JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.

-, 2024
ª 2024 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER

SOCIETAL STATEMENT

2024 Perioperative Cardiovascular

Management for Noncardiac Surgery
Guideline-at-a-Glance

Nicole M. Bhave, MD, FACC* *On behalf of the ACC Solution Set
Morgane Cibotti-Sun, MPH Oversight Committee.
Mykela M. Moore, MPH

INTRODUCTION Dissemination Workgroup selected 3 of the Top

Take-Home Messages (in bold) as key themes for this
The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/ Guideline-at-a-Glance as they represent the most
SVM Guideline for Perioperative Cardiovascular impactful recommendation changes compared to
Management for Noncardiac Surgery (AHA/ACC/Mul- previous guidelines and address known gaps in clin-
tisociety Perioperative Guideline) provides the latest ical practice.
guidance for clinicians on the cardiovascular man-
1. A stepwise approach to perioperative cardiac
agement of patients undergoing noncardiac surgery
1 assessment assists clinicians in determining when
(NCS). The guideline contains updated, evidence-
surgery should proceed or when a pause for
based recommendations that build on those from
2 further evaluation is warranted.
the 2014 Perioperative Guideline. This Guideline-at-
2. Cardiovascular screening and treatment of patients
a-Glance highlights practice-changing recommenda-
undergoing NCS should adhere to the same in-
tions from the guideline to accelerate adoption.
dications as nonsurgical patients, carefully timed
ACC guideline dissemination is an organization-
to avoid delays in surgery and chosen in ways to
wide effort facilitated by the Solution Set Oversight
avoid overscreening and overtreatment.
Committee to ensure the integration of guideline
3. Stress testing should be performed judiciously in
content throughout ACC’s clinical policy, education,
patients undergoing NCS, especially those at lower
registry, membership, and advocacy efforts. For each
risk, and only in patients in whom testing would be
guideline, an ACC Guideline Dissemination Work-
appropriate independent of planned surgery.
group is created to influence dissemination strategy
4. Team-based care should be emphasized when
and to develop tools to facilitate the implementation
managing patients with complex anatomy or un-
of key changes in practice. These tools include the
stable cardiovascular disease.
JACC Central Illustration, as well as tables highlighting
5. New therapies for management of diabetes, heart
updates in the AHA/ACC/Multisociety Perioperative
failure, and obesity have significant periopera-
Guideline and comparisons to the 2022 European So-
tive implications. Sodium-glucose cotransporter
ciety of Cardiology (ESC) Guidelines on Cardiovascu-
2 inhibitors (SGLT2i) should be discontinued 3 to
lar Assessment and Management of Patients
4 days before surgery to minimize the risk of
Undergoing Noncardiac Surgery.3
perioperative ketoacidosis associated with their
TOP TAKE-HOME MESSAGES use.
6. Myocardial injury after noncardiac surgery (MINS)
The following Top Take-Home Messages are taken is a newly identified disease process that should
directly from the AHA/ACC/Multisociety Periopera- not be ignored because it portends real conse-
tive Guideline. The ACC Perioperative Guideline quences for affected patients.

*On behalf of the ACC Solution Set Oversight Committee.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2024.08.018

2 Bhave et al JACC VOL. -, NO. -, 2024
2024 Perioperative Guideline-at-a-Glance -, 2024:-–-

7. Patients with newly diagnosed atrial fibrillation (AF) highest risk for thrombotic complications and is not
identified during or after NCS have an increased risk of recommended in the majority of cases.
stroke. These patients should be followed closely after 9. In patients with unexplained hemodynamic instability
surgery to treat reversible causes of arrhythmia and to and when clinical expertise is available, emergency
assess the need for rhythm control and long-term focused cardiac ultrasound can be used for periopera-
anticoagulation. tive evaluation; however, focused cardiac ultrasound
8. Perioperative bridging of oral anticoagulant therapy should not replace comprehensive transthoracic
should be used selectively only in those patients at echocardiography.

C E N T R A L IL LU ST R A T I O N 2024 Perioperative Cardiovascular Management for Noncardiac Surgery

Guideline-at-a-Glance

Bhave SD, et al. JACC. 2024;10.1016/j.jacc.2024.08.018.

*For warfarin, pre- and postop bridging only if high thrombotic risk. AF ¼ atrial fibrillation; FoCUS ¼ focused cardiac ultrasound; MINS ¼ myocardial injury
after noncardiac surgery; OAC ¼ oral anticoagulant; periop ¼ perioperative; postop ¼ postoperative; SGLT2i ¼ sodium-glucose cotransporter-2 inhibitors;
TEE ¼ transesophageal echocardiography.
JACC VOL. -, NO. -, 2024 Bhave et al 3
-, 2024:-–- 2024 Perioperative Guideline-at-a-Glance

TABLE 1 Select Differences Between the 2014 and the 2024 AHA/ACC/Multisociety Perioperative Guidelines

2014 2 2024 1
COR* Old Recommendations COR* New Recommendations

Stress testing 2a For patients with elevated risk and excellent (>10 2b For patients undergoing elevated-risk NCS with poor or
(Top Take-Home METs) functional capacity, it is reasonable to unknown functional capacity and elevated risk for
Message 3) forgo further exercise testing with cardiac perioperative cardiovascular events based on a
imaging and proceed to surgery. validated risk tool, stress testing may be considered
to evaluate for inducible myocardial ischemia.
2b For patients with elevated risk and unknown
functional capacity, it may be reasonable to
perform exercise testing to assess for functional
capacity if it will change management.

2b For patients with elevated risk and moderate to

good ($4 METs to 10 METs) functional
capacity, it may be reasonable to forgo further
exercise testing with cardiac imaging and
proceed to surgery.

2b For patients with elevated risk and poor (<4 METs)

or unknown functional capacity, it may be
reasonable to perform exercise testing with
cardiac imaging to assess for myocardial
ischemia if it will change management.

3: No Routine screening with noninvasive stress testing is 3: No In patients who are at low risk for perioperative
Benefit not useful for patients at low risk for NCS. Benefit cardiovascular events, have adequate† functional
capacity with stable symptoms, or who are undergoing
low-risk procedures, routine stress testing before NCS
is not recommended due to lack of benefit.

SGLT2i (Top Take-Home No corresponding guideline recommendation. 1 In patients with heart failure undergoing elective NCS,
Message 5) SGLT2i should be withheld for 3 to 4 days‡ before
surgery when feasible to reduce the risk of
perioperative metabolic acidosis.

1 In patients scheduled for NCS, SGLT2i should be

discontinued 3 to 4 days‡ days before surgery to
reduce the risk of perioperative metabolic acidosis.

Myocardial injury after 2b The usefulness of postoperative screening with 2b In patients with known CVD, with symptoms of CVD, or
noncardiac surgery troponin levels in patients at high risk for age $65 years with cardiovascular risk factors
(Top Take-Home perioperative MI, but without signs or undergoing elevated-risk NCS, it may be reasonable
Message 6) symptoms suggestive of myocardial ischemia or to measure cTn at 24 and 48 hours after surgery to
MI, is uncertain in the absence of established identify myocardial injury.
risks and benefits of a defined management
strategy.

3: No Routine postoperative screening with troponin 3: No In patients undergoing low-risk NCS, routine
Benefit levels in unselected patients without signs or Benefit postoperative screening with cTn levels is not
symptoms suggestive of myocardial ischemia or indicated without signs or symptoms suggestive of
MI is not useful for guiding perioperative myocardial ischemia or MI.
management.

No corresponding guideline recommendation. 2a In patients who develop MINS, especially in those not
previously known to have excess cardiovascular risk,
outpatient follow-up is reasonable for optimization
of cardiovascular risk factors.

No corresponding guideline recommendation. 2b In patients who develop MINS, antithrombotic therapy may
be considered to reduce thromboembolic events.

Atrial fibrillation (Top No corresponding guideline recommendation. 2a In patients with rapid AF identified in the setting of
Take-Home Message 7) NCS, it is reasonable to treat potential underlying
triggers contributing to AF and rapid ventricular
response (eg, sepsis, anemia, pain).

2a In patients with new-onset AF identified in the setting

of NCS, initiation of postoperative anticoagulation
therapy can be beneficial after considering the
competing risks associated with thromboembolism
and perioperative bleeding.

1 In patients with new-onset AF identified in the setting

of NCS, outpatient follow-up for thromboembolic
risk stratification and AF surveillance are
recommended given a high risk of AF recurrence.

*Colors in this table align with the classification system found in Table 3, “Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care,” in the AHA/ACC/Multisociety Perioperative Guideline.1
†Poor functional capacity is considered <4 METs or a DASI score of #34.
‡Canagliflozin, dapagliflozin, and empagliflozin should be stopped $3 days and ertugliflozin $4 days before scheduled surgery.
ACC ¼ American College of Cardiology; AF ¼ atrial fibrillation; AHA ¼ American Heart Association; COR ¼ Class of Recommendation; cTn ¼ cardiac troponin; CVD ¼ cardiovascular
disease; DASI ¼ Duke Activity Status Index; MET ¼ metabolic equivalent; MI ¼ myocardial infarction; MINS ¼ myocardial injury after noncardiac surgery; NCS ¼ noncardiac surgery;
SGLT2i ¼ sodium-glucose cotransporter-2 inhibitors.
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2024 Perioperative Guideline-at-a-Glance -, 2024:-–-

Select Comparison of 2024 AHA/ACC/Multisociety Perioperative Guideline and 2022 ESC Noncardiac Surgery
TABLE 2
Guidelines

ESC Guideline 3 AHA/ACC/Multisociety Guideline 1

COR* ESC recommendation COR* AHA/ACC/Multisociety recommendation

Stress testing 1 Stress imaging is recommended before high- 2b For patients undergoing elevated-risk NCS with
(Top Take-Home risk elective NCS in patients with poor poor or unknown functional capacity and
Message 3) functional capacity and high likelihood of elevated risk for perioperative cardiovascular
CAD or high clinical risk. events based on a validated risk tool, stress
testing may be considered to evaluate for
2a Stress imaging should be considered before
inducible myocardial ischemia.
high-risk NCS in asymptomatic patients with
poor functional capacity and previous PCI or
CABG.

2b Stress imaging may be considered before

intermediate-risk NCS when ischemia is of
concern in patients with clinical risk factors
and poor functional capacity.

3 Stress imaging is not recommended routinely 3: No Benefit In patients who are at low risk for perioperative
before NCS. cardiovascular events, have adequate†
functional capacity with stable symptoms,
or who are undergoing low-risk procedures,
routine stress testing before NCS is not
recommended due to lack of benefit.

SGLT2i (Top Take-Home 2a It should be considered to interrupt SGLT2i 1 In patients with heart failure undergoing
Message 5) therapy for at least 3 days before elective NCS, SGLT2i should be withheld for
intermediate- and high-risk NCS. 3 to 4 days‡ before surgery when feasible to
reduce the risk of perioperative metabolic
acidosis.

1 In patients scheduled for NCS, SGLT2i should be

discontinued 3 to 4 days‡ days before
surgery to reduce the risk of perioperative
metabolic acidosis.

MINS (Top Take-Home 1 In patients who have known CVD, 2b In patients with known CVD, with symptoms of
Message 6) cardiovascular risk factors (including CVD, or age $65 years with cardiovascular
age $65 years), or symptoms suggestive of risk factors undergoing elevated-risk NCS, it
CVD, it is recommended to measure hs-cTnT may be reasonable to measure cTn at 24
or hs-cTnI before intermediate- and high- and 48 hours after surgery to identify
risk NCS, and at 24 and 48 hours afterwards. myocardial injury.

No corresponding guideline recommendation. 3: No Benefit In patients undergoing low-risk NCS, routine

postoperative screening with cTn levels is
not indicated without signs or symptoms
suggestive of myocardial ischemia or MI.

No corresponding guideline recommendation. 2a In patients who develop MINS, especially in

those not previously known to have excess
cardiovascular risk, outpatient follow-up is
reasonable for optimization of
cardiovascular risk factors.

2b In patients with MINS and at low risk of 2b In patients who develop MINS, antithrombotic
bleeding, treatment with dabigatran 110 mg therapy may be considered to reduce
orally b.i.d. may be considered from about 1 thromboembolic events.
week after NCS.

Continued on the next page

JACC ILLUSTRATION preoperative, intraoperative, and postoperative—serving

as a call-to-action tool. It highlights key changes
Central Illustration: Major Changes in Perioperative throughout the guideline, ensuring that healthcare pro-
Cardiovascular Management for Noncardiac Surgery fessionals are equipped for optimizing patient outcomes
The AHA/ACC/Multisociety Perioperative Guideline pro- across all phases of care.
vides a comprehensive overview of risk assessment, in- COMPARISON TO PREVIOUS ACC/AHA/
dicates the appropriate use of cardiovascular testing and MULTISOCIETY GUIDELINE
screening, and outlines evidence-based management
strategies spanning from preoperative to postoperative The AHA/ACC/Multisociety Perioperative Guideline up-
care stages. 1 dates content previously covered in the 2014 Periopera-
The JACC Central Illustration for this guideline un- tive Guideline.2 Table 1 outlines changes in stress testing,
derscores the importance of the 3 distinct stages— SGLT2i therapy, MINS, and AF management between the
JACC VOL. -, NO. -, 2024 Bhave et al 5
-, 2024:-–- 2024 Perioperative Guideline-at-a-Glance

TABLE 2 Continued

ESC Guideline 3 AHA/ACC/Multisociety Guideline 1

COR* ESC recommendation COR* AHA/ACC/Multisociety recommendation

Atrial fibrillation (Top Take- No corresponding guideline recommendation. 2a In patients with rapid AF identified in the
Home Message 7) setting of NCS, it is reasonable to treat
potential underlying triggers contributing
to AF and rapid ventricular response (eg,
sepsis, anemia, pain).

2a In patients with postoperative AF after NCS, 2a In patients with new-onset AF identified in the
long-term OAC therapy should be setting of NCS, initiation of postoperative
considered in all patients at risk of stroke, anticoagulation therapy can be beneficial
considering the anticipated net clinical after considering the competing risks
benefit of OAC therapy, and informed associated with thromboembolism and
patient preferences. perioperative bleeding.

1 In patients with new-onset AF identified in the

setting of NCS, outpatient follow-up for
thromboembolic risk stratification and AF
surveillance are recommended given a high
risk of AF recurrence.

3 Routine use of beta blocker for the prevention No corresponding guideline recommendation.
of postoperative AF in patients undergoing
NCS is not recommended.

*Colors in this table align with the classification system found in Table 3, “Applying American College of Cardiology/American Heart Association Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care,” in the AHA/ACC/Multisociety Perioperative Guideline.1
†Poor functional capacity is considered <4 METs or a DASI score of #34.
‡Canagliflozin, dapagliflozin, and empagliflozin should be stopped $3 days and ertugliflozin $4 days before scheduled surgery.
ACC ¼ American College of Cardiology; AF ¼ atrial fibrillation; AHA ¼ American Heart Association; b.i.d. ¼ bis in die (twice a day); CABG ¼ coronary artery bypass graft; CAD ¼
coronary artery disease; COR ¼ Class of Recommendation; cTn ¼ cardiac troponin; CV ¼ cardiovascular; CVD ¼ cardiovascular disease; DASI ¼ Duke Activity Status Index; ESC ¼
European Society of Cardiology; hs-cTn ¼ high-sensitivity cardiac troponin; MET ¼ metabolic equivalent; MI ¼ myocardial infarction; MINS ¼ myocardial injury after noncardiac
surgery; NCS ¼ noncardiac surgery; OAC ¼ oral anticoagulant; PCI ¼ percutaneous coronary intervention; SGLT2i ¼ sodium-glucose cotransporter-2 inhibitors.

2014 and 2024 versions of the guideline. The comparison guideline.3 The comparison focuses on Top Take-Home
focuses on Top Take-Home Messages 3, 5, 6, and 7. Messages 3, 5, 6, and 7.
For further details, refer to the corresponding sections For further details, refer to the corresponding sections
of the AHA/ACC/Multisociety Perioperative Guideline 1: of the 2022 ESC noncardiac surgery guidelines3:

 Section 4.3. “Stress Testing”  Section 4.5.2. “Stress Tests”

 Section 6.3. “Heart Failure”  Section 5.2.9. “Sodium–Glucose Co-Transporter-2
 Section 7.8. “Perioperative Management of Blood Inhibitors”
Glucose”  Section 4.4. “Biomarkers”
 Section 9.1. “Myocardial Injury After Noncardiac Surgery  Section 8.7. “Perioperative Stroke”
Surveillance and Management”
 Section 6.5. “Atrial Fibrillation” ACKNOWLEDGMENTS The authors would like to thank
the ACC Solution Set Oversight Committee: Niti R.
Aggarwal, MD, FACC; Katie Bates, ARNP, DNP; John P.
COMPARISON OF AHA/ACC/MULTISOCIETY Erwin, III, MD, FACC; Martha Gulati, MD, MS, FACC;
PERIOPERATIVE GUIDELINE TO ESC GUIDELINE Dharam J. Kumbhani, MD, SM, FACC; Gurusher S. Pan-
jrath, MBBS, FACC; Barbara Wiggins, PharmD, FACC; and
In 2022, the ESC published a guideline on cardiovascular Megan Coylewright, MD, MPH, FACC–Ex Officio.
assessment and management of patients undergoing The authors would also like to thank the ACC Periop-
noncardiac surgery. 3 Table 2 compares the recommenda- erative Guideline Dissemination Workgroup: Nathaniel R.
tions related to stress testing, SGLT2i, MINS, and AF be- Smilowitz, MD, MS, FACC; Alison F. Ward, MD, FACC;
tween the 2024 AHA/ACC/Multisociety Perioperative John U. Doherty, MD, FACC; and Gilbert H.L. Tang, MD,
Guideline 1 and the 2022 ESC noncardiac surgery MSc, MBA, FACC.
6 Bhave et al JACC VOL. -, NO. -, 2024
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