrial fibrillation, and recent stroke; the utility of pre-operative testing such as ECGs or echocardiography; perioperative medical therapy involving common medications used for cardiovascular conditions; intraoperative use of TEE, mechanical circulatory support, or pulmonary artery catheters during noncardiac procedures; or risk mitigation after the diagnosis of myocardial injury after NCS. The 2024 guideline represents a significant update from the 2014 guideline, and it is essential for the anesthesiologist to be familiar with this guideline to best serve their patients.