Noncardiac Surgery: AHA/ACC Reaffirm 2024 Cardiovascular Guidance

The American Heart Association (AHA), American College of Cardiology (ACC), and 7 collaborating organizations have reaffirmed, without changes, their guideline on perioperative cardiovascular evaluation and management of adults undergoing noncardiac surgery. The guideline was originally approved in 2024 and superseded the 2014 ACC/AHA guideline; following a Surveillance Committee review in February 2026 that found no new evidence warranting revision, it was reaffirmed in March 2026 with recommendations, text, figures, tables, and references identical to the 2024 publication. It appears in the Journal of the American College of Cardiology (Vol. 88, No. 13, 2026).

The guideline covers patients aged 18 years or older from preoperative evaluation through postoperative care. It emphasizes risk assessment, functional status evaluation, appropriate use of cardiovascular testing and screening, and management of cardiovascular conditions. The guideline drew on a literature search conducted from August 2022 to March 2023.

Among its key messages, the guideline describes a stepwise approach to perioperative cardiac assessment to help determine when surgery should proceed or when a pause for further evaluation is warranted. According to the guideline, cardiovascular screening and treatment should follow the same indications as for nonsurgical patients, timed to avoid surgical delays, overscreening, and overtreatment. The authors state that stress testing should be used judiciously, particularly in lower-risk patients, and only when it would be appropriate independent of planned surgery.

The guideline notes that newer therapies for diabetes, heart failure, and obesity have significant perioperative implications. It recommends discontinuing sodium-glucose cotransporter 2 inhibitors 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis. Perioperative bridging of oral anticoagulation is recommended selectively for patients at highest thrombotic risk and not in most cases.

The authors describe myocardial injury after noncardiac surgery as a newly identified disease process with real consequences for patients. They also report that newly diagnosed atrial fibrillation identified during or after surgery carries increased stroke risk and warrants close follow-up. Emergency focused cardiac ultrasound may be used for unexplained hemodynamic instability when expertise is available, but the guideline states it should not replace comprehensive transthoracic echocardiography.

Source: Thompson A, Fleischmann KE, Smilowitz NR, et al. 2026 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. J Am Coll Cardiol. 2026;88(13):1543-1643. doi:10.1016/j.jacc.2026.06.017