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Summary 2024 AHA/ACC/ACS/ASNC/HRS/SCA/ SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines $15.99   Add to cart

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Summary 2024 AHA/ACC/ACS/ASNC/HRS/SCA/ SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

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Circulation Circulation. 2024;150:e00–e00. DOI: 10.1161/CIR. TBD TBD, 2024 e1 Circulation is available at *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information...

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Circulation

CLINICAL PRACTICE GUIDELINES

2024 AHA/ACC/ACS/ASNC/HRS/SCA/
SCCT/SCMR/SVM Guideline for Perioperative
Cardiovascular Management for Noncardiac
Surgery: A Report of the American College of
Cardiology/American Heart Association Joint
Committee on Clinical Practice Guidelines
Developed in Collaboration With and Endorsed by the American College of Surgeons, American Society of Nuclear
Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed
Tomography, Society for Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine

Writing Committee Members*
Annemarie Thompson, MD, MBA, FAHA, Chair; Kirsten E. Fleischmann, MD, MPH, FACC, Vice Chair;
Nathaniel R. Smilowitz, MD, MS, FACC, Vice Chair; Lisa de las Fuentes, MD, MS, FAHA, JC Liaison†;
Debabrata Mukherjee, MD, MS, FACC, FAHA, JC Liaison‡; Niti R. Aggarwal, MD, FACC, FASNC;
Faraz S. Ahmad, MD, MS, FACC, FAHA§; Robert B. Allen, JD; S. Elissa Altin, MD, FACC, FSVM‖; Andrew Auerbach, MD, MPH;
Downloaded from http://ahajournals.org by on October 3, 2024




Jeffrey S. Berger, MD, MS, FAHA, FACC; Benjamin Chow, MD, PhD, FACC, FASNC, MSCCT¶; Habib A. Dakik, MD, FACC;
Eric L. Eisenstein, DBA; Marie Gerhard-Herman, MD, FACC, FAHA; Kamrouz Ghadimi, MD, MHSc, FAHA;
Bessie Kachulis, MD#; Jacinthe Leclerc, RN, PhD, FAHA; Christopher S. Lee, PhD, RN, FAHA**;
Tracy E. Macaulay, PharmD, FACC; Gail Mates, BS; Geno J. Merli, MD, FSVM; Purvi Parwani, MBBS, MPH, FACC††;
Jeanne E. Poole, MD, FACC, FHRS‡‡; Michael W. Rich, MD, FACC; Kurt Ruetzler, MD, PhD, FAHA; Steven C. Stain, MD, FACS§§;
BobbieJean Sweitzer, MD; Amy W. Talbot, MPH; Saraschandra Vallabhajosyula, MD, MSc, FAHA, FACC; John Whittle, MD;
Kim Allan Williams Sr., MD, MACC, FAHA, MASNC‖‖


AIM: The “2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular
Management for Noncardiac Surgery” provides recommendations to guide clinicians in the perioperative cardiovascular
evaluation and management of adult patients undergoing noncardiac surgery.

METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies,
reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed),
EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to
this guideline.

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed
information. †Former ACC/AHA Joint Committee on Clinical Practice Guidelines member; current member during the writing effort. ‡ACC/AHA Joint Committee on Clinical
Practice Guidelines. §AHA/ACC Joint Committee on Clinical Data Standards. ‖Society for Vascular Medicine representative. ¶Society of Cardiovascular Computed Tomography
representative. #Society of Cardiovascular Anesthesiologists representative. **AHA/ACC Joint Committee on Performance Measures. ††Society for Cardiovascular Magnetic
Resonance representative. ‡‡Heart Rhythm Society representative. §§American College of Surgeons representative. ‖‖American Society of Nuclear Cardiology representative.
Peer Review Committee Members and AHA/ACC Joint Committee on Clinical Practice Guidelines Members, see page __.
The American Heart Association requests that this document be cited as follows: Thompson A, Fleischmann KE, Smilowitz NR, Aggarwal NR, Ahmad FS, Allen RB, Altin
SE, Auerbach A, Berger JS, Chow B, Dakik HA, de las Fuentes L, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G,
Merli GJ, Mukherjee D; Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA Sr. 2024 AHA/ACC/ACS/
ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/
American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;150:e00–e00. doi: 10.1161/CIR.0000000000001285
© 2024 by the American Heart Association, Inc., and the American College of Cardiology Foundation.
Circulation is available at www.ahajournals.org/journal/circ



Circulation. 2024;150:e00–e00. DOI: 10.1161/CIR.0000000000001285 TBD TBD, 2024 e1

, Thompson et al 2024 Perioperative Cardiovascular Management for Noncardiac Surgery Guideline



STRUCTURE: Recommendations from the “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and
CLINICAL STATEMENTS




Management of Patients Undergoing Noncardiac Surgery” have been updated with new evidence consolidated to guide
AND GUIDELINES




clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition,
evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for
cardiovascular disease and associated medical conditions, have been developed.

Key Words: AHA Scientific Statements ◼ anesthetics ◼ biomarkers ◼ cardiac ◼ preoperative evaluation ◼ cardiovascular ◼ diagnostic testing
◼ cardiovascular diseases ◼ cardiovascular risk score ◼ heart failure ◼ heart valve diseases ◼ intraoperative period
◼ major adverse cardiovascular events ◼ myocardial protection ◼ noncardiac surgery ◼ perioperative management ◼ postoperative complications
◼ preoperative care ◼ revascularization ◼ risk assessment ◼ treatment outcome




TABLE OF CONTENTS 6.1. Coronary Artery Disease��������������������������� eXXX
6.1.1. Coronary Revascularization �������eXXX
Abstract ����������������������������������������������������������������������������� eXXX 6.2. Hypertension and Perioperative
Top Take-Home Messages������������������������������������������� eXXX Blood Pressure Management������������������� eXXX
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . eXXX 6.3. Heart Failure������������������������������������������������� eXXX
1. Introduction��������������������������������������������������������������� eXXX 6.3.1. Hypertrophic Cardiomyopathy���eXXX
1.1. Methodology and Evidence Review������� eXXX 6.3.2. Pulmonary Hypertension�������������eXXX
1.2. Composition of the Writing
6.3.3. Adult Congenital Heart
Committee����������������������������������������������������� eXXX
Disease��������������������������������������������eXXX
1.3. Guideline Review and Approval��������������� eXXX
6.3.4. Left Ventricular Assist
1.4. Scope of the Guideline������������������������������� eXXX
Devices���������������������������������������������eXXX
1.5. Definitions of Surgical Timing
6.3.5. Heart Transplantation
and Risk��������������������������������������������������������� eXXX
Recipients ���������������������������������������eXXX
1.6. Class of Recommendations and Level
6.4. Valvular Heart Disease������������������������������� eXXX
of Evidence��������������������������������������������������� eXXX
6.4.1. Aortic Stenosis�������������������������������eXXX
1.7. Abbreviations������������������������������������������������� eXXX
6.4.2. Mitral Stenosis�������������������������������eXXX
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2. Epidemiology of Cardiovascular Disease and
Complications in Patients Undergoing Noncardiac 6.4.3. Chronic Aortic and Mitral
Surgery����������������������������������������������������������������������� eXXX Regurgitation ���������������������������������eXXX
2.1. Team Based Care����������������������������������������� eXXX 6.4.4. Previous Transcatheter
2.2. Quality of Life����������������������������������������������� eXXX Aortic Valve Implantation or
3. Risk Calculators������������������������������������������������������� eXXX Mitral Valve Transcatheter
Edge-to-Edge Repair�������������������eXXX
3.1. Cardiovascular Risk Indices ��������������������� eXXX
3.2. Functional Capacity Assessment������������ eXXX 6.5. Atrial Fibrillation������������������������������������������� eXXX
3.3. Frailty��������������������������������������������������������������� eXXX 6.6. Cardiovascular Implantable
3.4. Preoperative Biomarkers for Risk Electronic Devices��������������������������������������� eXXX
Stratification ������������������������������������������������� eXXX 6.7. Previous Stroke or Transient
4. Preoperative Cardiovascular Diagnostic Ischemic Attack ������������������������������������������� eXXX
Testing������������������������������������������������������������������������� eXXX 6.8. Obstructive Sleep Apnea��������������������������� eXXX
4.1. 12-Lead Electrocardiogram��������������������� eXXX 7. Perioperative Medical Therapy����������������������������� eXXX
4.2. Assessment of Ventricular Function������� eXXX 7.1. Statins������������������������������������������������������������� eXXX
4.2.1. Left Ventricular Function�������������eXXX 7.2. Renin-Angiotensin-Aldosterone
4.2.2. Right Ventricular Function�����������eXXX System Inhibitors����������������������������������������� eXXX
4.3. Stress Testing����������������������������������������������� eXXX 7.3. Calcium Channel Blockers����������������������� eXXX
4.4. Cardiopulmonary Exercise Testing��������� eXXX 7.4. Alpha-2 Receptor Agonists����������������������� eXXX
4.5. Coronary Computed Tomography 7.5. Antiplatelet Therapy and Timing of
Angiography ������������������������������������������������� eXXX Noncardiac Surgery in Patients With
4.6. Invasive Coronary Angiography��������������� eXXX Coronary Artery Disease��������������������������� eXXX
5. Approach to Perioperative Cardiac 7.6. Oral Anticoagulants������������������������������������� eXXX
Testing������������������������������������������������������������������������� eXXX 7.7. Perioperative Beta Blockers��������������������� eXXX
5.1. Stepwise Approach to Perioperative 7.8. Perioperative Management of
Cardiac Assessment����������������������������������� eXXX Blood Glucose ��������������������������������������������� eXXX
6. Cardiovascular Comorbidities and 8. Anesthetic Considerations and Intraoperative
Perioperative Management����������������������������������� eXXX Management������������������������������������������������������������� eXXX

e2 TBD TBD, 2024 Circulation. 2024;150:e00–e00. DOI: 10.1161/CIR.0000000000001285

, Thompson et al 2024 Perioperative Cardiovascular Management for Noncardiac Surgery Guideline



8.1.Choice of Anesthetic Technique 3. Stress testing should be performed judiciously in




CLINICAL STATEMENTS
and Agent������������������������������������������������������� eXXX patients undergoing noncardiac surgery, especially




AND GUIDELINES
8.2. Perioperative Pain Management������������� eXXX those at lower risk, and only in patients in whom testing
8.3. Intraoperative Monitoring would be appropriate independent of planned surgery.
Techniques����������������������������������������������������� eXXX 4. Team-based care should be emphasized when
8.3.1. Echocardiography�������������������������eXXX managing patients with complex anatomy or unsta-
8.3.2. Body Temperature������������������������� eXXX ble cardiovascular disease.
8.3.3. Temporary Mechanical 5. New therapies for management of diabetes, heart
Circulatory Support����������������������� eXXX failure, and obesity have significant periopera-
8.3.4. Pulmonary Artery tive implications. Sodium-glucose cotransporter 2
Catheters����������������������������������������� eXXX inhibitors should be discontinued 3 to 4 days
8.4. Perioperative Anemia before surgery to minimize the risk of perioperative
Management������������������������������������������������� eXXX ketoacidosis associated with their use.
9. Perioperative Surveillance and 6. Myocardial injury after noncardiac surgery is a
Management of Myocardial Injury and newly identified disease process that should not
Infarction�������������������������������������������������������������������� eXXX be ignored because it portends real consequences
9.1. Myocardial Injury After Noncardiac for affected patients.
Surgery Surveillance and 7. Patients with newly diagnosed atrial fibrillation
Management������������������������������������������������� eXXX identified during or after noncardiac surgery have
9.2. Management of Postoperative an increased risk of stroke. These patients should
STEMI/NSTEMI������������������������������������������� eXXX be followed closely after surgery to treat reversible
10. Special Populations������������������������������������������������� eXXX causes of arrhythmia and to assess the need for
10.1. Preoperative Evaluation Prior to rhythm control and long-term anticoagulation.
Liver and Kidney Transplantation������������ eXXX 8. Perioperative bridging of oral anticoagulant therapy
10.2. Obesity and Bariatric Surgery������������������� eXXX should be used selectively only in those patients at
11. Cost Value Considerations����������������������������������� eXXX highest risk for thrombotic complications and is not
11.1. Cost Value Considerations ����������������������� eXXX recommended in the majority of cases.
11.1.1. Cost Value Considerations for 9. In patients with unexplained hemodynamic instabil-
Biomarkers������������������������������������� eXXX ity and when clinical expertise is available, emer-
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11.1.2. Cost Value Considerations for gency focused cardiac ultrasound can be used for
12-Lead ECG��������������������������������� eXXX perioperative evaluation; however, focused cardiac
11.1.3. Cost Value Considerations ultrasound should not replace comprehensive
for CCTA ����������������������������������������� eXXX transthoracic echocardiography.
11.1.4. Cost Value Considerations
for Stress Testing�������������������������� eXXX
12. Evidence Gaps and Future Research PREAMBLE
Directions������������������������������������������������������������������� eXXX
Since 1980, the American College of Cardiology (ACC)
References������������������������������������������������������������������������� eXXX
and American Heart Association (AHA) have translated
Appendix����������������������������������������������������������������������������� eXXX
scientific evidence into clinical practice guidelines with
Author Relationships With Industry and
recommendations to improve cardiovascular health.
Other Entities������������������������������������������������������������� eXXX
These guidelines, which are based on systematic meth-
Appendix����������������������������������������������������������������������������� eXXX
ods to evaluate and classify evidence, provide a founda-
Peer Review Committee Relationships
tion for the delivery of quality cardiovascular care. The
With Industry and Other Entities ������������������������� eXXX
ACC and AHA sponsor the development and publication
of clinical practice guidelines without commercial sup-
port, and members volunteer their time to the writing and
TOP TAKE-HOME MESSAGES review efforts. Guidelines are official policy of the ACC
1. A stepwise approach to perioperative cardiac and AHA. For some guidelines, the ACC and AHA col-
assessment assists clinicians in determining when laborate with other organizations.
surgery should proceed or when a pause for fur-
ther evaluation is warranted.
2. Cardiovascular screening and treatment of patients Intended Use
undergoing noncardiac surgery should adhere to Clinical practice guidelines provide recommendations
the same indications as nonsurgical patients, care- applicable to patients with or at risk of developing cardio-
fully timed to avoid delays in surgery and chosen in vascular disease (CVD). The focus is on medical practice
ways to avoid overscreening and overtreatment. in the United States, but these guidelines are relevant to

Circulation. 2024;150:e00–e00. DOI: 10.1161/CIR.0000000000001285 TBD TBD, 2024 e3

, Thompson et al 2024 Perioperative Cardiovascular Management for Noncardiac Surgery Guideline



patients throughout the world. Although guidelines may Selection of Writing Committee Members
CLINICAL STATEMENTS




be used to inform regulatory or payer decisions, the in-
The Joint Committee strives to ensure that the guide-
AND GUIDELINES




tent is to improve quality of care and align with patients’
line writing committee contains requisite content exper-
interests. Guidelines are intended to define practices
tise and is representative of the broader cardiovascular
meeting the needs of patients in most, but not all, cir-
community by selection of experts across a spectrum of
cumstances and should not replace clinical judgment.
backgrounds, representing different geographic regions,
sexes, races, ethnicities, intellectual perspectives/biases,
Clinical Implementation and clinical practice settings. Organizations and profes-
sional societies with related interests and expertise are
Management, in accordance with guideline recommen-
invited to participate as collaborators.
dations, is effective only when followed by both practitio-
ners and patients. Adherence to recommendations can
be enhanced by shared decision-making between clini- Relationships With Industry and Other Entities
cians and patients, with patient engagement in select- The ACC and AHA have rigorous policies and methods
ing interventions based on individual values, preferences, to ensure that documents are developed without bias or
and associated conditions and comorbidities. improper influence. The complete policy on relationships
with industry and other entities (RWIs) can be found
Methodology and Modernization online. Appendix 1 of the guideline lists writing commit-
tee members’ comprehensive and relevant RWIs.
The AHA/ACC Joint Committee on Clinical Practice
Guidelines (Joint Committee) continuously reviews, up-
dates, and modifies guideline methodology on the basis Evidence Review and Evidence Review
of published standards from organizations, including Committees
the National Academy of Medicine (formerly the Insti- In developing recommendations, the writing commit-
tute of Medicine),1,2 and on the basis of internal reevalu- tee uses evidence-based methodologies that are based
ation. Similarly, presentation and delivery of guidelines are on all available data.4,5 Literature searches focus on
reevaluated and modified in response to evolving technolo- randomized controlled trials (RCTs) but also include reg-
gies and other factors to optimally facilitate dissemination of istries, nonrandomized comparative and descriptive stud-
information to health care professionals at the point of care.
Downloaded from http://ahajournals.org by on October 3, 2024




ies, case series, cohort studies, systematic reviews, and
Numerous modifications to the guidelines have been expert opinion. Only key references are cited.
implemented to make them shorter and enhance “user An independent evidence review committee is com-
friendliness.” Guidelines are written and presented in a missioned when there are ≥1 questions deemed of
modular recommendation format in which each chunk utmost clinical importance and merit formal systematic
includes a table of recommendations, a brief synopsis, review to determine which patients are most likely to ben-
recommendation-specific supportive text and, when efit from a drug, device, or treatment strategy, and to what
appropriate, flow diagrams or additional tables. Hyper- degree. Criteria for commissioning an evidence review
linked references are provided for each modular knowl- committee and formal systematic review include absence
edge chunk to facilitate quick access and review. of a current authoritative systematic review, feasibility of
In recognition of the importance of cost–value con- defining the benefit and risk in a time frame consistent
siderations, in certain guidelines, when appropriate and with the writing of a guideline, relevance to a substantial
feasible, an assessment of value for a drug, device, or number of patients, and likelihood that the findings can
intervention may be performed in accordance with the be translated into actionable recommendations. Evidence
ACC/AHA methodology.3 review committee members may include methodologists,
To ensure that guideline recommendations remain cur- epidemiologists, clinicians, and biostatisticians. Recom-
rent, new data will be reviewed on an ongoing basis by mendations developed by the writing committee on the
the writing committee and staff. When applicable, recom- basis of the systematic review are marked “SR.”
mendations will be updated with new evidence, or new
recommendations will be created when supported by
published evidence-based data. Going forward, targeted Guideline-Directed Management and Therapy
sections/knowledge chunks will be revised dynamically The term guideline-directed management and therapy
after publication and timely peer review of potentially (GDMT) encompasses clinical evaluation, diagnostic
practice-changing science. The previous designations of testing, and both pharmacological and procedural treat-
“full revision” and “focused update” will be phased out. ments. For these and all recommended drug treatment
For additional information and policies on guideline devel- regimens, the reader should confirm dosage with prod-
opment, readers may consult the ACC/AHA guideline uct insert material and evaluate for contraindications
methodology manual4 and other methodology articles.5–7 and interactions. Recommendations are limited to drugs,


e4 TBD TBD, 2024 Circulation. 2024;150:e00–e00. DOI: 10.1161/CIR.0000000000001285

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