2024 Perioperative CV Management Guideline Slide Set GL

2024
AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SV
M Guideline for Perioperative
Cardiovascular Management for Noncardiac
Surgery
A Report of the American Heart Association/American College of Cardiology
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 of Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine
Citation
This slide set is adapted from the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for
Perioperative Cardiovascular Management for Noncardiac Surgery. Published ahead of print September 24,
2024, available at: Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001285 and Journal
of the American College of Cardiology, published online ahead of print September 24, 2024. J Am Coll Cardiol.
https://www.jacc.org/doi/10.1016/j.jacc.2024.06.013
© 2024 the American Heart Association, Inc. and the American College of Cardiology Foundation.
All rights reserved. This article has been published in Circulation and the Journal of the American
College of Cardiology.
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 Tracy E. Macaulay, PharmD, FACC

Faraz S. Ahmad, MD, MS, FACC, FAHA§ Gail Mates, BS
Robert B. “Skip” Allen, JD Geno J. Merli, MD, FSVM
S. Elissa Altin, MD, FACC, FSVM║ Purvi Parwani, MBBS, MPH, FACC††
Andrew Auerbach, MD, MPH Jeanne E. Poole, MD, FACC, FHRS‡‡
Jeffrey S. Berger, MD, MS, FAHA, FACC Michael W. Rich, MD, FACC
Benjamin Chow, MD, PhD, FACC, FASNC, MSCCT¶ Kurt Ruetzler, MD, PhD, FAHA
Habib A. Dakik, MD, FACC Steven C. Stain, MD, FACS§§
Eric L. Eisenstein, DBA BobbieJean Sweitzer, MD
Marie Gerhard-Herman, MD, FACC, FAHA Amy W. Talbot, MPH
Kamrouz Ghadimi, MD, MHSc, FAHA Saraschandra Vallabhajosyula, MD, MSc, FAHA, FACC
Bessie Kachulis, MD# John Whittle, MD
Jacinthe Leclerc, RN, PhD, FAHA Kim Allan Williams, Sr., MD, MACC, FAHA, MASNC║║
Christopher S. Lee, PhD, RN, FAHA**
*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 JCCPG 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.
3
Top Take-Home Messages
Top Take Home
Messages
1. A stepwise approach to perioperative

cardiac assessment assists clinicians in
determining when surgery should proceed or
when a pause for further evaluation is
warranted.
5
Top Take Home
Messages
2. Cardiovascular screening and treatment
of patients undergoing noncardiac surgery
(NCS) should adhere to the same indications
as nonsurgical patients, carefully timed to
avoid delays in surgery and chosen in ways
to avoid overscreening and overtreatment.
Top Take Home
Messages
3. Stress testing should be performed
judiciously in patients undergoing NCS,
especially those at lower risk, and only in
patients in whom testing would be appropriate
independent of planned surgery.
7
Top Take Home
Messages
4. Team-based care should be

emphasized when managing patients
with complex anatomy or unstable
cardiovascular disease.
Top Take Home
Messages
5. New therapies for management of diabetes,
heart failure, and obesity have significant
perioperative implications. Sodium-glucose
cotransporter 2 inhibitors should be discontinued
3 to 4 days before surgery to minimize the risk of
perioperative ketoacidosis associated with their
use.
9
Top Take Home
Messages
6. Myocardial injury after NCS is a

newly identified disease process that
should not be ignored because it
portends real consequences for
affected patients.
Top Take Home
Messages
7. Patients with newly diagnosed atrial
fibrillation identified during or after NCS have
an increased risk of stroke. These patients
should be followed closely after surgery to
treat reversible causes of arrhythmia and to
assess the need for rhythm control and long-
term anticoagulation.
11
Top Take Home
Messages
8. Perioperative bridging of oral
anticoagulant therapy should be used
selectively only in those patients at highest
risk for thrombotic complications and is not
recommended in the majority of cases.
Top Take Home
Messages
9. In patients with unexplained hemodynamic
instability and when clinical expertise is
available, emergency focused cardiac
ultrasound can be used for preoperative
evaluation; however, focused cardiac ultrasound
should not replace comprehensive transthoracic
echocardiography.
13
Table 2. Definitions of
Surgical Timing and Surgical
Timing Risk
Definition
Emergency Immediate threat to life or limb without surgical intervention, where there is very
limited or no time for preoperative clinical evaluation, typically <2 h.
Urgent Threat to life or limb without surgical intervention, where there may be time for
preoperative clinical evaluation to allow interventions that could reduce risk of
MACE or other postoperative complications, typically ≥2 to <24 h.
Time-sensitive Surgery may be delayed up to 3 mo to allow for preoperative evaluation and

management without negatively impacting outcomes.
Elective The surgical procedure can be delayed to permit a complete preoperative evaluation
and appropriate management.
*Determining elevated calculated risk depends on the calculator used. Traditionally a Revised Cardiac Risk Index (RCRI) >1 or a
calculated risk of MACE with any perioperative risk calculator >1% is used as a threshold to identify patients at elevated risk.
†Encompasses patients at intermediate or high surgical risk.
MACE indicates major adverse cardiovascular event; and RCRI, Revised Cardiac Risk Index.
Table 2. Definitions of Surgical
Timing and Surgical Risk
(con’t.)
Risk Category* Definition
Low risk Combined surgical and patient
characteristics predict a low risk of MACE
of <1%.*
Elevated risk† Combined surgical and patient

characteristics predict an elevated risk of
MACE of ≥1%.*
*Determining elevated calculated risk depends on the calculator used. Traditionally a Revised Cardiac Risk Index (RCRI) >1 or a
calculated risk of MACE with any perioperative risk calculator >1% is used as a threshold to identify patients at elevated risk.
†Encompasses patients at intermediate or high surgical risk.
MACE indicates major adverse cardiovascular event; and RCRI, Revised Cardiac Risk Index.
15
Table 3. Applying
the American
College of
Cardiology/Americ
an Heart
Association Class
of
Recommendation
and Level of
Evidence to
Clinical
Strategies,
Interventions,
Treatments, or
Diagnostic Testing
in Patient Care
Risk Calculators
17
Cardiovascular Risk
Indices
Recommendation for Cardiovascular Risk Indices
Referenced studies that support the recommendations are summarized in the Online Data
Supplement.
COR LOE Recommendation
1. In patients with known CVD being considered for NCS, a validated

2a B-NR risk-prediction tool can be useful to estimate the risk of
perioperative MACE.
18
Table 4. Risk Scores and
Goldman Index of
Calculators
Revised Cardiac Gupta NSQIP Risk Calculator for Surgical Outcome
NSQIP Geriatric-
AUB-HAS2
ACS NSQIP Surgical Sensitive
Cardiac Risk Risk Index Perioperative Myocardial Infarction Risk Tool (2014) Cardiovascular Risk
Risk Calculator (2023) Perioperative Cardiac
(1977) (RCRI) (1999) or Cardiac Arrest (MICA) (2011) Index (2019)
Risk Index (2017)
Criteria • Age >70 y (5 • Ischemic heart • Age • Age group • Age group •ASA class • Age ≥75 y
points) disease • ASA class • Sex • ASA class • History of HF • History of heart disease
• Recent MI within • Cerebrovascular • Preoperative function • ASA class • Urgency of surgery • History of stroke • Symptoms of
6 mo (10 points) disease • Creatinine • Functional status • Specialty • Diabetes angina/dyspnea
• Jugular venous • History of HF • Procedure type (anorectal surgery, • Emergency case • Severity of surgery • Functional status • Hemoglobin <12 mg/dL
distention or a third • Insulin therapy aortic, bariatric, brain, breast, cardiac, • Steroid use for chronic • Cancer (partially versus totally • Vascular surgery
heart sound on for diabetes ENT, foregut/hepato-pancreatobiliary, condition dependent) • Emergency surgery
auscultation (11 • Serum creatinine gallbladder/appendix/adrenal/spleen, • Ascites within 30 d • Creatinine >1.5mg/dL
points) ≥2.0 mg/dL intestinal, neck, obstetric/ gynecologic, preoperatively • Surgical category
• ≥5 PVCs per • Planned high- orthopedic, other abdomen, peripheral • System sepsis within 48
minute (7 points) risk procedure vascular, skin, spine, thoracic, urology, h preoperatively
• Nonsinus rhythm (intraperitoneal, vein) • Ventilator dependent
or PACs on intrathoracic, or • Disseminated cancer
preoperative ECG vascular surgery) • Diabetes
(7 points) • HTN requiring
• Aortic stenosis (3 (1 point for each medication
points) criterion) • Previous cardiac event
• Intraperitoneal, • HF in 30 d
intrathoracic, or preoperatively
aortic surgery (3 • Dyspnea
points) • Current smoker within 1
• Any emergency y
surgery (4 points) • History of COPD
• Dialysis
• Acute renal failure
• BMI class
• CPT-specific linear risk
Table 4. Risk Scores and Calculators
(con’t.)
Class I: 0-5 points 0%-100% CVRI Score 0 (lowest
Class I: RCRI 0
(lowest risk) risk)
(lowest risk) 0%-100% 0%-100%
Class II: 6-12 points 0%-100% (0% lowest risk, 100% CVRI Score 1
Class II: RCRI 1
Score Range Class III: 13-25 highest risk) CVRI Score 2
Class III: RCRI 2 (0% lowest risk, 100% (0% lowest risk, 100%
points (0% lowest risk, 100% highest risk) CVRI Score 3
Class IV: RCRI highest risk) highest risk)
Class IV: ≥26 points CVRI Score >3 (highest
3+ (highest risk)
(highest risk) risk)
Threshold
Class II or higher
Denoting RCRI >1 >1% >1% >1% CVRI Score ≥2
(≥6 points)
Elevated Risk
MI, pulmonary
Intraoperative/ edema, ventricular 30-d mortality
Cardiac arrest, MI, all- Cardiac arrest, MI, all-
postoperative MI, fibrillation, Intraoperative/postoperative MI or Death, MI, or stroke at 30
Outcome cause mortality within 30 cause mortality within
pulmonary edema, complete heart cardiac arrest within 30 d d
d 30 d
VT, cardiac death block, cardiac
death
Derivation (n) 1001 1422 211,410 1,414,006 19,097 584,931 3284
Derivation Set 0.90 (cardiac arrest or MI)
0.61 0.76 0.88 N/A 0.90
ROC 0.94 (mortality)
0.88 (cardiac arrest or 0.83*
Validation Set 0.81 0.91‡
0.70 0.87* MI)* (0.76 in adults age ≥65 0.82*
ROC 0.75†
0.94 (mortality)* y)
Class I: 0-5 points CVRI Score 0 (lowest
Class I: RCRI 0 0%-100%
(lowest risk) risk)
(lowest risk) 0%-100% 0%-100%
Class II: 6-12 points 0%-100% CVRI Score 1
Class II: RCRI 1 (0% lowest risk, 100%
Score Range Class III: 13-25 CVRI Score 2
Class III: RCRI 2 (0% lowest risk, 100% highest risk) (0% lowest risk, 100%
points (0% lowest risk, 100% highest risk) CVRI Score 3
Class IV: RCRI highest risk) highest risk)
Class IV: ≥26 points CVRI Score >3 (highest
3+ (highest risk)
(highest risk) risk)
20
Table 4. Risk Scores and Calculators
(con’t.)
*Validated using the NSQIP database.
†Pooled validation studies assessing the performance of the RCRI in mixed noncardiac
surgery.
‡Derived and validated using the NCEPOD Knowing the Risk study.
ACS indicates American College of Surgeons; ASA, American Society of Anesthesiologists;

AUB, American University of Beirut; BMI, body mass index; COPD, chronic obstructive
pulmonary disease; CPT, current procedural terminology; CVRI, Coronary Vascular
Resistance Index; ECG, electrocardiogram; ENT, ear, nose and throat; HF, heart failure;
HTN, hypertension; MI, myocardial infarction; MICA, MI and cardiac arrest; NCEPOD,
National Confidential Enquiry into Patient Outcome and Death; NSQIP, National Surgical
Quality Improvement Program; PAC, premature atrial contraction; PVC, premature
ventricular complex; RCRI, Revised Cardiac Risk Index; ROC, receiver operating
characteristic; and VT, ventricular tachycardia.
Functional Capacity
Assessment
Recommendation for Functional Capacity Assessment
Supplement.
1. In patients undergoing elevated-risk NCS, a structured

assessment of functional capacity (such as the Duke Activity
2a B-NR
Status Index [DASI]) is reasonable to stratify the risk of
perioperative adverse cardiovascular events.
22
Table 5. Duke Activity Status Index
(DASI)
Activity: Can you… Weight
take care of yourself (eg, eating, dressing, bathing, or using the toilet)? 2.75
walk indoors, such as around your house? 1.75
walk a block or 2 on level ground? 2.75
climb a flight of stairs or walk a hill? 5.5
run a short distance? 8
do light work around the house (eg, dusting, washing dishes)? 2.7
do moderate work around the house (eg, vacuuming, sweeping floors, carrying in 3.5
groceries)?
do heavy work around the house (eg, scrubbing floors, lifting or moving heavy furniture)? 8
do yardwork (eg, raking leaves, weeding, pushing a power mower)? 4.5
have sexual relations? 5.25
participate in moderate recreational activities (eg, golf, bowling, dancing, doubles tennis, 6
throwing a baseball or football)?
The DASI score is calculated by adding the points of all performed activities together. The higher the score (range, 0-58.2),
participate infunctional
the higher the strenuous sports (eg, swimming, singles tennis, basketball, skiing)?
status. 7.5
Frailty
Recommendation for Frailty

Supplement.

1. In all patients ≥65 years of age and in those <64 years with
perceived frailty who are undergoing elevated-risk NCS,
2a B-NR preoperative frailty assessment using a validated tool can be

useful for evaluating perioperative risk and guiding
management.
24
Table 6. Frailty Assessment
Tools
Name Items Scoring
Physical Frailty Phenotype Slowness, low activity, 0=Nonfrail
(Fried Phenotype) weight loss, exhaustion, 1-2=Prefrail
weakness (1 point each) 3-5=Frail
Deficit Accumulation Index Variable; typically 30-70 Number of deficits/number of

items from multiple items scored; higher scores
domains indicate greater frailty
Edmonton Frail Scale 10 items across multiple Sum of scores/17; higher

domains scores indicate greater
frailty
Table 6. Frailty Assessment Tools
(con’t.)
Name Items Scoring
FRAIL Scale Fatigue, stair climb, 0=Nonfrail
ambulation, illnesses >5, 1-2=Intermediate
weight loss ≥5% (1 point 3-5=Frail
each)
Clinical Frailty Scale 9 categories ranging from Categories 5-8 indicate mild,
very fit to terminally ill as moderate, severe, and very
assessed by clinicians severe frailty
SPPB Gait speed, chair stands, Maximum 4 points per item,

balance tests range, 0-12 points;
≥10=Nonfrail, 3-9=Frail,
≤2=Disabled
SPPB indicates Short Physical Performance Battery.
26
Preoperative Biomarkers for Risk
Stratification
Recommendations for Preoperative Biomarkers for Risk Stratification
Referenced studies that support the recommendations are summarized in the Online Data Supplement.
COR LOE Recommendations

1. In patients with known CVD, or age ≥65 years, or age ≥45 years with
symptoms suggestive of CVD undergoing elevated-risk NCS, it is
2a B-NR 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.
2. 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
2b B-NR
reasonable to measure cardiac troponin (cTn) before surgery to
supplement evaluation of perioperative risk.
Preoperative Cardiovascular
Diagnostic Testing
28
12-Lead
Electrocardiogram
Recommendations for 12-Lead Electrocardiogram
1. For patients with known coronary heart disease, significant arrhythmia, peripheral
arterial disease, cerebrovascular disease, other significant structural heart disease, or
2a B-NR symptoms* of CVD undergoing elevated-risk surgery, a preoperative resting 12-lead

electrocardiogram (ECG) is reasonable to establish a preoperative baseline and guide
perioperative management.
*Active symptoms and signs of CVD include chest pain, dyspnea, undiagnosed palpitations, tachycardia, syncope, or murmurs.
29
12-Lead Electrocardiogram
(con’t.)
2. In patients undergoing NCS with a preoperative ECG exhibiting new
2a B-NR abnormalities†, further evaluation is reasonable to refine assessment of
cardiovascular risk.
3. For asymptomatic patients undergoing elevated-risk surgeries without known

CVD, a preoperative resting 12-lead ECG may be considered to establish a
2b B-NR
baseline and guide perioperative management.
3: No 4. For asymptomatic patients undergoing low-risk surgical procedures, a routine

B-NR preoperative resting 12-lead ECG is not recommended to improve outcomes.
benefit
†Abnormalities may include ST-segment elevation, ST depression, T-wave inversions, left ventricular (LV) hypertrophy, significant pathologic
Q-waves, Mobitz type II or higher atrioventricular (AV) block, bundle branch block, QT prolongation, or AF.
Left Ventricular
Function
Recommendations for Assessment of Left Ventricular Function

1. In patients undergoing NCS with new dyspnea, physical examination
findings of HF, or suspected new/worsening ventricular dysfunction, it is
1 B-NR
recommended to perform preoperative evaluation of LV function to help
guide perioperative management.
2. In patients with a known diagnosis of HF with worsening dyspnea or other

2a C-LD change in clinical status undergoing NCS, preoperative assessment of LV
function is reasonable to help guide perioperative management.
3. In asymptomatic and clinically stable patients undergoing NCS, routine

3: No
B-NR preoperative evaluation of LV function is not recommended due to lack of
Benefit
benefit.
31
Stress
Testing
Recommendations for Stress Testing
Supplement.
1. For patients undergoing elevated-risk NCS with poor or unknown

functional capacity and elevated risk for perioperative
2b B-NR
cardiovascular events based on a validated risk tool, stress testing
may be considered to evaluate for inducible myocardial ischemia.
2. In patients who are at low risk for perioperative cardiovascular

3: No events, have adequate* functional capacity with stable symptoms,
B-R
benefit or who are undergoing low-risk procedures, routine stress testing
before NCS is not recommended due to lack of benefit.
*Poor functional capacity is considered <4 METS or a DASI score of

≤34.
Table 7. Considerations and
Contraindications for Specific Stress Testing
Modalities
Modality Contraindication*
Vasodilator pharmacological Significant arrhythmias (eg, VT, second- or third-degree
stress imaging atrioventricular block), significant hypotension (SBP <90
mm Hg), known or suspected bronchoconstrictive or
bronchospastic disease or recent use of dipyridamole or
methylxanthines (eg, aminophylline, caffeine) within 12 h
Exercise stress testing (with Inability to exercise

or without imaging)
Dobutamine stress Critical aortic stenosis, hemodynamically significant LVOT
echocardiography obstruction
*In general, the following contraindications apply to all stress testing modalities: ACS, decompensated HF,
severe/symptomatic aortic stenosis, uncontrolled arrhythmia, systemic arterial HTN (eg, ≥200/110 mm Hg),
acute aortic dissections, pericarditis/myocarditis, pulmonary embolism, and severe pulmonary HTN.
ACS indicates acute coronary syndrome; HF, heart failure; HTN, hypertension; LVOT, left ventricular outflow
tract; SBP, systolic blood pressure; and VT, ventricular tachycardia.
33
Coronary Computed Tomography Angiography
Recommendations for Coronary Computed Tomography Angiography


1. For patients undergoing elevated-risk surgery with poor* or unknown
functional capacity, and elevated risk for perioperative cardiovascular
2b B-NR events based on a validated risk tool, coronary computed tomography

angiography (CCTA) for the detection of high-risk coronary anatomy†
may be considered.
2. In patients who are at low risk for perioperative cardiovascular events,

have adequate* functional capacity with stable symptoms, or who are
3: No benefit B-NR
undergoing low-risk procedures, routine CCTA before NCS is not
recommended due to lack of benefit.
*Poor functional capacity is considered <4 METS or a DASI score of ≤34.
†High-risk coronary anatomy is defined as patients with obstructive stenosis who have ≥50% left main stenosis or anatomically
significant 3-vessel disease (≥70% stenosis).6
Invasive Coronary
Angiography
Recommendation for Invasive Coronary Angiography

1. In patients undergoing NCS, routine preoperative
3: No invasive coronary angiography (ICA) is not

C-LD recommended to improve perioperative outcomes.
benefit
35
Approach to Perioperative
Cardiac Testing
36
Figure 1.
Stepwise
Approach to
Perioperative
Cardiac
Assessment. BNP indicates B-type natriuretic
peptide; CABG, coronary artery bypass
grafting; CAD, coronary artery disease;
*Cardiovascular risk factors: HTN, smoking, high CCTA, coronary computed tomography
cholesterol, diabetes, women age >65; men age angiography; CIED, cardiovascular
>55; obesity; family history of premature CAD. implantable electronic device; CVD,
cardiovascular disease; DASI, Duke
†Determining elevated calculated risk depends on Activity Status Index; ECG,
the calculator used. Traditionally, RCRI >1 or a electrocardiogram; GDMT, guideline-
calculated risk of MACE with any perioperative directed management and therapy;
risk calculator >1% is used as a threshold to HTN, hypertension; ICD, implantable
identify patients at elevated risk. cardioverter-defibrillator; LM, left main;
MACE, major adverse cardiovascular
§Abnormal biomarker thresholds: troponin >99th event; METS, metabolic equivalents;
percentile URL for the assay; BNP >92 ng/L, NT- NCS, noncardiac surgery; NT-proBNP,
proBNP ≥300 ng/L. N-terminal pro b-type natriuretic
peptide; RCRI, Revised Cardiac Risk
‡Conditions that pose additional risk for MACE. Index; and URL, upper reference limit.
║Noninvasive stress testing or CCTA suggestive of Colors correspond to

LM or multivessel CAD. Class of Recommendation
in Table 3.
Cardiovascular
Comorbidities and
Perioperative Management
38
Coronary
Revascularization
Recommendations for Revascularization

1. In patients with ACS being considered for elective NCS, coronary
1 C-LD revascularization as appropriate and deferral of surgery is recommended to
reduce perioperative cardiovascular events.
2. In patients with CCD and hemodynamically significant left main coronary

artery stenosis ≥50% who are planning elective NCS, coronary
2a C-LD
revascularization and deferral of surgery is reasonable to reduce perioperative
cardiovascular events.
3. In patients with non-left main CAD who are planned for NCS, routine
3: No
B-R preoperative coronary revascularization is not recommended to reduce
benefit
perioperative cardiovascular events.*
*Modified from the 2021 ACC/AHA/SCAI Coronary Revascularization Guideline.
39
Hypertension and
Perioperative Blood Pressure
Management
Recommendations for Hypertension and Perioperative Blood Pressure Management
Preoperative Blood Pressure Management
1. In most* patients with HTN planned for elective NCS, it is reasonable to
2a C-EO
continue medical therapy for HTN throughout the perioperative period.†
2. In patients undergoing elective elevated-risk surgery who have cardiovascular

risk factors for perioperative complications‡ and recent history of poorly
2b C-LD controlled HTN (systolic blood pressure [SBP] ≥180 mm Hg or diastolic blood
pressure [DBP] ≥110 mm Hg before the day of surgery), deferring surgery
may be considered to reduce the risk of perioperative complications.†
*Caution is advised when continuing antihypertensive therapy in patients with low or low-normal perioperative BPs, older adults (≥65
years), and patients in whom the risk for perioperative hypotension is high based on an evaluation of the patient’s overall clinical
status, surgery type, and anesthetic plan.
†Modified from the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA High Blood Pressure Guideline.”

Hypertension and Perioperative
Blood Pressure Management (con’t.)
Intraoperative Blood Pressure Management
3. In patients undergoing NCS, maintaining an intraoperative mean

1 B-NR arterial pressure (MAP) ≥60 to 65 mm Hg or SBP ≥90 mm Hg is
recommended to reduce the risk of myocardial injury.
Postoperative Blood Pressure Management
4. In patients undergoing NCS, treatment of hypotension (MAP <60-65 or
1 B-NR SBP <90 mm Hg) in the postoperative period is recommended to limit
the risk of cardiovascular, cerebrovascular, renal events, and mortality.
5. In patients with HTN undergoing NCS, it is recommended that

1 C-EO preoperative antihypertensive medications be restarted as soon as
clinically reasonable to avoid complications from postoperative HTN.
41
Heart Failure
Recommendations for Heart Failure
Supplement.

1. In patients with HF undergoing elective NCS, sodium-glucose
cotransporter-2 inhibitors (SGLT2i) should be withheld for 3 to 4
1 C-LD
days* before surgery when feasible to reduce the risk of
perioperative metabolic acidosis.
2. In patients with compensated HF undergoing NCS, it is reasonable

2a C-LD to continue GDMT (excluding SGLT2i) in the perioperative period,
unless contraindicated, to reduce the risk of worsening HF.
*Canagliflozin, dapagliflozin, and empagliflozin should be stopped ≥3 days and ertugliflozin ≥4 days before
scheduled surgery.
Table 8. Association of Heart Failure and
Left Ventricular Ejection Fraction With 90-
day Mortality in Patients Undergoing
Noncardiac Surgery
N Crude Mortality Crude OR Adjusted OR
No heart failure 561,738 1.22% Reference Reference
HFpEF, LVEF 28,742 4.88% 4.14 (3.90-4.39) 1.51 (1.40-1.62)
≥50%
LVEF 40-49% 7,612 5.11% 4.34 (3.91-4.82) 1.53 (1.38-1.71)
LVEF 30-39% 6,048 6.58% 5.68 (5.12-6.31) 1.85 (1.68-2.05)
LVEF<30% 4,185 8.34% 7.34 (6.56-8.21) 2.35 (2.09-2.63)
HFpEF indicates heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; and OR, odds
ratio (with 95% CI).
43
Hypertrophic Cardiomyopathy
Recommendation for Hypertrophic Cardiomyopathy

1. For patients with hypertrophic cardiomyopathy (HCM)
undergoing NCS, factors that aggravate or trigger dynamic
3-Harm C-LD outflow obstructions (eg, positive inotropic agents,

tachycardia, or reduced preload) are harmful and should be
avoided to reduce the risk of hemodynamic instability.
Table 9. Preoperative and Intraoperative
Management Considerations in Patients
With Hypertrophic Cardiomyopathy
Management Considerations
Continue beta blockers and/or nondihydropyridine calcium channel blockers without interruption in the
perioperative period
Avoid hypovolemia and reduced preload (can worsen LVOT obstruction)
Avoid hypotension and reduced afterload (can worsen LVOT obstruction)
Avoid tachycardia to ensure adequate LV filling
If hypotension develops:
 Prioritize intravenous fluid administration to correct hypovolemia
 Use alpha-agonists, such as phenylephrine or vasopressin, 7 rather than beta-agonists, which can
worsen LVOT obstruction
 Consider intraoperative echocardiography to evaluate LVOT obstruction in the setting of hypotension
 In selected cases, intravenous beta-blockade may be necessary to reduce LV myocardial contractility
and relieve LVOT obstruction
LV indicates left ventricular; and LVOT, left ventricular outflow
tract.
45
Pulmonary Hypertension
Recommendations for Pulmonary Hypertension

Supplement.
1. In patients receiving stable doses of targeted medical therapies*
for pulmonary arterial hypertension (PAH) undergoing NCS, it is
1 C-LD
recommended to continue these agents to reduce the risk for the
development of perioperative MACE.
*For example, nitric oxide pathway mediators, endothelin receptor antagonists, prostacyclin pathway agonists, or a
combination of these.
Pulmonary Hypertension (con’t.)
2. In patients with severe† pulmonary hypertension (PH) undergoing elevated-risk
NCS, referral to or consultation with a specialized PH center that can support
2a C-LD risk assessment, optimization, and postoperative management (with
consideration of intensive care after NCS) is reasonable to reduce perioperative
cardiopulmonary complications.
3. In patients with severe† PH undergoing elevated-risk NCS, invasive
2a C-LD hemodynamic monitoring is reasonable to guide intraoperative and
postoperative care.
4. In patients with precapillary PH undergoing elevated-risk NCS, perioperative
administration of short-acting inhaled pulmonary vasodilators (eg, nitric oxide,
2b C-EO
aerosolized prostacyclins) may be reasonable to reduce elevated RV afterload
and prevent acute decompensated right HF.
†Severe PH is defined according to hemodynamics (severe precapillary PH component by right heart catheterization and echocardiography) and additional
data derived from clinical assessment, exercise tests, and laboratory biomarkers. Hemodynamically, severe PH displays a mean pulmonary artery (PA)
pressure >40 mm Hg, pulmonary vascular resistance >5 Wood units, or echocardiographic evidence of significant RV dysfunction (eg, RV-to-LV diastolic
diameter ratio >0.8 or RV dysfunction that is graded as moderate or severe). Although all 5 World Symposium Pulmonary Hypertension group classifications
display some degree of risk for developing severe PH, Group 1 (PAH), Group 3 (PH due to lung disease), and Group 4 (chronic thromboembolic PH) are at high
risk for developing severe PH if left untreated and may be best managed and followed at a center with PH specialists.
47
Adult Congenital Heart
Disease
Recommendation for Adult Congenital Heart Disease
Referenced studies that support the recommendation are summarized in the Online Data
Supplement.

1. In patients with intermediate- to elevated-risk congenital heart
disease (CHD) lesions (Table 10) undergoing elective NCS,
1 B-NR
preoperative consultation with an adult congenital heart disease
(ACHD) specialist is recommended before the surgery.*
*Modified from the “2018 AHA/ACC Guideline for Management of

ACHD.”
Table 10. ACHD Risk Stratification
Before Noncardiac Surgery
Risk Anatomy Functional/Hemodynamic Status

Low Risk Patients with isolated small NYHA class I functional status, normal exercise capacity
CHD lesions No chamber enlargement on imaging
Patients with repaired CHD No residual shunt
lesion with no residual shunt No PAH
Patients with bicuspid aortic No arrhythmias
valve disease and aortopathy
ASD indicates atrial septal defect; AVSD, atrioventricular septal defect; CCTGA, congenitally corrected transposition of the great arteries;
CHD, congenital heart disease; CoA, coarctation of the aorta; d-TGA, dextro-transposition of the great arteries; FC, functional class; HF, heart
failure; L-TGA, Levo-transposition of the great arteries; NYHA, New York Heart Association; PA, pulmonary artery; PAH, pulmonary arterial
hypertension; TGA, transposition of the great arteries; VHD, valvular heart disease, anatomic and physiological; and VSD, ventricular septal
defect.
49
Before Noncardiac Surgery (con’t.)
Unrepaired moderate-large shunts
Intermediate risk NYHA class II-IV functional status
(ASD, VSD, PDA, AVSD)
Limited exercise capacity
Repaired CHD with moderate to
Presence of residual shunt
large residual shunt (ASD, VSD,
PDA, AVSD) Presence of PAH
Presence of cardiac chamber enlargement
Obstructive left-sided lesions
(congenital mitral stenosis, Significant valvular dysfunction (more than mild in
subaortic stenosis, supravalvular
severity)
aortic stenosis, coarctation of
aorta) except the ones described Arrhythmias requiring treatment
as low risk
Presence of HF
Obstructive right-sided lesion
(pulmonary stenosis, branch
pulmonary stenosis, repaired
tetralogy of Fallot)
ASD indicates atrial septal defect; AVSD, atrioventricular septal defect; CCTGA, congenitally corrected transposition of the great arteries;
CHD, congenital heart disease; CoA, coarctation of the aorta; d-TGA, dextro-transposition of the great arteries; FC, functional class; HF, heart
failure; L-TGA, Levo-transposition of the great arteries; NYHA, New York Heart Association; PA, pulmonary artery; PAH, pulmonary arterial
hypertension; TGA, transposition of the great arteries; VHD, valvular heart disease, anatomic and physiological; and VSD, ventricular septal
defect.
Ebstein anomaly (disease spectrum
Intermediate risk NYHA class II-IV functional status
includes mild, moderate, and
severe variations) Limited exercise capacity
Presence of residual shunt
Anomalous coronary artery arising
from the pulmonary artery Presence of PAH
Presence of cardiac chamber enlargement
Anomalous aortic origin of a
coronary artery from the opposite Significant valvular dysfunction (more than mild in
sinus, especially with an
severity)
interarterial or intramural course
Arrhythmias requiring treatment
Presence of HF
ASD indicates atrial septal defect; AVSD, atrioventricular septal defect; CCTGA, congenitally corrected transposition of the great arteries; CHD,
congenital heart disease; CoA, coarctation of the aorta; d-TGA, dextro-transposition of the great arteries; FC, functional class; HF, heart failure; L-
TGA, Levo-transposition of the great arteries; NYHA, New York Heart Association; PA, pulmonary artery; PAH, pulmonary arterial hypertension; TGA,
transposition of the great arteries; VHD, valvular heart disease, anatomic and physiological; and VSD, ventricular septal defect.
51
Elevated risk Single-ventricle patients (palliated NYHA class II-IV functional status
or status post Fontan procedure), Limited exercise capacity
unrepaired or palliated cyanotic Significant valvular dysfunction (more than mild in
CHD, double outlet right severity)
ventricle, pulmonary atresia, Arrhythmias requiring treatment
truncus arteriosus, TGA (classic Presence of PAH
or d-TGA; CCTGA or l-TGA), Presence of HF
interrupted aortic arch
ASD indicates atrial septal defect; AVSD, atrioventricular septal defect; CCTGA, congenitally corrected transposition of the great arteries; CHD, congenital
heart disease; CoA, coarctation of the aorta; d-TGA, dextro-transposition of the great arteries; FC, functional class; HF, heart failure; L-TGA, Levo-
transposition of the great arteries; NYHA, New York Heart Association; PA, pulmonary artery; PAH, pulmonary arterial hypertension; TGA, transposition of
the great arteries; VHD, valvular heart disease, anatomic and physiological; and VSD, ventricular septal defect.
Table 11. ACHD Patient Management for Noncardiac
Surgery
Clarify the ACHD diagnosis and review cardiac anatomy
Clarify prior procedures, residua, sequelae, and current functional status
Identify factors associated with increased risk of perioperative morbidity and mortality
Cyanosis
HF
Poor functional capacity
Pulmonary hypertension
Intermediate- to high-risk CHD lesions
Urgent/emergency procedures
Operations of the respiratory and nervous systems

ACHD indicates adult congenital heart disease; CHD, congenital heart disease; and HF, heart failure.
53
Table 11. ACHD Patient Management
for Noncardiac Surgery (con’t.)
Multidisciplinary team discussion to develop management strategies to minimize risk and optimize outcomes
Issues to consider
Endocarditis prophylaxis
Prevention of venous thrombosis
Monitoring of renal and liver function and appropriate drug dosing
Complications related to underlying hemodynamics
Need for hemodynamic monitoring
Periprocedural anticoagulation
Abnormal venous and/or arterial anatomy affecting venous and arterial access
Meticulous line care, including air filters for intravenous lines to reduce risk of paradoxical embolus in patients
who are cyanotic because of right-to-left shunts
Arrhythmias, including bradyarrhythmias
Erythrocytosis
Pulmonary vascular disease
Adjustment of anticoagulant volume in tubes for some blood work in cyanotic patients
Left Ventricular Assist
Devices
Recommendation for Left Ventricular Assist Devices
1. In patients with a left ventricular assist device
(LVAD), coordination with the LVAD care team on
the appropriate timing and perioperative
1 C-EO
considerations of elective NCS is recommended to
mitigate the risk of perioperative MACE.
55
Aortic Stenosis
Recommendations for Aortic Stenosis

1. Patients with severe AS should be evaluated for the need for aortic
1 C-LD
valve intervention before elective NCS to reduce perioperative risk.*
2. In patients with suspected moderate or severe AS who are
undergoing elevated-risk NCS, preoperative echocardiography is
1 C-EO
recommended before elective NCS to guide perioperative
management.*
3. In asymptomatic patients with moderate or severe AS and normal

2a C-LD LV systolic function as assessed by echocardiography within the past
year, it is reasonable to proceed with elective low-risk NCS.
*Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
Figure 2.
Management of
Patients With
Severe Aortic
Stenosis
Requiring
Elective or Time-
Sensitive
Noncardiac
Surgery.
Colors correspond to Class of Recommendation
in Table 3.
*Severe aortic stenosis: aortic valve area <1.0 cm2, mean
aortic valve gradient ≥40 mm Hg, or peak aortic valve velocity
Vmax ≥4.0 m/s.
†Symptoms of exertional dyspnea, angina, HF, syncope, or AVR indicates aortic valve replacement; BAV, balloon
presyncope. aortic valvuloplasty; CAD, coronary artery disease;
LVEF, left ventricular ejection fraction; NCS,
‡Including elevated risk for hemodynamic instability, large noncardiac surgery; SAVR, surgical aortic valve
volume shifts, or major bleeding. replacement; and TAVI, transcatheter aortic valve
implantation.
57
Mitral
Stenosis
Recommendations for Mitral Stenosis

1. Patients with severe mitral stenosis (MS) should be evaluated for the need for
1 B-NR
mitral valve (MV) intervention before elective NCS.
2. In patients with severe MS who cannot undergo MV intervention before NCS,
2a C-EO perioperative invasive hemodynamic monitoring is reasonable to guide
management to reduce the risk of cardiovascular complications.
3. In patients with severe MS who cannot undergo MV intervention before NCS,

perioperative heart-rate control (eg, beta blockers, calcium channel blockers
2b C-LD
[CCBs], ivabradine, digoxin) may be considered to prolong diastolic filling time
and decrease perioperative cardiovascular complications.
Chronic Aortic and Mitral
Regurgitation
Recommendations for Chronic Aortic and Mitral Regurgitation
1. In patients with suspected moderate or severe valvular regurgitation, preoperative
1 C-EO echocardiography is recommended before elective NCS to guide perioperative
management.*
2. In patients with VHD who meet indications for valvular intervention based on clinical
1 C-EO presentation and severity of regurgitation, the need for valvular intervention should be
considered before elective elevated-risk NCS to reduce perioperative risk.*
3. In asymptomatic patients with moderate or severe MR, normal LV systolic function, and
2a C-LD
estimated PA systolic pressure <50 mm Hg, it is reasonable to perform elective NCS.*
4. In asymptomatic patients with moderate or severe aortic regurgitation and normal LV
2a C-LD
systolic function (LVEF >55%), it is reasonable to perform elective NCS.*
*Modified from the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”
59
Previous Transcatheter Aortic Valve
Implantation or Mitral Valve
Transcatheter Edge-to-Edge Repair
Recommendations for Patients With Previous Transcatheter Aortic Valve Implantation or Mitral
Valve Transcatheter Edge-to-Edge Repair

1. For patients who undergo successful transcatheter aortic valve
2a B-NR implantation (TAVI), it is reasonable to perform NCS early* as
clinically indicated.
2. For patients who undergo MV TEER, it is reasonable to perform

2a C-EO
NCS after the successful MV intervention as clinically indicated.
*Evidence supports the safety of NCS within 30 days of TAVI, if indicated.
Atrial Fibrillation
Recommendations for Atrial Fibrillation

Perioperative
1. In patients with rapid AF identified in the setting of NCS, it is reasonable to
2a C-LD treat potential underlying triggers contributing to AF and rapid ventricular
response (eg, sepsis, anemia, pain).*
2. In patients with new-onset AF identified in the setting of NCS, initiation of

postoperative anticoagulation therapy can be beneficial after considering
2a C-LD
the competing risks associated with thromboembolism and perioperative
bleeding.*
Post-discharge
3. In patients with new-onset AF identified in the setting of NCS, outpatient
1 C-LD follow-up for thromboembolic risk stratification and AF surveillance are
recommended given a high risk of AF recurrence.*
*Adapted from the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.”
61
Cardiovascular Implantable Electronic
Devices
Recommendations for Preoperative Management of Patients With Cardiovascular Implantable Electronic
Devices

1. Patients with cardiovascular implantable electronic devices (CIED) having
elective NCS should have a management plan developed before surgery if
1 B-NR electromagnetic interference (EMI) is anticipated, including identification of

the type of CIED (eg, pacemaker, implantable cardioverter-defibrillator
[ICD], implantable monitor), manufacturer, and model.
2. Patients who are pacemaker-dependent having surgeries above the umbilicus

with anticipated EMI should have the pacemaker reprogrammed or have a
1 B-NR
magnet placed on the generator to provide an asynchronous mode to avoid
pacing inhibition.
Cardiovascular Implantable
Electronic Devices (con’t.)
3. Pacemaker-dependent patients with a transvenous ICD undergoing surgery
above the umbilicus with anticipated EMI should have the device
1 B-NR reprogrammed*; if the patient is not pacemaker-dependent, then either

reprogramming or a magnet placed on the generator can be used to inhibit
tachytherapies or inappropriate shocks.
4. Patients who have a pacemaker or ICD reprogrammed to asynchronous pacing

1 B-NR or have tachytherapies programmed off before surgery should have device
functioning restored in the postoperative period before hospital discharge.
5. Patients with leadless pacemakers who are pacemaker-dependent having

1 C-LD surgeries with anticipated EMI above the umbilicus should have their
pacemakers reprogrammed to an asynchronous mode.
6. For patients with subcutaneous ICD having noncardiac or nonthoracic surgery

2a C-LD with anticipated EMI above the groin, it is reasonable to reprogram the device
or use a magnet to temporarily disable tachytherapies.
*For pacemaker-dependent patients with an ICD, tachytherapies should be disabled and the device should be reprogrammed to an
asynchronous mode to avoid pacing inhibition.
63
Figure 3. Patients
With
Transvenous
CIEDs.
Colors correspond to
Class of Recommendation
in Table 3.
*EMI is considered a
significant risk when the
source is <15 cm from the
CIED generator. External
pacing and/or defibrillation
must be available. Clinicians CIED indicates
must confirm device magnet cardiovascular
capabilities are enabled and implantable electronic
individual magnet responses device; EMI,
are known. Consider electromagnetic
consulting a CIED team for interference; and ICD,
cardiac resynchronization implantable cardioverter-
therapy devices. defibrillator.
Figure 4. Patients
With
Nontransvenous
Devices.
in Table 3.
EMI indicates
electromagnetic
interference; and ICD,
implantable cardioverter-
defibrillator.
*For patients with a leadless pacemaker, a magnet will not force asynchronous pacing.
†A subcutaneous ICD does not currently provide pacing. A magnet, if used, should be
secured with adhesive tape. If the patient is in a position other than supine, or extensive
EMI is anticipated when performing the surgery above the diaphragm, consider
reprogramming.
A magnet placed over the subcutaneous ICD will emit an R wave synchronous beep,
indicating that the magnet is correctly positioned. If the tone is not audible,
reprogramming is necessary.
65
Previous Stroke or Transient Ischemic
Attack
Recommendation for Previous Stroke or Transient Ischemic Attack
Supplement.

1. In patients with a history of stroke or transient ischemic
attack, it is reasonable to delay elective NCS for ≥3 months
2a B-NR
after the most recent cerebrovascular event to reduce the
incidence of recurrent stroke, MACE, or both.
Obstructive Sleep
Apnea
Recommendation for Obstructive Sleep Apnea
Supplement.
1. In patients scheduled for NCS, obstructive sleep apnea (OSA)

2a B-NR screening using validated questionnaires is reasonable to assess
the risk of perioperative complications.
67
Perioperative Medical
Therapy
68
Statins
Recommendations for Statins

Supplement.

1. In patients currently on statins and scheduled for NCS,
1 B-NR continuation of statin therapy is recommended to reduce
the risk of MACE.
2. In statin-naïve adult patients who meet criteria for statin

use based on ASCVD history or 10-year risk assessment
1 B-R
and are scheduled for NCS, perioperative initiation of
statin is recommended with intention of long-term use.
Renin-Angiotensin-Aldosterone System
Inhibitors
Recommendations for Perioperative Renin-Angiotensin-Aldosterone System Inhibitors
1. In select* patients on chronic renin-angiotensin-aldosterone system
inhibitors (RAASi) for HTN undergoing elevated-risk NCS, omission
2b B-R
24 hours before surgery may be beneficial to limit intraoperative
hypotension.
2. In patients on chronic RAASi for HFrEF, perioperative continuation

2a C-EO
is reasonable.†
*Patients with controlled BP and undergoing elevated-risk surgical procedures.
†Modified from the “2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.”
70
Alpha-2 Receptor
Agonists
Recommendation for Perioperative Alpha-2 Receptor Agonists Management
Supplement.

1. In patients undergoing NCS, initiation of low-dose
3: No
B-R clonidine perioperatively is not recommended to reduce
benefit
cardiovascular risk.
Antiplatelet Therapy and Timing of Noncardiac
Surgery in Patients With Coronary Artery Disease
Recommendations for Antiplatelet Therapy and Timing of Noncardiac Surgery in Patients With
Coronary Artery Disease

1. For patients with CAD undergoing elective NCS, management of
perioperative antiplatelet therapy and timing of surgery should be
1 B-NR determined by a multidisciplinary team with shared decision-making

to weigh the risks of bleeding, thrombosis, and consequences of
delayed surgery.
72
Antiplatelet Therapy and Timing of Noncardiac Surgery
in Patients With Coronary Artery Disease (con’t.)
Timing of NCS After PCI

2. In patients with recent coronary artery balloon angioplasty without
1 C-LD stent placement, elective NCS should be delayed for a minimum of 14
days to minimize perioperative MACE.
3. In patients with DES-PCI placed for ACS who require elective NCS
1 B-NR with interruption of ≥1 antiplatelet agents, surgery should ideally be
delayed ≥12 months to minimize perioperative MACE.
4. In patients with DES-PCI placed for CCD who require elective NCS
2a B-NR with interruption of ≥1 antiplatelet agents, it is reasonable to delay
surgery for ≥6 months after PCI to minimize perioperative MACE.
Antiplatelet Therapy and Timing of
Noncardiac Surgery in Patients With
Coronary Artery Disease (con’t.)
5. In patients with DES-PCI who require time-sensitive NCS with interruption of
2b B-NR ≥1 antiplatelet agents, NCS may be considered ≥3 months after PCI if the risk
of delaying surgery outweighs the risk of MACE.
6. In patients with a recent (≤30 days) bare-metal stent (BMS) or DES-PCI,

3: Harm B-NR elective NCS requiring interruption of ≥1 antiplatelet agents is potentially
harmful due to a high risk of stent thrombosis and ischemic complications.
Perioperative Antiplatelet Management Post PCI

7. In patients with prior PCI undergoing NCS, it is recommended to continue
1 B-R
aspirin* (75-100 mg), if possible, to reduce the risk of cardiac events.
8. In patients with CAD who require time-sensitive NCS within 30 days of PCI
1
B-NR 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.
*Platelet adenosine diphosphate receptor (P2Y12) monotherapy may be considered if surgical bleeding risks are acceptable or if
aspirin is not tolerated.
74
Antiplatelet Therapy and Timing of
Noncardiac Surgery in Patients With
Coronary Artery Disease (con’t.)
9. In patients with prior PCI in whom OAC monotherapy must be discontinued before
1 B-NR NCS, aspirin should be substituted when feasible in the perioperative period until
OAC can be safely reinitiated.
10. In select patients after PCI who have a high thrombotic risk, perioperative bridging
2b B-NR with intravenous antiplatelet therapy may be considered <6 months after DES or
<30 days after BMS if NCS cannot be deferred.
Perioperative Antiplatelet Management in Patients Without Prior PCI

11. In patients with CCD without prior PCI undergoing elective NCS, it may be
2b B-R reasonable to continue aspirin in selected patients when the risk of cardiac events
outweighs the risk of bleeding.
3: No 12. In patients with CAD but without prior PCI who are undergoing elective noncarotid
B-R
Benefit NCS, routine initiation of aspirin is not beneficial.
Table 12. Duration of
Antiplatelet Therapy
Effect
Antiplatelet Agent Minimum Time From Drug Interruption
to Restoration of Platelet Function
Aspirin 4d
Clopidogrel 5-7 d
Prasugrel 7-10 d
Ticagrelor 3-5 d
Minimum times from drug interruption to noncardiac surgery should be guided by
pharmacokinetic data, restoration of platelet function after drug withdrawal, and
drug-specific FDA-prescribing information.
76
Figure 5. Optimal
Timing of
Elective or Time-
Sensitive NCS for
Prior PCI
Requiring
Management of
DAPT.
in Table 3.
BMS indicates bare-metal stent; DAPT, dual

antiplatelet therapy; DES, drug-eluting
stent; NCS, noncardiac surgery; and PCI,
percutaneous coronary intervention.
Oral Anticoagulants
Recommendations for Oral Anticoagulants Management

Referenced studies that support the recommendations are summarized in the Online
Data Supplement.

OAC Management
1. For patients with CVD receiving OAC who require elective
NCS, a multidisciplinary team-based approach to time-
1 B-NR based* interruption is recommended to balance the

competing risks of thromboembolism and perioperative
bleeding (Tables 13 and 14).
*Timing of preoperative interruption is based on patient-specific factors (eg, thrombotic risk,
age, sex, body weight, renal clearance), surgical bleeding risk, and drug factors (eg, pharmacokinetics,
dosing, drug interactions).
78
Oral Anticoagulants (con’t.)
OAC Bridging
2. In patients with CVD and high thrombotic risk (Table 14)
undergoing NCS where interruption of vitamin K antagonist
2a C-LD
(VKA) is required, preoperative bridging with parenteral
heparin can be effective to reduce thromboembolic risk.
3. In most patients with CVD who are undergoing elective NCS

3:
C-LD where OAC interruption is warranted, routine periprocedural
Harm
bridging is not recommended due to increased bleeding risk.
OAC Resumption
4. In patients with preoperative OAC interruption, resumption of
2a C-LD
OAC is reasonable after hemostasis is achieved.
Table 13. Perioperative Management of Direct
Oral Anticoagulants and Vitamin K
Antagonists
Preoperative DOAC Schedule
Procedure Bleeding Preoperative Interruption Surgery/ Postoperative Resumption
Risk Procedure
Day Day Day Day Day Day Day 0 Day Day Day Day
-6 -5 -4 -3 -2 -1 +1 +2 +3 +4
Apixaban, edoxaban, High * * * * † † † † † * *
rivaroxaban Low/Moderate * * * * * † † * * * *
Minimal * * * * * * * * * * *
Apixaban, edoxaban, High * * * † † † † † † * *
rivaroxaban Low/Moderate * * * * † † † * * * *
with renal impairment (CrCl Minimal * * * * * * * * * * *
<30 mL/min)
CrCl indicates
Dabigatran CrCl ≥50 High * * * * † † † † † * * creatinine clearance;
DOAC, direct oral
mL/min Low/Moderate * * * * * † † * * * * anticoagulants; GI,
gastrointestinal; INR,
Minimal * * * * * * * * * * * international
Dabigatran CrCl <50 High * * † † † † † † † * * normalized ratio;
LMWH, low-molecular-
mL/min Low/ * * * * † † † * * * * weight heparin; and
Moderate VKA, vitamin K
agonist.
Minimal * * * * * * * * * * *
80
Oral Anticoagulants and Vitamin K Antagonists
(con’t.)
VKA Schedule
Procedure Bleeding Preoperative Interruption Surgery/ Postoperative Resumption
Risk Procedure
Day Day Day Day Day Day Day 0 Day Day Day Day
-6 -5 -4 -3 -2 -1 +1 +2 +3 +4
High * † † † † † † * * * *
Warfarin in low/moderate Low/ Moderate * † † † † † † * * * *
thrombotic risk Minimal * * * * * * * * * * *
High * † † ‡ ‡ ‡ † * * *# *#
Warfarin in high thrombotic
Low/ Moderate * † † ‡ ‡ ‡ † * *# *# *#
risk
Minimal * * * * * * * * * * *
CrCl indicates creatinine clearance; DOAC, direct oral anticoagulants; GI, gastrointestinal; INR, international normalized ratio; LMWH, low-molecular-weight
heparin; and VKA, vitamin K agonist.
Oral Anticoagulants and Vitamin K Antagonists
(con’t.)
*Administer DOAC or VKA.
†Withhold DOAC or VKA.
‡While withholding VKA in select very high thrombotic risk patients, preoperative bridging with parenteral heparin
once INR less than desired therapeutic range.
#Resuming postoperative LMWH bridge at either full dose or prophylaxis dose until INR within therapeutic range is a
team-based decision that weighs the risks and benefits.
Management for perioperative bleeding risk and DOAC or VKA schedule should incorporate team-based decision-
making, especially in high thrombotic risk patients or when undergoing procedures with higher risks of adverse
outcome, should bleeding occur (eg, neuraxial anesthesia).
Minimal bleeding risk = 30-day risk of major bleeding 0% (eg, cataract surgery, minor dental/dermatological
procedures).
Low/moderate bleeding risk = 30-day risk of major bleeding <2% (eg, complex dental, GI, breast surgery, procedures
using large-bore needles).
High bleeding risk = 30-day risk of major bleeding ≥2%.

82
Table 14. Thromboembolic Risk for
Common OAC Indications
Risk Venous Atrial Fibrillation Mechanical Valve Other
Category Thromboembolism Anticoagulation
Indications
Low VTE >12 mo CHA2DS2-VASc 1-4 Bileaflet mechanical AVR
(without prior history of without major risk factors
stroke) for stroke*
Moderate VTE ≤3-12 mo CHA2DS2-VASc 5-6 Bileaflet mechanical AVR Nonsevere
with major risk factors forcoagulopathy
Recurrent VTE stroke* (heterozygous factor V
Leiden or prothrombin
Mitral valve without major gene G20210A
risk factors for stroke* mutation)
Active cancer
*Major risk factors for stroke include AF, multiple prior strokes/TIAs (>3 months), prior perioperative stroke, or prior valve thrombosis.
AVR indicates aortic valve replacement; LV, left ventricular; MHV, mechanical heart valve; TIA, transient ischemic attack; and VTE, venous
thromboembolism.
Table 14. Thromboembolic Risk for
Common OAC Indications (con’t.)
Risk Venous Atrial Fibrillation Mechanical Valve Other
Category Thromboembolism Anticoagulation
Indications
High Recent VTE (<1 mo or <3 CHA2DS2-VASc ≥7 (or 5- Mechanical mitral valve Recent cardioembolic
mo) 6 with recent stroke or stroke (<3 mo)‡
TIA) Caged ball or tilting-disk
valve Active cancer
AF with rheumatic associated with high
valvular heart disease Mechanical heart valve in VTE risk
any position with recent
stroke or TIA (<3 mo) LV thrombus (within
last 3 mo)
Severe thrombophilia‡
Antiphospholipid
antibodies
‡Deficiency of protein C, protein S, or antithrombin; homozygous factor V Leiden or prothrombin gene G20210A mutation or double heterozygous for
each mutation, multiple thrombophilias.
AVR indicates aortic valve replacement; LV, left ventricular; MHV, mechanical heart valve; TIA, transient ischemic attack; and VTE, venous
thromboembolism.
84
Table 15. Pharmacokinetic Characteristics,
Monitoring, and Reversal of VKA and
DOACs
Warfarin Apixaban Rivaroxaban Edoxaban Dabigatran
Mechanism of
VKORC1 (vitamin Factor Xa Factor Xa inhibitor Factor Xa Factor IIa inhibitor
Action
K-dependent inhibitor inhibitor (direct thrombin
factors) inhibitor)
Bioavailability
>95% 50% 100% (66% 62% 3-7%
without food)
Time to Cmax
2-6 h 3-4 h 2-4 h 1-2 h 1.25-3 h
Plasma Half-Life
36-48 h 9-14 h 6-9 h (11-13 h in 10-14 h 12-15 h
(t1/2)
older persons)
Duration of Action
~5 d (beyond 24 h 24 h 24 h 24 h
normalization of
INR)
ACT indicates activated clotting time; Anti-Xa, assay to measure anticoagulation activity; aPCC, activated prothrombin complex concentrate;
aPTT, activated partial thromboplastin time; CYP, cytochrome; DOAC, direct oral anticoagulant; DTT, diluted thrombin time; ECT, ecarin clotting
time; FFP, fresh frozen plasma; INR, international normalized ratio; PT, prothrombin; and 4F-PCC, 4-factor prothrombin complex concentrate.
Table 15. Pharmacokinetic Characteristics,
Monitoring, and Reversal of VKA and DOACs
(con’t.)0%
Renal Clearance
27% 33% 37-59% 85%
(%)
(partially
dialyzable)
Drug Interaction
CYP p450 3A4, CYP 450 3A4/2J2, CYP 450 3A4 p-glycoprotein
p-glycoprotein p-glycoprotein (<5%), p-
glycoprotein
Altered
PT, aPTT, ACT PT, aPTT, ACT PT, aPTT, aPTT, ACT,
Anticoagulation
Parameters ACT PT/INR, DTT
Monitor for
PT/INR Anti-Xa* Anti-Xa* Anti-Xa* ECT (DOAC)
Presence of Drug
Effect (DOAC) (DOAC) (DOAC)
Antidote/ Reversal
Vitamin K, 4F- 4F-PCC, 4F-PCC, andexanet 4F-PCC, 4F-PCC,
PPC, FFP andexanet alfa alfa andexanet alfa idarucizumab
*Quantitative assessment requires drug-specific calibrators. With no therapeutic levels, use can indicate ongoing drug effect.
ACT indicates activated clotting time; Anti-Xa, assay to measure anticoagulation activity; aPCC, activated prothrombin complex concentrate;
aPTT, activated partial thromboplastin time; CYP, cytochrome; DOAC, direct oral anticoagulant; DTT, diluted thrombin time; ECT, ecarin clotting
time; FFP, fresh frozen plasma; INR, international normalized ratio; PT, prothrombin; and 4F-PCC, 4-factor prothrombin complex concentrate.
86
Perioperative Beta
Blockers
Recommendations for Perioperative Beta Blockers
1. In patients on stable doses of beta blockers undergoing NCS, beta blockers

1 B-NR should be continued through the perioperative period as appropriate based on
the clinical circumstances.
2. In patients scheduled for elective NCS who have a new indication for beta
2b B-NR blockade, beta blockers may be initiated far enough before surgery (optimally >7
days) to permit assessments of tolerability and drug titration if needed.
3. In patients undergoing NCS and with no immediate need for beta blockers, beta
3: Harm B-R blockers should not be initiated on the day of surgery due to increased risk for
postoperative mortality.
Perioperative Management of Blood
Glucose
Recommendations for Perioperative Management of Blood Glucose

1. In patients with or at risk for diabetes who are scheduled for elective NCS,
2a B-NR preoperative hemoglobin A1c (HbA1C) testing is reasonable if it has not
been performed in ≤3 months.
2. In patients scheduled for NCS, SGLT2i should be discontinued 3 to 4 days*

1 C-LD
days before surgery to reduce the risk of perioperative metabolic acidosis.
3. In patients with diabetes or impaired glucose tolerance, continuation of
2a C-LD metformin during the perioperative period is reasonable to maintain
glycemic control.
*Canagliflozin, dapagliflozin, and empagliflozin should be stopped ≥3 days and ertugliflozin ≥4 days before scheduled surgery.
88
Anesthetic Considerations
and Intraoperative
Management
89
Choice of Anesthetic Technique and
Agent
Recommendations for Choice of Anesthetic Technique and Agent
Supplement.
1. In patients undergoing NCS, use of a volatile-based anesthetic agent

or total intravenous anesthesia is reasonable for general anesthesia
2a A with no apparent difference in associated cardiovascular events (eg,
MI, ischemia).
2. In patients undergoing NCS where neuraxial is feasible, either

2a B-R neuraxial or general anesthesia is reasonable with no apparent
difference in associated cardiovascular events.
Perioperative Pain
Management
Recommendations for Perioperative Pain Management
Supplement.

1. For patients undergoing major abdominal surgery, the use of
2a B-R epidural analgesia for postoperative pain relief is reasonable
to decrease the incidence of perioperative cardiac events.
2. For patients with a hip fracture waiting for surgical repair,

2b B-R epidural analgesia may be considered to decrease the
incidence of preoperative cardiac events.
91
Echocardiography
Recommendations for Echocardiography

Supplement.
1. In patients with unexplained hemodynamic instability

undergoing NCS, the emergency use of perioperative TEE or
2a C-LD
FoCUS is reasonable to determine the cause if expertise is
readily available.
2. In patients undergoing NCS without risk factors or procedural

3: No risks for significant hemodynamic compromise, the routine use
C-LD
benefit of intraoperative TEE is not recommended to screen for cardiac
abnormalities or to monitor for myocardial ischemia.
Body
Temperature
Recommendation for Body Temperature
Supplement.

1. In patients with CVD undergoing NCS, maintenance of
2a B-R normothermia is reasonable to avoid perioperative
complications overall.
93
Temporary Mechanical Circulatory
Support
Recommendation for Temporary Mechanical Circulatory Support
1. In patients with acute, severe hemodynamic instability and
cardiopulmonary dysfunction undergoing urgent or emergency NCS,
2b C-LD temporary MCS devices may be used preemptively or as rescue
therapy.
Pulmonary Artery
Catheters
Recommendations for Pulmonary Artery Catheters
1. In patients with CVD undergoing NCS, the use of PA catheterization may
be considered when underlying medical conditions that significantly
2b C-LD affect hemodynamics (eg, decompensated HF, severe valvular disease,

combined shock states, pulmonary HTN) cannot be corrected before
surgery.
3: No 2. In patients with CVD undergoing NCS, routine use of PA catheterization

A
benefit is not recommended to reduce morbidity or mortality.
95
Perioperative Anemia
Management
Recommendations for Perioperative Anemia Management
Supplement.

1. In patients having NCS with expected blood loss, tranexamic
2a A acid is reasonable to reduce intraoperative blood loss, reduce
transfusions, and avoid anemia.
2. In patients with iron deficiency anemia having elective NCS,

iron therapy (either oral or intravenous) administered
2a B-R
preoperatively is reasonable to reduce blood transfusions and
to increase Hgb.
Perioperative Surveillance
and Management of
Myocardial Injury and
Infarction
97
Myocardial Injury After Noncardiac Surgery
Surveillance and Management
Recommendations for Myocardial Injury After Noncardiac Surgery

Supplement.

MINS Surveillance
1. In patients with known CVD, symptoms of CVD, or age ≥65 years
with cardiovascular risk factors undergoing elevated-risk NCS, it
2b B-NR
may be reasonable to measure cTn at 24 and 48 hours after surgery
to identify myocardial injury.
2. In patients undergoing low-risk NCS, routine postoperative

3: No
B-NR screening with cTn levels is not indicated without signs or symptoms
benefit
suggestive of myocardial ischemia or MI.
98
Myocardial Injury After Noncardiac Surgery
Surveillance and Management (con’t.)
MINS Management
1. In patients who develop MINS, especially in those not previously
known to have excess cardiovascular risk, outpatient follow-up is
2a B-NR
reasonable for optimization of cardiovascular risk factors.
2. In patients who develop MINS, antithrombotic therapy may be

2b C-LD considered to reduce thromboembolic events.
Figure 6.
Evaluation of
an Abnormal
Troponin
Obtained for
Postoperative
Surveillance.
in Table 3.
*Presumes a rise and fall of troponin

consistent with acute myocardial injury.
Troponin may be measured using a
conventional fourth-generation or a high- ECG indicates electrocardiogram; GDMT,
sensitivity assay. guideline-directed management and therapy;
MI, myocardial infarction; NCS, noncardiac
†Nonischemic myocardial injury surgery; NSTEMI, non ST-segment-elevation
encompasses pulmonary embolism, myocardial infarction; STEMI, ST-segment-
sepsis, acute decompensated heart elevation myocardial infarction; and URL,
failure, or acute stroke. upper reference limit.
100
Management of Postoperative ST-Segment-Elevation
Myocardial Infarction/Non ST-Segment-Elevation
Myocardial Infarction
Recommendations for Management of Postoperative ST-Segment-Elevation Myocardial Infarction/Non ST-Segment-
Elevation Myocardial Infarction
1. Patients who develop STEMI after NCS should be considered for GDMT, including
1 B-NR consideration of ICA, balancing bleeding and thrombotic risks with the severity of the
clinical presentation.
2. Patients who develop NSTEMI after NCS should receive medical therapy as
1 C-EO recommended for patients with spontaneous MI but after consideration of postoperative
bleeding risks and hemodynamic status.
3. Patients who develop NSTEMI after NCS can be considered for ICA, balancing bleeding
2a C-LD
and thrombotic risks with the severity of clinical presentation.
Abbreviations
Abbreviations Meaning/Phrase
ACEi angiotensin-converting enzyme inhibitors
ACHD adult congenital heart disease
ACS acute coronary syndrome
AF atrial fibrillation
ARB angiotensin receptor blocker
ARR absolute risk reduction
AS aortic stenosis
ASCVD atherosclerotic cardiovascular disease
AV atrioventricular
102
AVR aortic valve replacement
Abbreviations
Abbreviations(con’t.) Meaning/Phrase
BMS bare-metal stent
BNP B-type natriuretic peptide
BP blood pressure
CAD coronary artery disease
CCD chronic coronary disease
CCB calcium channel blocker
CHD congenital heart disease
CIED cardiovascular implantable electronic device
CKD chronic kidney disease
CPET cardiopulmonary exercise testing

Abbreviations
Abbreviations(con’t.) Meaning/Phrase
CT coronary tomography
cTn cardiac troponin
CVD cardiovascular disease
DAPT dual antiplatelet therapy
DASI Duke Activity Status Index
DBP diastolic blood pressure
DOAC direct oral anticoagulants
ECG electrocardiogram
Abbreviations
Abbreviations
(con’t.) Meaning/Phrase
EMI electromagnetic interference
ESU electrosurgery units
FDA Food and Drug Administration, US
FoCUS focused cardiac ultrasound
GDMT guideline-directed management and therapy
GLP-1 glucagon-like polypeptide-1
HbA1c hemoglobin A1c
HCM hypertrophic cardiomyopathy
Hgb hemoglobin
105
HF heart failure
Abbreviations
(con’t.)
HFrEF heart failure with reduced ejection fraction
HTN hypertension
HR hazard ratio
ICA invasive coronary angiography
ICD implantable cardioverter-defibrillator
LDL low-density lipoproteins
LV left ventricular
LVAD left ventricular assist device
LVOT left ventricular outflow tract
LVEF left ventricular ejection fraction
MACE major adverse cardiovascular event

Abbreviations
(con’t.)
MACCE major adverse cardiac and cerebral event
MAP mean arterial pressure
MCS mechanical circulatory support
METs metabolic equivalents
MR mitral regurgitation
MI myocardial infarction
MICA myocardial infarction and cardiac arrest
MINS myocardial injury after noncardiac surgery
MS mitral stenosis
MV mitral valve
107
Abbreviations
(con’t.)
NSQIP National Surgical Quality Improvement Program
NSTEMI non ST-segment elevation myocardial infarction
NT-proBNP N-terminal pro-B-type natriuretic peptide
NYHA New York Heart Association
OAC oral anticoagulant
OR odds ratio
OSA obstructive sleep apnea
PA pulmonary artery
PAH pulmonary arterial hypertension
P2Y12 platelet adenosine diphosphate receptor

Abbreviations
Abbreviations
(con’t.) Meaning/Phrase
PCI percutaneous coronary intervention
POAF perioperative/postoperative atrial fibrillation
QOL quality of life
RAASi renin-angiotensin-aldosterone system inhibitors
RCT randomized controlled trial
RCRI Revised Cardiac Risk Index
RR relative risk
RV right ventricular
SBP systolic blood pressure
SGLT2i Sodium-glucose cotransporter-2 inhibitors

109
STEMI ST-segment elevation myocardial infarction

Abbreviations
(con’t.)
TAVI transcatheter aortic valve implantation
TEA thoracic epidural analgesia
TEE transesophageal echocardiography
TEER transcatheter edge-to-edge repair
TTE transthoracic echocardiogram
VHD valvular heart disease
VKA vitamin K antagonist

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2024

Niti R. Aggarwal, MD, FACC, FASNC Tracy E. Macaulay, PharmD, FACC

1. A stepwise approach to perioperative

4. Team-based care should be

6. Myocardial injury after NCS is a

Time-sensitive Surgery may be delayed up to 3 mo to allow for preoperative evaluation and

Elevated risk† Combined surgical and patient

COR LOE Recommendation

1. In patients with known CVD being considered for NCS, a validated

ACS indicates American College of Surgeons; ASA, American Society of Anesthesiologists;

COR LOE Recommendation

1. In patients undergoing elevated-risk NCS, a structured

Recommendation for Frailty

COR LOE Recommendation

2a B-NR preoperative frailty assessment using a validated tool can be

Deficit Accumulation Index Variable; typically 30-70 Number of deficits/number of

Edmonton Frail Scale 10 items across multiple Sum of scores/17; higher

SPPB Gait speed, chair stands, Maximum 4 points per item,

COR LOE Recommendations

2a B-NR reasonable to measure B-type natriuretic peptide (BNP) or N-Terminal

COR LOE Recommendations

2a B-NR symptoms* of CVD undergoing elevated-risk surgery, a preoperative resting 12-lead

3. For asymptomatic patients undergoing elevated-risk surgeries without known

3: No 4. For asymptomatic patients undergoing low-risk surgical procedures, a routine

COR LOE Recommendations

2. In patients with a known diagnosis of HF with worsening dyspnea or other

3. In asymptomatic and clinically stable patients undergoing NCS, routine

COR LOE Recommendations

1. For patients undergoing elevated-risk NCS with poor or unknown

2. In patients who are at low risk for perioperative cardiovascular

*Poor functional capacity is considered <4 METS or a DASI score of

Exercise stress testing (with Inability to exercise

Recommendations for Coronary Computed Tomography Angiography

COR LOE Recommendations

2b B-NR events based on a validated risk tool, coronary computed tomography

2. In patients who are at low risk for perioperative cardiovascular events,

COR LOE Recommendation

3: No invasive coronary angiography (ICA) is not

║Noninvasive stress testing or CCTA suggestive of Colors correspond to

COR LOE Recommendations

2. In patients with CCD and hemodynamically significant left main coronary

2. In patients undergoing elective elevated-risk surgery who have cardiovascular

†Modified from the “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA High Blood Pressure Guideline.”

3. In patients undergoing NCS, maintaining an intraoperative mean

5. In patients with HTN undergoing NCS, it is recommended that

COR LOE Recommendations

2. In patients with compensated HF undergoing NCS, it is reasonable

Recommendation for Hypertrophic Cardiomyopathy

COR LOE Recommendation

3-Harm C-LD outflow obstructions (eg, positive inotropic agents,

Recommendations for Pulmonary Hypertension

COR LOE Recommendation

*Modified from the “2018 AHA/ACC Guideline for Management of

Risk Anatomy Functional/Hemodynamic Status

Clarify prior procedures, residua, sequelae, and current functional status

Poor functional capacity

Intermediate- to high-risk CHD lesions

Operations of the respiratory and nervous systems

Prevention of venous thrombosis