Authors: Sweitzer et al.
Anesthesia & Analgesia, April 2026, 142(4):697-708
Executive Summary of the American College of Cardiology/American Heart Association Joint Committee (2024) on Clinical Practice for Cardiac Evaluation and Management of Patients Having Noncardiac Surgeries
Key Points
The 2024 ACC/AHA perioperative cardiovascular guideline is the first major update since 2014.
The guideline continues to use a stepwise preoperative cardiac risk assessment algorithm, but adds greater emphasis on risk modifiers not captured by traditional calculators.
Routine testing should be avoided unless results are likely to change management.
Newer guidance emphasizes cardiac biomarkers, postoperative troponin surveillance in selected high-risk patients, frailty screening, and broader long-term cardiovascular optimization.
Major risk modifiers include severe pulmonary hypertension, adult congenital heart disease, severe valvular disease, prior coronary revascularization, cardiac implantable electronic devices, and frailty.
Summary
This Anesthesia & Analgesia perspective article summarizes the 2024 American College of Cardiology/American Heart Association guideline update on perioperative cardiovascular evaluation and management for adults undergoing noncardiac surgery. The guideline applies to patients 18 years and older who are being considered for noncardiac procedures and who have risk factors or cardiovascular conditions that may increase perioperative risk. It covers the entire surgical episode, from preoperative evaluation through postoperative monitoring and long-term risk modification.
A major theme is that perioperative cardiovascular evaluation should be practical, stepwise, and focused on decisions that actually change care. The guideline again uses a stepwise algorithm for cardiac evaluation before noncardiac surgery. However, the authors emphasize that the algorithm is not meant to replace clinical judgment. Emergency surgery, for example, does not allow time for extensive preoperative workup, and the priority becomes focused assessment, intraoperative and postoperative monitoring, multidisciplinary care, and postoperative critical care when appropriate.
The guideline identifies extremely high-risk conditions that generally warrant postponing all nonemergency surgery. These include acute coronary syndrome, decompensated heart failure, complete heart block, ventricular tachycardia, and other unstable cardiovascular conditions. These patients should be evaluated and stabilized before proceeding unless the surgery is truly emergent. Heart failure is especially important because even well-controlled heart failure carries significantly higher perioperative risk than ischemic heart disease alone.
For low-risk procedures, such as cataract surgery in asymptomatic patients, routine cardiac assessment or testing is not needed. For patients with known cardiovascular disease or risk factors, the guideline recommends formal risk assessment using validated tools such as the Revised Cardiac Risk Index or the ACS-NSQIP surgical risk calculator. Patients with a predicted risk of major adverse cardiovascular events below 1% can generally proceed without further cardiac testing.
One important update is the addition of risk modifiers. These are conditions that can increase perioperative morbidity and mortality but are often not included in traditional risk calculators. They include severe pulmonary arterial hypertension, adult congenital heart disease, prior coronary revascularization, severe valvular disease, cardiac implantable electronic devices, and frailty. These conditions often require independent evaluation, sometimes with specialist input, even when standard calculators do not fully capture their risk.
Functional capacity remains an important part of perioperative risk assessment. The guideline favors structured tools such as the Duke Activity Status Index rather than relying only on informal patient self-report or clinician estimates. A functional capacity below 4 metabolic equivalents or a DASI score below 35 is associated with increased perioperative cardiac risk. Patients with adequate functional capacity can often proceed without additional cardiac testing.
Cardiac biomarkers now play a more prominent role. BNP, NT-proBNP, and troponin can help refine risk assessment in selected patients, particularly older adults and patients with known or suspected heart disease undergoing elevated-risk surgery. The guideline also suggests that postoperative troponin measurement at 24 and 48 hours is reasonable in selected high-risk patients to identify myocardial injury after noncardiac surgery. This is important because many cases of myocardial injury are clinically silent but still carry significant short-term mortality risk.
The article emphasizes avoiding unnecessary stress testing, coronary angiography, and coronary revascularization. Routine preoperative cardiac testing has not been shown to improve outcomes in stable patients, and coronary revascularization should not be performed solely to reduce perioperative risk except in patients who would meet standard nonoperative indications, such as significant left main coronary disease. Testing should be ordered only when the results would change management.
The guideline includes detailed recommendations for coronary artery disease and prior PCI. Elective noncardiac surgery should generally not occur within 30 days of PCI. Surgery after PCI for acute coronary syndrome should ideally be delayed for 1 year, while surgery after drug-eluting stent placement for chronic disease may be considered after 6 months, or after 3 months when the benefits of surgery outweigh the cardiac risk. If time-sensitive surgery must occur soon after PCI, dual antiplatelet therapy should be continued when possible unless bleeding risk is prohibitive.
Heart failure is another major focus. Patients with systolic or diastolic dysfunction have higher perioperative risk, even when asymptomatic. Routine echocardiography is not recommended for clinically stable, asymptomatic patients, but it is reasonable when symptoms worsen, new dyspnea develops, signs of heart failure are present, or biomarkers are elevated. Most guideline-directed medical therapy for heart failure should be continued perioperatively, although SGLT2 inhibitors should be held for 3 to 4 days before surgery to reduce the risk of metabolic acidosis.
The article also reviews atrial fibrillation, hypertension, valvular disease, cardiac implantable electronic devices, adult congenital heart disease, pulmonary hypertension, stroke history, diabetes, frailty, anemia, blood pressure goals, blood management, and myocardial injury after noncardiac surgery. Across these topics, the common theme is individualized management based on the patient’s underlying disease, the urgency of surgery, the bleeding risk, and whether further evaluation or treatment would improve outcomes.
Frailty is a major new emphasis. The guideline recommends preoperative frailty screening for patients older than 65 years or patients with suspected frailty who are undergoing elevated-risk surgery. Frailty is associated with cardiac complications, infections, bleeding, falls, functional decline, longer hospitalization, discharge to skilled nursing facilities, and mortality. The guideline also supports prehabilitation in selected patients, including physical conditioning, disease optimization, nutritional support, and psychological preparation.
The guideline recommends maintaining intraoperative and postoperative mean arterial pressure at or above 60 to 65 mm Hg or systolic blood pressure above 90 mm Hg to reduce cardiovascular, cerebrovascular, renal, and mortality risk. It also supports patient blood management strategies, including restrictive transfusion thresholds in selected patients and use of tranexamic acid to reduce blood loss and transfusion without increasing major thrombotic complications in appropriate patients.
What You Should Know
This article is important because it moves perioperative cardiac evaluation away from reflexive testing and toward targeted, evidence-based decision-making. The goal is not to “clear” a patient for surgery through unnecessary testing. The goal is to identify unstable disease, optimize treatable conditions, estimate overall risk, and avoid delaying beneficial surgery unless there is a clear reason.
For anesthesia providers, the most useful practical changes include attention to risk modifiers, structured functional assessment, selective use of biomarkers, postoperative troponin surveillance in high-risk patients, and frailty screening. The guideline also reinforces that stress testing, coronary angiography, and revascularization should be reserved for patients whose results would change management independent of the planned surgery.
The broader message is that perioperative cardiovascular care should improve both short-term surgical safety and long-term health. When new disease is discovered before surgery, clinicians should use that opportunity to begin guideline-directed management and therapy rather than focusing only on the immediate operation.
Overall, the 2024 ACC/AHA update supports a thoughtful, multidisciplinary approach to noncardiac surgery patients with cardiovascular risk. It encourages clinicians to avoid overtesting, reduce unnecessary surgical delays, identify high-risk conditions not captured by calculators, and optimize patients in ways that matter beyond the operating room.
Thank you to Anesthesia & Analgesia for allowing us to summarize and share this article.