2024 AHA/ACC Perioperative Cardiovascular Management Guidelines

What's New in 2024

This guideline supersedes the 2014 ACC/AHA Perioperative Evaluation and Management of Patients Undergoing Noncardiac Surgery. Major updates include stepwise assessment framework, functional capacity emphasis (DASI scoring), perioperative troponin monitoring for MINS, refined statin/beta-blocker recommendations, SGLT2i withdrawal protocols, and updated guidance on valvular disease, arrhythmias, and CIED management.

Preoperative Risk Assessment

Stepwise Approach (Figure 1)

Systematic Preoperative Cardiac Evaluation Framework

Step 1 — Emergency Status: Emergency/urgent surgery? Proceed with minimal delay. Optimize intraoperative/postoperative care. COR 1

Step 2 — Active Cardiac Conditions: Evaluate for unstable angina, recent MI, decompensated HF, severe arrhythmia, severe valvular disease. COR 1

Step 3 — Surgical Risk: Classify surgery as low-risk or elevated-risk. COR 1

Step 4 — Functional Capacity: Assess DASI or METs. ≥4 METs = low risk; <4 METs = elevated risk. COR 1

Step 5 — Risk Estimation: Apply RCRI, NSQIP, or AUB-HAS2. Estimate 30-day MACE risk. COR 1

Step 6 — Testing & Decisions: Order ECG, echo, stress testing, troponin based on risk and capacity. COR 1

Key Risk Calculators

Risk Score	Key Components	Prediction
RCRI	Age, high-risk surgery, CAD, HF, CVA, Cr >2, DM on insulin	30-day MI/cardiac death
NSQIP	Age, Cr, DM, HF, CVA, surgery type, functional status	30-day MACE
AUB-HAS2	Age ≥75, Cr >1.5, renal disease, high-risk surgery, emergency	30-day death/MI/stroke
DASI	12 activities (stairs, sexual relations, heavy work)	Functional capacity (METs)

Pearl: Functional capacity is as important as age and comorbidities. Patients climbing stairs or performing heavy housework (≥4 METs) are lower risk and may proceed with minimal testing.

Preoperative Cardiovascular Testing

12-Lead ECG

COR 1 Obtain in patients with known CAD, arrhythmia, structural heart disease, or elevated-risk surgery. COR 3 NOT recommended in asymptomatic low-risk patients.

Echocardiography

COR 1 Indicated for suspected severe AS/MR or HF symptoms. NOT recommended routinely in asymptomatic stable patients.

Stress Testing

COR 2a Selectively in elevated-risk with poor functional capacity (<4 METs). COR 3 NOT recommended in low-risk or adequate-capacity patients.

Coronary CT Angiography (CCTA)

COR 2a May be considered in elevated-risk with low clinical suspicion of CAD and normal functional capacity. Not replacing stress testing.

Preoperative Biomarkers

COR 2a BNP/NT-proBNP for age ≥45 with CVD symptoms or eGFR <30. COR 1 High-sensitivity troponin baseline + 24–48 h postop in elevated-risk for MINS surveillance.

Medication Management Perioperatively

Statins

COR 1 Continue chronic statin therapy perioperatively. Do NOT discontinue.

Beta-Blockers

Do

COR 1 Continue in chronic users

Don't

COR 1 Do NOT initiate de novo for low-risk patients

ACEi/ARB

Hold morning of surgery; restart postoperatively once stable. Caution: rebound hypertension upon withdrawal.

DAPT Timing After PCI

Stent Type	Minimum Delay	DAPT Duration
BMS	≥30 days COR 1	Aspirin + clopidogrel ≥1 month
DES	≥3–6 months COR 1	Aspirin + P2Y12i ≥6 months

SGLT2 Inhibitors

COR 2a Withdraw 3–4 days preoperatively (euglycemic DKA risk). Restart postoperatively when orally tolerant.

Coronary Artery Disease & Stent Management

Preoperative Revascularization

COR 1 Reasonable for ACS (STEMI/high-risk NSTEMI). COR 2a Consider for non-left main CAD ≥50% in selected elevated-risk. COR 1 CABG preferred for left main >50%.

Stent Timing Summary

BMS: Proceed ≥30 days with aspirin + clopidogrel. DES: Defer ≥3–6 months; individualize based on ACS risk and procedure urgency.

Heart Failure Perioperative Management

HFrEF (LVEF <40%)

Recommendations

COR 1 Continue GDMT (ACEi/ARB, beta-blockers, MRAs, SGLT2i) perioperatively
ACEi/ARB: hold morning of surgery; restart postoperatively
SGLT2i: withdraw 3–4 days preop; restart when orally tolerant
Optimize diuretics to euvolemia
Inotropic support reserved for acute decompensation

HFpEF & HFmrEF

Hypertension control paramount. Continue antihypertensives. Volume optimization critical. No specific perioperative intensification beyond routine management.

Pulmonary Hypertension

COR 2a Group 1 PH undergoing elevated-risk NCS: specialty consultation recommended. Continue targeted therapies. Consider invasive hemodynamic monitoring and ICU care.

Valvular Heart Disease Management

Severe Aortic Stenosis

COR 1 Symptomatic severe AS: delay elective NCS or pursue TAVR/SAVR first. COR 2a Asymptomatic with LVEF ≥50%: reasonable to proceed cautiously with elective low-risk NCS after multidisciplinary discussion.

Mitral Stenosis

COR 1 Severe MS undergoing elevated-risk NCS: perioperative invasive hemodynamic monitoring to guide intraoperative management.

AR & MR

Mild-to-moderate without LV dysfunction: minimal risk. Severe AR: maintain preload, avoid tachycardia. Severe MR: optimize afterload reduction.

Arrhythmia & Device Management

Atrial Fibrillation

COR 1 Preoperative AF: optimize rate control; assess anticoagulation per CHA₂DS₂-VASc. COR 2a New-onset perioperative AF: aggressive rate control; consider anticoagulation (high stroke risk).

CIED Management

Device Type	Perioperative Strategy	COR
Transvenous PM/ICD	Reprogram to asynchronous (VVI/DOO) if pacemaker-dependent; magnet placement 5 cm from generator; postop interrogation mandatory	COR 1
Leadless PM	No magnet effect; no reprogramming needed; confirm postop functionality	COR 1
Subcutaneous ICD	EMI above groin: program therapies off; confirm battery postop	COR 1

Perioperative Myocardial Injury (MINS) & Monitoring

Troponin Monitoring

COR 1 Elevated-risk patients: baseline high-sensitivity troponin preop + 24–48 h postop. MINS (troponin elevation without overt ischemia) occurs in 7–25%; associated with increased 30-day mortality.

Hemodynamic Goals

COR 1 Maintain intraoperative MAP ≥60 mmHg (SBP ≥90)
Avoid tachycardia unless HF compensation needed
CVP/PAC monitoring: selective use (severe AS, PH, LVAD, advanced HF)
Postoperative telemetry: 24–48 h for elevated-risk (AF detection)

Quick Reference: Do's and Don'ts

DO

Perform stepwise preoperative assessment (Figure 1)
Assess functional capacity (DASI, METs)
Continue home statin, beta-blocker, GDMT
Order ECG for known CAD, arrhythmia, elevated-risk surgery
Order echo for suspected severe valvular disease/HF
Continue aspirin in CAD (balance bleeding risk)
Reprogram transvenous CIED; magnet check for pacemaker-dependent
Maintain intraoperative MAP ≥60 mmHg
Monitor troponin in elevated-risk (baseline + 24–48 h)
Defer elective NCS ≥30d post-BMS, ≥3–6m post-DES
Withdraw SGLT2i 3–4 days preop

DON'T

Initiate beta-blockers de novo for low-risk
Order routine ECG in asymptomatic low-risk
Perform routine stress testing in low-risk
Continue SGLT2i without caution (euglycemic DKA)
Delay emergency/urgent NCS for extensive testing
Proceed with elective NCS in symptomatic severe AS without intervention
Use magnet on leadless pacemakers
Ignore postoperative troponin elevation (prognostically significant)

Key Takeaways

Stepwise Assessment: Use Figure 1 algorithm as primary framework
Functional Capacity is Key: DASI/METs as important as age and comorbidities
Medication Continuity: Continue statin, beta-blocker, GDMT; hold ACEi/ARB morning of surgery
Troponin Monitoring: Baseline + 24–48 h in elevated-risk; MINS is prognostically significant
CAD/Stent Timing: BMS ≥30 days, DES ≥3–6 months
Valvular Disease: Severe symptomatic AS → intervention before elective NCS
CIED Management: Reprogram transvenous devices; postoperative interrogation mandatory
No Routine Testing: Avoid ECG, stress testing, angiography in asymptomatic low-risk
Intraoperative Goals: Maintain MAP ≥60 mmHg
Emergency Surgery: Proceed with surgery; optimize intraoperatively and postoperatively