AHA Clinical Update PPTX

CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

CLASS 1 (STRONG) Benefit >>> Risk LEVEL A
Suggested phrases for writing recommendations: • High-quality evidence‡ from more than 1 RCT
• Is recommended • Meta-analyses of high-quality RCTs
• Is indicated/useful/effective/beneficial • One or more RCTs corroborated by high-quality registry studies
• Should be performed/administered/other
• Comparative-Effectiveness Phrases†: LEVEL B-R (Randomized)
− Treatment/strategy A is recommended/indicated in preference to treatment B
• Moderate-quality evidence‡ from 1 or more RCTs
− Treatment A should be chosen over treatment B
• Meta-analyses of moderate-quality RCTs
CLASS 2a (MODERATE) Benefit >> Risk LEVEL B-NR (Nonrandomized)
Suggested phrases for writing recommendations:
• Moderate-quality evidence‡ from 1 or more well-designed, well-executed
• Is reasonable
nonrandomized studies, observational studies, or registry studies
• Can be useful/effective/beneficial
• Meta-analyses of such studies
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD (Limited Data)
treatment B
− It is reasonable to choose treatment A over treatment B • Randomized or nonrandomized observational or registry studies with
limitations of design or execution
CLASS 2b (Weak) Benefit ≥ Risk • Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects
Suggested phrases for writing recommendations:
• May/might be reasonable LEVEL C-EO (Expert Opinion)
• May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established • Consensus of expert opinion based on clinical experience.

CLASS 3: No Benefit (MODERATE) Benefit = Risk

•COR and LOE are determined independently (any COR may be paired with any LOE).
Suggested phrases for writing recommendations: •A recommendation with LOE C does not imply that the recommendation is weak. Many
• Is not recommended important clinical questions addressed in guidelines do not lend themselves to clinical
• Is not indicated/useful/effective/beneficial trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
particular test or therapy is useful or effective.
• Should not be performed/administered/other
•*The outcome or result of the intervention should be specified (an improved clinical
CLASS 3: Harm (STRONG) Risk > Benefit outcome or increased diagnostic accuracy or incremental prognostic information).
• †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
Suggested phrases for writing recommendations: studies that support the use of comparator verbs should involve direct comparisons of
the treatments or strategies being evaluated.
• Potentially harmful
• Causes harm •‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic
• Associated with excess morbidity/mortality reviews, the incorporation of an Evidence Review Committee.
• Should not be performed/administered/other
•COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE,
Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled
trial.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Immediate threat to life or limb without
surgical intervention, <2 hours
Threat to life or limb without surgical
intervention, 2-24 hours Endocrine General Vascular
May delay surgery up to 3 months to Breast ENT Thoracic
complete evaluation + manage
Gynecology Genitourinary Transplant
Complete evaluation + manage prior to
surgery Obstetrics Orthopedic Neurosurgery

*Based on RCRI or other risk prediction tool

Abbreviations: ENT indicates ear nose throat; MACE, major adverse cardiovascular event; and RCRI, Revised Cardiac Risk Index.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
  

Case cancellation
Pre-operative
Healthcare utilization Improved Patient
Satisfaction

Post-operative Readmission

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
Risk In patients with known cardiovascular disease (CVD) being
Calculators considered for NCS, a validated risk-prediction tool can be
useful to estimate the risk of perioperative MACE.

Patient Surgical
Factors Factors
Functional Surgical timing
status, frailty, and risk •
Medical
Conditions •

OLDEST
•

Cardiac •
Biomarkers*
Troponin(2a), •

NEWEST
BNP or NT-
proBNP (2b) •

* For pts with CVD, age ≥65 years, or age ≥45 years with symptoms suggestive of •
CVD undergoing elevated risk NCS

Abbreviations: AUB indicates American University of Beirut; COR, class of recommendation; CVD, cardiovascular disease; LOE, level of evidence; MACE,
major cardiovascular adverse events; NCS, non-cardiac surgery; and NSQIP, National Surgical Quality Improvement Program.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS COR RECOMMENDATIONS
In patients undergoing elevated risk NCS, structured In all patients with perceived frailty who are undergoing
assessment of functional capacity is reasonable to elevated risk NCS, preoperative frailty assessment using a
stratify risk of perioperative adverse cardiovascular validated tool can be useful for evaluating perioperative risk
events. and guiding management.

• “Physiologic declines across multiple organ systems resulting in

increased vulnerability to stressors”
• Prevalence 10.7% among community-dwelling individuals ≥65
years of age
• Frailty 2x higher in women ♀ than men ♂
• Validated instruments: Physical Frailty Phenotype, Deficit
Accumulation Index, FRAIL Scale, Clinical Frailty Scale, SPPB

Abbreviations: COR indicates class of recommendation; LOE, level of evidence;

MET, metabolic equivalent; NCS, non-cardiac surgery; and SPPB, Short Physical Performance Battery
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS

In patients with known CVD, or age ≥65 years, or age ≥45 years with symptoms suggestive
of CVD undergoing elevated-risk NCS, it is reasonable to measure B-type natriuretic
peptide (BNP) or N-terminal pro–B-type natriuretic peptide (NT-proBNP) before surgery to
supplement evaluation of perioperative risk.

COR RECOMMENDATIONS

In patients with known CVD, or age ≥65 years, or age ≥45 years with symptoms suggestive
of CVD undergoing elevated-risk NCS, it may be reasonable to measure cardiac troponin
(cTn) before surgery to supplement evaluation of perioperative risk.

Abbreviations: COR indicates class of recommendation; BNP, B-type natriuretic peptide; cTn, cardiac troponin; CVD, cardiovascular disease; NCS,
noncardiac surgery; and NT-proBNP, N-terminal pro-B-type natriuretic peptide.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 IF preoperative ECG shows new abnormalities* Elevated (intermediate, high) risk surgery?

Yes No
Obtain further evaluation to refine cardiovascular risk
(Class 2a) Known CAD, significant arrhythmia, PAD,
ECG
cerebrovascular disease, significant
(Class 3: No benefit)
SHD, or symptoms?
*Abnormalities may include:
• ST segment elevation or depression, T wave inversions
Yes No
• Left ventricular hypertrophy
• Significant pathologic Q-waves
• Mobitz type II or higher AV block Obtain ECG Obtain ECG
• Bundle branch block (Class 2a) (Class 2b)
• QT prolongation
• Atrial fibrillation

Abbreviations: CAD indicated coronary artery disease; ECG, electrocardiogram; MACE, major adverse cardiovascular events;
PAD, peripheral artery disease; and SHD, structural heart disease.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
• RV dysfunction associated with adverse CV New dyspnea, physical exam findings of HF, or
outcomes in NCS. suspected new/worsening LV dysfunction?
• Routine preoperative evaluation of RV function
is not recommended in asymptomatic and Yes No
clinically stable patients.
Known diagnosis of HF? Routine preoperative
evaluation of LV function
(Class 3: No benefit)
Yes No

Preoperative Preoperative
assessment of LV assessment of LV
function is function is
reasonable recommended
(Class 2a) (Class 1)

Abbreviations: CV indicates cardiovascular; HF, heart failure; LV, left ventricular; NCS, non-cardiac surgery; and RV indicates right ventricular.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
Low risk for perioperative CV events Functional capacity ≥4 METS with
Low-risk procedure
(<1% MACE) stable symptoms

Routine stress test not recommended (Class 3: No benefit)

Poor or unknown Elevated risk

Undergoing elevated
functional status (<4 perioperative CV
risk NCS
METS) events (≥1% MACE)

Consider stress test to evaluate for inducible

myocardial ischemia (Class 2b)

Abbreviations: CPET indicates cardiopulmonary exercise testing; CV, cardiovascular; LVOT, left ventricular outflow tract;
MACE, major adverse cardiovascular events; MET, metabolic equivalent; NCS, non-cardiac surgery; and VT, ventricular tachycardia.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Low High
Using validated risk tool

Low High

Adequate ≥ 4 METs
Poor or Unknown <
4 METs

Abbreviations: CCTA indicates coronary computed tomography angiography; CT, computed tomography; and METs, metabolic equivalents.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
In patients undergoing NCS, routine preoperative ICA is not
No Benefit recommended to improve perioperative outcomes.

Abbreviations: ACS indicates acute coronary syndrome; ICA, invasive coronary angiography; and NCS, non-cardiac surgery
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Yes No

Emergency surgery Yes Proceed to surgery

No

Does the patient have?

• Acute coronary syndrome
• Unstable cardiac arrhythmias
• Decompensated heart failure

Yes No

Perioperative Risk Estimation

Management of acute cardiac condition and Does the patient have any of the following risk modifiers?
• Severe valvular heart disease • Recent stroke
multidisciplinary team discussion for deferral of
• Severe pulmonary hypertension • CIED (Pacemaker/ICD) present
surgery, noninvasive Tx, or palliation.
Risk calculator • Elevated-risk congenital heart • Frailty
for adverse CV events (2a) disease
• Prior coronary stents/CABG

Abbreviations: CABG indicates coronary artery bypass grafting; CIED, cardiovascular implantable electronic devices; CV, cardiovascular;
Continued
ICD, implantable cardioverter-defibrillator; NCS, noncardiac surgery; and Tx, treatment.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Continued Perioperative Risk Estimation

Low risk †, Risk modifier present with

Elevated risk †, no risk modifiers
no risk modifiers any calculated risk †

Consider appropriate team-based consultation for

Proceed to surgery Consider ECG in elevated risk asymptomatic patients
NCS timing and perioperative diagnostic testing and
without CVD (2b)
management.
GDMT initiation for long-term CV risk reduction and ECG is reasonable in patients with established CVD
† Determining disease management, as applicable or symptoms (2a)
elevated calculated
Echocardiography for suspected moderate/severe
risk depends on the Poor or unknown functional capacity valvular stenosis/regurgitation, new dyspnea, or
No
calculator used. (DASI ≤34, METS <4) (2a) suspected new/worsening ventricular dysfunction
Traditionally, RCRI >1 (Class 1/2a)
or a calculated risk of Yes
MACE with any GDMT initiation for long-term cardiovascular risk
perioperative risk Proceed to surgery or consider Will further testing impact decision making or reduction and disease management, as applicable
alternatives
No
calculator >1% is used perioperative care?
as a threshold to Yes
identify patients at
elevated risk.
Continued
Abbreviations: ECG indicates electrocardiography; CV, cardiovascular; CVD, cardiovascular disease; DASI, Duke activity status index; GDMT, guideline
directed medical therapy; METS, metabolic equivalents; and NCS, noncardiac surgery
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Proceed to surgery or
Will further testing impact decision
Continued consider alternative No
making or perioperative care?
strategies.
Yes

Pre-op biomarker risk assessment:

Proceed to surgery Normal BNP/NT-proBNP (2a) Consider Troponin (2b) Abnormal Multidisciplinary team discussion
of risks/benefits of additional
cardiac evaluation

Pursue cardiac evaluation Defer cardiac evaluation

Consider Echocardiography
Consider alternative strategies or
Low Risk Consider Non-invasive stress testing, or CCTA (2b) Elevated Risk
proceed with surgery

Consider Post-op troponin surveillance (2b)

Abbreviations: BNP indicates b-type natriuretic peptide; CCTA, coronary computed tomography angiography;
NCS, noncardiac surgery; and NT-proBNP, N-terminal pro b-type natriuretic peptide.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
For patients with ACS, pre-operative
revascularization is recommended .

For patients with chronic coronary disease and

increased risk of significant left main stenosis (>50%), consider
perioperative MACE pre-operative revascularization.

For patients with non-left main CAD,

No Benefit revascularization not recommended.

increased risk of
perioperative MACE

Abbreviations: ACS indicates acute coronary syndrome; CAD, coronary artery disease;
MACE, major adverse cardiovascular events; MI, myocardial infarction; and NCS, non-cardiac surgery.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS

In patients undergoing NCS, maintaining intraoperative MAP

≥60-65 mmHg or SBP ≥90 mmHg is recommended.

COR RECOMMENDATIONS
COR RECOMMENDATIONS
In most patients with HTN, it is reasonable to continue
medical therapy for HTN throughout the preoperative In patients undergoing NCS, treatment of hypotension MAP
period. <60-65 or SBP <90 mmHg in the post-operative period is
recommended.
In most patients undergoing elective elevated risk
surgery who have cardiovascular risk factors and recent In patients with HTN undergoing NCS, it is recommended
history of poorly controlled HTN (SBP ≥180 mm Hg or that preoperative antihypertensive medications be restarted
DBP ≥110 mmHg), consider deferring surgery. as soon as clinically reasonable.

Abbreviations: DBP indicates diastolic blood pressure; HTN, hypertension;

MAP, mean arterial pressure; NCS, non-cardiac surgery; and SBP, systolic blood pressure
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Advanced HF who are Clinically
Compensated HF
Elective NCS Decompensated or Hemodynamically
undergoing NCS
Unstable

Hold SGLT2i 3-4 days Reasonable to continue GDMT, excluding Postpone elective surgery and obtain
prior to surgery. SGLT2i, unless contraindicated. cardiology consult

Abbreviations: GDMT indicates guideline-directed medical therapy; ACEi, angiotensin-converting enzyme inhibitor;
ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; BB, beta blocker;
MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-glucose cotransporter-2 inhibitor.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
In patients undergoing NCS, factors that aggravate or
trigger dynamic outflow obstructions are harmful and
Harm should be avoided to reduce the risk of hemodynamic
instability.

Abbreviations: LVOT indicates left ventricular outflow tract; LV, left ventricle; HCM, hypertrophic cardiomyopathy; and NCS, noncardiac surgery.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS

In patients receiving stable doses of targeted medical therapies* for pulmonary arterial hypertension undergoing NCS, it is
recommended to continue these agents to reduce risk for the development of perioperative MACE.

In patients with severe† pulmonary hypertension undergoing elevated risk NCS, referral to or consultation with a specialized PH
center that can support risk assessment, optimization, and post-operative management (with consideration of intensive care after
NCS) is reasonable to reduce perioperative cardiopulmonary complications.

In patients with severe† PH undergoing elevated risk NCS, invasive hemodynamic monitoring is reasonable to guide intraoperative
and postoperative care.

In patients with precapillary PH undergoing elevated NCS, perioperative administration of short-acting inhaled pulmonary
vasodilators may be reasonable to reduce elevated right ventricular afterload and prevent acute decompensated right HF.

*See section 6.3.2 for specific medical therapies

† See section 6.3.2 for the definition of severe PH

Abbreviations: HF indicates heart failure; MACE, major adverse cardiac event; NCS, noncardiac surgery; and PH, pulmonary hypertension.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 In patients with intermediate to elevated risk CHD lesions preoperative consultation
with an ACHD specialist is recommended (Class 1)

• In patients with isolated • Unrepaired moderate-large • Ebstein anomaly • Single ventricle patients (palliated or
small CHD lesions shunts • Anomalous coronary artery status post Fontan procedure)
• In patients with CHD • Repaired CHD with moderate arising from the pulmonary • Unrepaired or palliated cyanotic CHD
repaired lesion with no to large residual shunt artery • Double outlet right ventricle
residual shunt • Obstructive left sided lesions • Anomalous aortic origin of a • Pulmonary atresia
• In patients with bicuspid coronary artery from the
• Obstructive right sided lesion
aortic valve disease and opposite sinus • Truncus arteriosus
aortopathy • TGA
• Interrupted aortic arch
• NYHA Class I functional • NYHA class II- IV functional • Significant valvular • NYHA class II- IV functional status
status, normal exercise status dysfunction • Limited exercise capacity
capacity • Limited exercise capacity • Arrhythmias requiring • Significant valvular dysfunction (more
• No chamber enlargement treatment
• Presence of residual shunt than mild in severity)
on imaging • Presence of HF
• Presence of PAH • Arrhythmias requiring treatment.
• No residual shunt
• Presence of cardiac chamber • Presence of PAH
• No PAH enlargement • Presence of HF
• No arrhythmias

Abbreviations: ACHD indicates adult congenital heart disease; CHD, congenital heart disease; HF, heart failure;
NYHA, New York Heart Association; PAH, pulmonary arterial hypertension; TGA, transposition of the great vessels
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS
In patients with severe AS should be Multidisciplinary team discussions:
evaluated for the need for aortic valve cardiology, anesthesiology, and surgery
intervention prior to elective NCS to
reduce perioperative risk.
Symptomatic aortic stenosis† Asymptomatic aortic stenosis
In patients with suspected moderate or
severe AS who are undergoing elevated
risk NCS, preoperative LVEF <50% LVEF ≥50%
Candidate for AVR?
echocardiography is recommended
prior to elective NCS. No Yes Yes

Evaluate for AVR before elective Can delay Yes Elevated Risk
In asymptomatic patients with NCS?
Consider non-surgical elevated risk NCS (1) Surgery‡
moderate or severe AS and normal LV management, minimally
systolic function as assessed by invasive alternatives, BAV
No No
echocardiography within the past year, prior to NCS, palliative care, Team-based, patient centered
it is reasonable to proceed with elective or proceed with elevated- decision for procedural modality Team-based, patient Reasonable to
low risk NCS. risk surgery after shared centered decision proceed with
decision making regarding how to elective low risk
TAVI SAVR proceed NCS (2a)

Abbreviations: AS indicates aortic stenosis; AVR, aortic valve replacement; BAV, balloon aortic valvuloplasty; LV, left ventricular; LVEF, left ventricular ejection
fraction; NCS, non-cardiac surgery; SAVR, surgical aortic valve replacement and TAVR, transcatheter aortic valve replacement.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients with severe MS should be evaluated for the need for MV intervention prior to elective NCS.

In patients with severe MS who cannot undergo MV intervention prior to NCS, perioperative invasive hemodynamic monitoring is
reasonable to guide management.

In patients with severe MS who cannot undergo MV intervention prior to NCS, perioperative heart-rate control may be considered to
prolong diastolic filling time and decrease perioperative cardiovascular complications.

Abbreviations: MS indicates mitral stenosis; MV, mitral valve; and NYHA, New York Heart Association.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients with suspected moderate or severe valvular regurgitation, preoperative echocardiography is recommended prior to
elective NCS.

In patients with valvular heart disease who meet indications for valvular intervention based on clinical presentation and severity of
regurgitation, the need for valvular intervention should be considered before elective elevated risk NCS.

In asymptomatic patients with moderate or severe MR, normal left ventricular systolic function, and estimated PA systolic pressure
<50 mm Hg, it is reasonable to perform elective NCS.

In asymptomatic patients with moderate or severe aortic regurgitation and normal left ventricular systolic function, it is reasonable
to perform elective NCS.

Abbreviations: MR indicates mitral regurgitation; NCS, noncardiac surgery; PA, pulmonary artery.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS
For patients who undergo transcatheter aortic valve
implantation (TAVI), it is reasonable to perform NCS
early after successful TAVI as clinically indicated.

COR RECOMMENDATIONS
For patients who undergo MV TEER, it is reasonable to
perform NCS after the successful MV intervention as
clinically indicated.

Abbreviations: MV indicates mitral valve; NCS, noncardiac surgery; TAVI indicates transcatheter aortic valve implant;
and TEER, transcatheter edge-to-edge repair.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Perioperative Post Discharge

In patients with new-onset AF identified

In patients with new-onset AF identified
in the setting of NCS, initiation of In patients with rapid AF identified in the
in the setting of NCS, outpatient follow-
postoperative anticoagulation therapy setting of NCS, it is reasonable to treat
up for thromboembolic risk stratification
can be beneficial after considering the potential underlying triggers contributing
and AF surveillance are recommended
competing risks associated with to AF and rapid ventricular response.
given a high risk of AF recurrence. (Class
thromboembolism and perioperative (Class 2a)
1)
bleeding. (Class 2a)

Abbreviations: AF indicates atrial fibrillation; and NCS, noncardiac surgery.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients with CIEDs having elective NCS should have a management plan developed before surgery if EMI is anticipated,
including identification of the type of CIED, manufacturer, and model.

Patients who are PM-dependent having surgeries above umbilicus with anticipated EMI should have the PM reprogrammed
or place magnet on the generator to provide an asynchronous mode to avoid pacing inhibition.

PM-dependent patients with a transvenous ICD undergoing surgery above the umbilicus with anticipated EMI should have
the device reprogrammed; If not PM-dependent, then either reprogramming or magnet placed on the generator can be used
to inhibit tachytherapies or inappropriate shocks.

Patients who have a PM or ICD reprogrammed to asynchronous pacing or have a tachytherapies programmed off before
surgery should have device functioning restored in the post-operative setting before to hospital discharge.

Abbreviations: CIED indicates cardiovascular implantable electronic device EMI, electromagnetic interference;
ICD, implantable cardioverter-defibrillator; NCS, non-cardiac surgery; and PM, pacemaker.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS

Patients with leadless PMs who are pacemaker-dependent having surgeries with
anticipated EMI above the umbilicus should have their PMs reprogrammed to an
asynchronous mode.

For patients with subcutaneous ICD having noncardiac or nonthoracic surgery with
anticipated EMI above the groin, it is reasonable to reprogram the device or use a
magnet to temporarily disable tachytherapies.

Abbreviations: ICD indicates implantable cardioverter defibrillator; EMI, electromagnetic interference;

NCS, non-cardiac surgery; and PM, pacemaker.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Elective NCS ≥3 months

COR RECOMMENDATIONS

In patients with a history of stroke or TIA, reasonable to delay elective NCS for at least 3 months after
the most recent event to reduce the incidence of recurrent stroke and/or MACE.

Abbreviations: MACE indicates major adverse cardiovascular event; NCS, non-cardiac surgery; and TIA, transient ischemic attack.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Normal Breathing Sleep Apnea

COR RECOMMENDATIONS

In patients scheduled for NCS, screening for OSA using validated questionnaires is reasonable to
assess the risk of perioperative complications.

Abbreviations: NCS indicates noncardiac surgery; and OSA, obstructive sleep apnea.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
In patients scheduled for NCS, continue statins in those already on one to reduce MACE risk.
In statin naïve patients, who meet criteria* and are scheduled for NCS, recommend initiation of
statin perioperatively with the intention of long-term use.
*based on ASCVD history or 10-year risk assessment

COR RECOMMENDATIONS
In patients, with controlled blood pressure undergoing elevated risk NCS, on chronic RAASi holding
24 hours prior to surgery may be beneficial to limit intraoperative hypotension.

In patients on chronic RAASi for HFrEF, reasonable to continue perioperatively.

COR RECOMMENDATIONS
Initiation of low-dose clonidine perioperatively is not recommended to reduce cardiovascular risk in
No
Benefit patients undergoing NCS.

Abbreviations: HFrEF indicates heart failure with reduced ejection fraction; MACE, major adverse cardiovascular events;
NCS, non-cardiac surgery; and RAASi, renin-angiotensin-aldosterone system inhibitors.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
In patients with CAD undergoing elective NCS, perioperative management of antiplatelet therapy and timing of
surgery should be determined by a multidisciplinary team with shared decision making to weigh the risks of
bleeding, thrombosis, and consequences of delayed surgery.

COR RECOMMENDATIONS
In patients with prior PCI undergoing NCS, it is recommended to continue low-dose aspirin* (75-100 mg), if
possible, to reduce the risk of cardiac events.
In patients with CAD who require time sensitive NCS within 30 days of PCI with BMS or <3 months of PCI with
DES, DAPT should be continued unless the risk of bleeding outweighs the benefit of the prevention of stent
thrombosis.
*P2Y12 inhibitors monotherapy may be considered if surgical bleeding risks are acceptable or if aspirin is not tolerated

Abbreviations: BMS indicates bare-metal stent; CAD, coronary artery disease; DES, drug-eluting stent;
DAPT, dual antiplatelet therapy; NCS, non-cardiac surgery; and PCI, percutaneous coronary intervention.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS
In patients with prior PCI in whom OAC monotherapy must be discontinued prior to NCS, ASA should be
substituted when feasible in the perioperative period until the OAC can be safely re-initiated.
In select patients after PCI who have a high thrombotic risk, perioperative bridging with intravenous
antiplatelet therapy may be considered <6 months after DES or <30 days after BMS if NCS cannot be
deferred.

COR RECOMMENDATIONS
In patients with CCD without prior PCI undergoing elective NCS, it may be reasonable to continue ASA in
selected patients when the risk of cardiac events outweighs the risk of bleeding.

In patients with CAD but without prior PCI undergoing elective non-cardiac non-carotid surgery, routine ASA
No
Benefit is not beneficial.

Abbreviations: ASA indicates aspirin; BMS, bare-metal stent; CAD, coronary artery disease; CCD, chronic coronary disease;
DES, drug-eluting stent; NCS, noncardiac surgery; OAC, oral anticoagulation; and PCI, percutaneous coronary intervention.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Optimal Timing of Elective of Time-Sensitive NCS for Prior
PCI Requiring Management of DAPT

Ballon angioplasty only

(no coronary stents BMS-PCI DES-PCI
placed)

ACS CCD
Delay NCS>14 days (1) Delay NCS>30 days (1)
Delay NCS for ≥12 months after Delay NCS for ≥6 months after
DES-PCI (1) DES-PCI (2a)
Delay NCS for ≥3 months after Delay NCS for ≥3 months after
DES-PCI if time-sensitive DES-PCI if time-sensitive
indication for surgery (2b) indication for surgery (2b)
If DES-PCI ≤1 month, do not If DES-PCI ≤1 month, do not
perform NCS (3: Harm) perform NCS (3: Harm)

Abbreviations: ACS indicates acute coronary syndrome; BMS; bare-metal stent; CCD; chronic coronary syndrome;
DAPT, dual antiplatelet therapy; DES, drug-eluting stent; NCS, non-cardiac surgery; and PCI, percutaneous coronary intervention.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS
In patients with CVD receiving OAC who require elective NCS, multidisciplinary team-based approach to duration of
interruption* is recommended to balance competing risks of thromboembolism and bleeding.

COR RECOMMENDATIONS
In patients with CVD and high thrombotic risk* undergoing NCS where interruption of VKA is required, preoperative
bridging with parenteral heparin can be effective for thromboembolic risk reduction.
In most patients with CVD who are planned for an elective NCS where OAC interruption is warranted, routine bridging
Harm is not recommended due to increased bleeding risk.

COR RECOMMENDATIONS
In patients with preoperative OAC interruption, resumption of OAC is reasonable after hemostasis is achieved.

*See tables with full details in the guidelines.

Abbreviations: CVD indicates cardiovascular disease; NCS, non-cardiac surgery; OAC, oral anticoagulation; and VKA vitamin K antagonist.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients on stable BB doses undergoing NCS, BB should be continued through the

perioperative period as clinically appropriate.

In patients planned for elective NCS with a new indication for beta blockade, BB may be initiated
well in advance before surgery (optimally >7 days) to allow for the assessments of tolerability and
drug titration, as needed.

In patients undergoing NCS who have no immediate BB need, BB should not be initiated on the
Harm day of surgery due to increased risk for postoperative mortality.

Abbreviations: BB indicates beta blockers; and NCS, non-cardiac surgery.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients with or at risk for DM who are scheduled for elective NCS, preoperative HgbA1C
testing is reasonable if not performed within 3 months.

In patients scheduled for NCS, SGLT-2i should be discontinued 3-4 days* before surgery to
reduce the risk of perioperative metabolic acidosis.

In patients with DM or impaired glucose tolerance, continuation of metformin during the

perioperative period is reasonable to maintain glycemic control.

*Canagliflozin, dapagliflozin and empagliflozin should be stopped ≥3 days and ertugliflozin ≥4 days prior to scheduled surgery

Abbreviations: DM indicates diabetes mellitus; Hgb, hemoglobin; NCS, noncardiac surgery; SGLT2-I, sodium-glucose co-transporter 2 inhibitors.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS

In patients undergoing NCS, use of a volatile-based anesthetic or total

intravenous anesthesia is reasonable * for general anesthesia.

In patients undergoing NCS, when neuraxial anesthesia is available, either

neuraxial or general anesthesia is reasonable*.

*: No apparent difference in cardiovascular events, such as myocardial injury or infarction

Abbreviations: NCS indicates noncardiac surgery.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS COR RECOMMENDATIONS
Postoperatively in patients
Preoperatively in patients with
undergoing major abdominal
hip fracture
surgery*

*: e.g., gastrectomy, distal esophagectomy, Whipple procedure, and open abdominal procedures

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 May be used if acute, severe hemodynamic instability
and cardiopulmonary dysfunction prior to or during
urgent/emergent NCS (Class 2b)

TEE or FoCUS if available to assess cause May be considered when

of unexplained hemodynamic instability hemodynamically-significant conditions*
(Class 2a) are present and cannot be corrected pre-
Echo NCS (Class 2b)
Routine TEE not recommended in PAC
absence of risk factors for hemodynamic In patients with CVD undergoing NCS,
compromise routine PAC not recommended (Class3:
(Class 3: No benefit) No benefit)

*e.g., mixed shock, pulmonary hypertension, or

severe valvular disease

Body Temperature

Maintaining normothermia is reasonable in

patients with CVD (Class 2a)

Abbreviations: CVD indicates cardiovascular disease; FoCUS, focused cardiac ultrasound; NCS, noncardiac surgery;
PAC, pulmonary artery catheterization; TEE, transesophageal echocardiography; and tMCS, temporary mechanical circulatory support.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
COR RECOMMENDATIONS

In patients undergoing NCS with expected blood loss, tranexamic acid* is

reasonable to reduce intraoperative blood loss, blood transfusions, and
incident anemia.

In patients with iron deficiency anemia undergoing elective NCS,

preoperative iron therapy (either oral or intravenous) is reasonable to
increase hemoglobin and reduce blood transfusions.

*: An antifibrinolytic; has been shown to be safe even in high-risk patients with history of venous
thromboembolism, prior myocardial infarction, and prior ischemic stroke

Abbreviations: NCS indicates noncardiac surgery.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 COR RECOMMENDATIONS
May be reasonable to measure
cTn at 24 & 48 hours after • cTn* >99th percentile of
elevated risk NCS if: URL with rise-and-fall COR RECOMMENDATIONS
• Known CVD
pattern Outpatient follow-up is
• Symptoms of CVD reasonable for further evaluation
• Age ≥65 years with CV • Presumed ischemic origin and optimization of CV risk
risk factors (Class 2b) • 12-lead ECG without STE factors
Routine perioperative cTn • No evidence of MI (4th
screening not recommended in Universal Definition) Antithrombotic therapy may be
No low risk NCS without signs and sx considered to reduce CV events
Benefit of MI.
*: Conventional 4th generation or
high-sensitivity assay

Abbreviations: cTn indicates cardiac troponin; CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram;
MI, myocardial infarction; NCS, noncardiac surgery; STE, ST-segment elevation; sx, symptoms; URL, upper reference limit.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 History, physical examination, and 12-lead ECG

ST-segment elevations?
≥1 criteria* for MI met? No Yes ST Segment Elevation MI (STEMI)
No Yes

Post-operative Non-ST Segment GDMT, including ICA*

myocardial injury Elevation MI (NSTEMI) * Balancing bleeding and thrombotic risks
with severity of the presentation
Non-ischemic process Plaque rupture
suspected? suspected?
Yes No No Yes

Non-ischemic MINS Type 2 NSTEMI Type 1 NSTEMI

myocardial injury
Recognition & Treat underlying GDMT*
consideration of cause and ICA*
Treat referral optimize GDMT*
underlying
cause Abbreviations: ECG indicates electrocardiogram; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography;
MI, myocardial infarction; and MINS, myocardial injury after noncardiac surgery.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Prevalence of risk factors
and cardiovascular disease

Refer to “Emerging Evidence

on Coronary Heart Disease
Screening in Kidney and Liver
Transplantation Candidates: A
Scientific Statement From the
Targeted pre-operative screening American Heart Association
associated with similar outcomes (2022)” for further guidance
compared to routine screening

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Abbreviations: BNP indicates brain natriuretic peptide; NT-proBNP, N-terminal prohormone of brain natriuretic peptide.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
 Abbreviations: ECG, electrocardiogram; H&P, history & physical; MI, myocardial infarction.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
Abbreviations: CCTA indicates coronary computed tomography angiography; ECG, electrocardiogram; and MI, myocardial infarction.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
*Complete list available in Section 12 of the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery

• Impact of multidisciplinary care models on • Data lacking to support pre-operative assessment of

perioperative testing – namely remote LV function
visits/telemedicine on pre-operative • Further need to define efficacy and safety of shorter
assessment DAPT duration
• Lack of evidence to support use of one • Elucidating perioperative role of the angiotensin
perioperative risk index over another receptor/neprilysin inhibitor, sacubitril/valsartan
• Perioperative care of patients with DM – including
glucose monitoring and management post-
operatively
• Approach to perioperative blood pressure
assessment, thresholds, and measurement
frequency
• Perioperative management of new-onset atrial
fibrillation – including rate vs rhythm control • Effectiveness of routine intraoperative TEE
and optimal surveillance • Routine use of mechanical circulatory support in
• Impact of coronary revascularization in stable patients at high risk of cardiogenic shock
patients • Utility of pulmonary artery catheters during
• Optimal timing delay of NCS after stroke noncardiac surgery

Abbreviations: DAPT indicates dual anti-platelet therapy; LV, left ventricular; NCS, noncardiac surgery; and TTE, transesophageal echocardiogram.
Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.
The American Heart Association requests this electronic slide deck be cited as follows:
Chen, Y., Cheng, E., Elhamdani, A., Kolkailah, A.A., Ostrominski, J., Yeow, R., Reyna, G.G., Bezanson, J. L., &
Antman, E. M. (2024). AHA Clinical Update; Adapted from: [PowerPoint slides]. Retrieved from the 2024
AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for
Noncardiac Surgery. https://professional.heart.org/en/science-news.

Thompson, A., et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation.