2024 AHA/ACC Perioperative CV Management Guideline: Key Points
The following are key points to remember from the 2024 American Heart Association/American College of Cardiology (AHA/ACC)/multisociety guideline for perioperative cardiovascular (CV) management for noncardiac surgery:
- This guideline supersedes the previously published “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.” The simultaneously published guideline-at-a-glance includes comparisons to the 2014 version of the guideline and to the “2022 European Society of Cardiology Guidelines on Cardiovascular Assessment and Management of Patients Undergoing Noncardiac Surgery.”
- The 2024 guideline encourages a stepwise approach to perioperative CV assessment. For patients who have known cardiovascular disease (CVD) or risk factors, or symptoms concerning for CVD, use of validated risk-prediction tools such as the Revised Cardiac Risk Index (RCRI) or the National Surgical Quality Improvement Program (NSQIP) calculators can inform clinical decision-making.
- Preoperative stress testing should be performed only in highly selected patients, including those with poor or unknown functional capacity and at elevated risk for perioperative events based on a validated risk tool (Class 2b recommendation). Patients who are at low risk for perioperative events, have good functional capacity, or who are undergoing low-risk procedures should not undergo routine stress testing (Class 3 recommendation).
- The guideline emphasizes a team-based, patient-centered approach to perioperative care, particularly for patients with complex or unstable CVD.
- Sodium-glucose cotransporter-2 inhibitors, prescribed for heart failure and/or diabetes, should be stopped 3-4 days prior to planned surgery to reduce the risk of perioperative metabolic acidosis (Class 1 recommendation).
- For most patients on therapeutic anticoagulation, withholding direct oral anticoagulants or warfarin prior to surgery is appropriate, and bridging with parenteral heparin may cause harm due to increased bleeding risk (Class 3 recommendation for bridging). In patients at high thrombotic risk, including those with mechanical mitral valves, left ventricular thrombus within the past 3 months, and atrial fibrillation (AF) with recent stroke, bridging with heparin or low-molecular-weight heparin can reduce thromboembolic risk (Class 2a recommendation).
- AF is a common perioperative problem, and it is reasonable to address medical triggers for rapid AF such as anemia and sepsis (Class 2a recommendation). Consideration of postoperative anticoagulation for stroke prevention is reasonable, weighing the risks of bleeding (Class 2a recommendation). AF that is newly diagnosed in the perioperative period should prompt outpatient cardiology follow-up AF surveillance and anticoagulation management (Class 1 recommendation).
- Myocardial injury after noncardiac surgery (MINS), encompassing both type 1 and type 2 myocardial infarction, is associated with increased 30-day postoperative mortality, and outpatient CV follow-up is reasonable (Class 2a recommendation). Optimal medical therapy for MINS remains uncertain, especially considering that pathophysiologic mechanisms are heterogeneous, but antithrombotic therapy may be reasonable to reduce risk of subsequent events (Class 2b recommendation).
