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

Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.

Management, in accordance with guideline recommendations, is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities.

The AHA/ACC Joint Committee on Clinical Practice Guidelines (Joint Committee) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the National Academy of Medicine (formerly the Institute of Medicine),^1,2 and on the basis of internal reevaluation. Similarly, presentation and delivery of guidelines are reevaluated and modified in response to evolving technologies and other factors to optimally facilitate dissemination of information to health care professionals at the point of care.

Numerous modifications to the guidelines have been implemented to make them shorter and enhance “user friendliness.” Guidelines are written and presented in a modular recommendation format in which each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided for each modular knowledge chunk to facilitate quick access and review.

In recognition of the importance of cost–value considerations, in certain guidelines, when appropriate and feasible, an assessment of value for a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology.³

To ensure that guideline recommendations remain current, new data will be reviewed on an ongoing basis by the writing committee and staff. When applicable, recommendations will be updated with new evidence, or new recommendations will be created when supported by published evidence-based data. Going forward, targeted sections/knowledge chunks will be revised dynamically after publication and timely peer review of potentially practice-changing science. The previous designations of “full revision” and “focused update” will be phased out. For additional information and policies on guideline development, readers may consult the ACC/AHA guideline methodology manual⁴ and other methodology articles.^5–7

The Joint Committee strives to ensure that the guideline writing committee contains requisite content expertise and is representative of the broader cardiovascular community by selection of experts across a spectrum of backgrounds, representing different geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and clinical practice settings. Organizations and professional societies with related interests and expertise are invited to participate as collaborators.

The ACC and AHA have rigorous policies and methods to ensure that documents are developed without bias or improper influence. The complete policy on relationships with industry and other entities (RWIs) can be found online. Appendix 1 of the guideline lists writing committee members’ comprehensive and relevant RWIs.

In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.^4,5 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited.

An independent evidence review committee is commissioned when there are ≥1 questions deemed of utmost clinical importance and merit formal systematic review to determine which patients are most likely to benefit from a drug, device, or treatment strategy, and to what degree. Criteria for commissioning an evidence review committee and formal systematic review include absence of a current authoritative systematic review, feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, relevance to a substantial number of patients, and likelihood that the findings can be translated into actionable recommendations. Evidence review committee members may include methodologists, epidemiologists, clinicians, and biostatisticians. Recommendations developed by the writing committee on the basis of the systematic review are marked “^SR.”

The term guideline-directed management and therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and evaluate for contraindications and interactions. Recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.

The recommendations listed in this guideline are, whenever possible, evidence based. An initial extensive evidence review—which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline—was conducted from August 2022 to March 2023. Key search words included but were not limited to the following: ACC/AHA clinical practice guideline; anesthesia, general; anesthetics; anesthetics, inhalation; anesthetics, intravenous; bariatric surgery; cardiac assessment; cardiac evaluation; cardiac preoperative evaluation; cardiac protection; cardiovascular risk prediction; cardiovascular risk score; death; death, sudden, cardiac; elective surgical procedures; evaluation; heart function tests; hospital mortality; intraoperative period; intraoperative complications; lifestyle; major adverse cardiovascular events; myocardial injury time factors; myocardial protection; noncardiac surgery; outcome assessment, health care; patient care team; perioperative; perioperative cardiovascular risk; periprocedural; perioperative assessment; perioperative management; perioperative medicine; perioperative nursing; perioperative period; postoperative complications; predictive value of tests; preoperative care; preoperative stress testing; quality of life; risk assessment; risk, cardiac; risk factors; surgical procedures, operative; treatment outcome.

Additional relevant studies, which were published through November 2023 during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables are included in the Online Data Supplement and summarize the evidence used by the writing committee to formulate recommendations. References selected and published in the present document are representative and not all-inclusive.

The writing committee consisted of anesthesiologists, general cardiologists, interventional cardiologists, electrophysiologists, heart failure cardiologists, cardiac imaging experts, critical care physicians, internists, internal medicine hospitalists, general surgeons, family practitioners, advance practice nurses, clinical pharmacists, health economists, and patient advocates. The writing committee included representatives from the AHA, ACC, 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. Appendix 1 of the current document lists writing committee members’ comprehensive and relevant RWIs.

The Joint Committee appointed a peer review committee to review the document. The peer review committee comprised individuals nominated by the ACC, AHA, and the collaborating organizations. Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC and the AHA and was 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.

The focus of this clinical practice guideline is the perioperative cardiovascular evaluation and management of the adult patient (≥18 years of age) being considered for noncardiac surgery (NCS). This guideline addresses the time spanning from preoperative evaluation through postoperative care and emphasizes risk assessment, evaluation of functional status, appropriate use of cardiovascular testing and screening, and management of cardiovascular conditions and risks. Also addressed are evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for CVD and associated medical conditions.

This guideline is intended to inform all clinicians involved in the care of patients being considered for NCS. Preoperative evaluation encompasses the assessment of perioperative risk and determination of the need for additional cardiovascular testing through exercise, imaging, or biomarker assessment. Although the primary goal of the evaluation should be evaluation and reduction of a patient’s immediate surgical risk, follow-up is warranted throughout and beyond the surgical period, when modifiable cardiovascular risk is identified. The preoperative cardiovascular evaluation begins with a focused history and physical examination and a careful review of a patient’s medical history. This assessment informs perioperative care and can be used to implement changes in management and therapy. Through a patient-centered, team-based approach, management changes could be made to medical therapy, lifestyle modifications, interventional treatment, and perioperative monitoring. Additional management strategies may include modifications of the surgical technique or procedure, identification of the appropriate surgery location (ambulatory surgery center, outpatient surgery, or inpatient surgery), and optimal disposition and monitoring of the patient after surgery and upon discharge from the hospital. At times, the best decision from a team-based, patient-centered approach might be to pursue noninvasive or palliative strategies.

The guideline is developed to assist clinicians in applying an evidence-based, expert-informed approach to the perioperative cardiovascular management of patients being considered for NCS. This optimally occurs when there is communication between all relevant parties: surgeon, anesthesiologist, intensivist, primary clinician, and consultants, and especially the patient. The overarching goal of perioperative evaluation and management is to encourage patient engagement and facilitate shared decision-making through clear and understandable communication of information regarding perioperative cardiovascular risk and recommendations for risk mitigation and management. This guideline is primarily, but not exclusively, focused on the perioperative management of patients referred for elevated-risk NCS. Little evidence exists to support extensive preoperative testing in patients planned for low-risk surgeries, and care is rarely improved by additional cardiovascular testing. This is particularly true for very low-risk procedures, including cataract and other ophthalmology surgeries, dental procedures, endoscopic procedures, and skin biopsies. Surgical procedures that are low risk but require general anesthesia may require additional preoperative consideration given the hemodynamic effects of anesthesia.

In developing this guideline, the writing committee reviewed previously published guidelines and related scientific statements. Table 1 contains a list of publications deemed pertinent to this writing effort and is intended for use as a resource, obviating the need to repeat existing guideline recommendations, some of which have been carried forward from previously published guidelines. If unchanged, those recommendations remain current. Any changes to the formatting or content of these recommendations are defined as:

Changes are depicted in a footnote below the recommendation tables. Clinicians should be advised that this guideline supersedes the previously published “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”²¹

In describing the temporal necessity of operations within this guideline, we have developed the definitions in Table 2 by writing committee consensus. Elevated risk encompasses intermediate or high surgical risk and is generally defined as a ≥1% risk of a major adverse cardiovascular event (MACE); however, due to varying populations, risk criteria, and endpoints, there is significant variability in the reporting of predicted risk of cardiovascular complications among the available risk-prediction tools (Section 3.1, “Cardiovascular Risk Indices”).^1,2 Although many risk scores exist, data are lacking to support the use of one risk index over another.

NCS can be classified by the risk of major adverse cardiac and cerebral event (MACCE) associated with each surgery. Risk calculator criteria (Section 3.1, “Cardiovascular Risk Indices”) frequently include the type and location of surgery. Suprainguinal vascular, thoracic, transplant, and neurosurgery operations are associated with the highest risk of MACCE. General, otolaryngology, genitourinary, and orthopedic surgery are considered intermediate risk, and endocrine, breast, gynecology, and obstetrics are considered to have the lowest risk of MACCE. This list does not include the breadth of surgical procedures or account for changes in surgical approach and should therefore only be used as a guide.³ Additionally, patient comorbidities may also affect the risk of MACCE, and the risk associated with anesthesia in patients with comorbid disease may not be completely captured when solely considering surgery type. Changes in surgical approach can reduce the risk of MACE in some surgeries. For instance, an aortic aneurysm repair has a lower risk of MACE when performed using endovascular techniques rather than an open repair.⁴ The timing of surgery also affects risks, with emergency surgeries generally associated with a higher risk of MACCE than elective surgeries.

The COR indicates the strength of recommendation and encompasses the estimated magnitude and certainty of benefit in proportion to risk. The LOE is a measure of the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 3).¹

Multidisciplinary care models are increasingly used to manage complex conditions and care pathways in perioperative medicine. Team-based care models in the perioperative setting span the pre-, intra-, and posthospital phases of care and are important parts of the care delivery system, providing efficiency of care, ability to improve broad clinical outcomes, and alignment with patient-centered care goals, such as recovery at home. Few data exist demonstrating that interdisciplinary models improve perioperative cardiac care quality or outcomes, but they provide the framework that is critical to meaningful quality and outcome improvements. These models are often described as “pathways” that standardize perioperative cardiac care practices and accelerate the coordination of recovery activities (eg, early mobilization and feeding, use of opioid-sparing pain regimens, deep venous thrombosis prophylaxis). Although there are concerns about patients leaving the hospital after a shorter inpatient stay, these concerns have largely been offset by focusing on improved pain control and earlier rehabilitation and recovery.^1–9 Few data from these meta-analyses support whether standardized protocols or enhanced recovery pathways specifically reduce the risk for cardiovascular complications of surgery, GDMT, or use of preoperative cardiac testing.^1–10 In the contemporary era, screening and preoperative planning is often conducted by phone or video visits, with trends accelerated during the coronavirus disease-2019 pandemic.^10–13 Similar to the results for enhanced recovery pathways, substantial evidence supports the use of remote visits/televisits to lower rates of case cancellation and improve patient satisfaction, although the impact of remote visits on cardiovascular outcomes, guideline-concordant preoperative testing practices, or how remote preoperative consultations might be used to coordinate specialty care for higher risk patients has not been reported.^{2–4,6–9,14–20} The role of telemedicine, remote monitoring (gathering patient weights, oxygen saturation, or physical activity data remotely), and mobile (“m-health”) interventions in managing chronic illnesses such as heart failure (HF) is increasingly described.²¹ The evidence base for similar models for the postoperative care of patients undergoing NCS is still early in its development.^22–30 Available evidence supports the benefit to readmission and patient satisfaction with use of these approaches.^4,28,31–36

The World Health Organization defines quality of life (QOL) as “an individual's perception of their position in life in the context of the culture and value systems in which they live and about their goals, expectations, standards and concerns.”¹ Assessment of QOL may improve patient experiences and outcomes of health care procedures and treatments. Patient-reported outcome measures can be used to survey patients’ health-related QOL. Instruments specific to the therapeutic area may be more sensitive than those that are generic.^2,3 Although questionnaires are commonly employed, listening to patients and inquiring about their priorities is extremely important to tailor care to their unique needs. Because surgery confers risks of complications, especially for high-risk patients with existing CVD, discussing patients’ goals and priorities with respect to QOL may guide perioperative planning.⁴ In the last decades, a few groups have assessed interventions that might impact perioperative QOL.^5,6 Unfortunately, solid evidence is still lacking to formulate actionable recommendations aimed at improving QOL in patients undergoing NCS. Although long-term benefits on QOL from an NCS may outweigh short-term cardiac risks for some patients, this ratio is unevenly balanced in the literature. Greater patient satisfaction has been associated with perioperative assessment that involves shared decision-making.⁷

Preoperative cardiovascular risk assessment can help estimate the likelihood of perioperative adverse outcomes. Several risk indices have been developed based on multivariable analyses of large observational data and have been validated in large datasets (Table 4). Commonly used cardiovascular risk scores include the RCRI,² the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) perioperative MI and cardiac arrest (MICA) risk calculator,⁵ and the universal American College of Surgeons NSQIP surgical risk calculator.³ Risk calculators can be used in addition or as an alternative to the assessment of separately discussed surgery-related (eg, anesthesia type, surgery type) and patient-related (eg, physical activity, physical examination) risk factors. Combined, there is significant variability in the predicted risk of cardiovascular complications using different risk-prediction tools.^1,6 Evaluated endpoints were not consistent in all risk scores (Table 4). Although many risk scores exist, data are lacking to support the use of one risk index over another, and research is underway to further refine perioperative risk. For example, a recently published study has shown that perioperative risk stratification may be enhanced by combining traditional risk indices with estimates of coronary calcium burden from existing, nongated chest computed tomography (CT) imaging in the year before NCS.⁴ Differences in surgical populations may also affect risk prediction. Risk scores have poorer discrimination in patients undergoing vascular surgery, likely due to the underestimation of the risk of MI.^7–9 Despite their reasonable ability to predict perioperative risk of MACE, there have been few studies in which perioperative treatment strategies were modified based on preoperative risk prediction tools; future studies are needed to inform this practice.

Functional capacity is an important predictor of risk of adverse cardiovascular events after NCS.^1–9 It is usually measured in metabolic equivalents (METs) of task, with 4 METs considered the threshold for poor functional capacity. Functional capacity is commonly assessed by asking patients if they can climb 2 flights of stairs (an activity associated with >4 METs) or by using a patient-reported instrument such as the DASI (Table 5), a semiquantitative tool to assess functional capacity based on patients’ reported ability to perform a set of 12 daily activities.⁶ In selected cases, exercise stress testing (Section 4.3, “Stress Testing”) can provide an objective assessment of functional capacity. Patients with poor functional capacity are at increased risk of cardiac events post surgery. Assessments of functional capacity can be used to identify patients who may warrant additional preoperative cardiovascular risk stratification before surgery. In most cases, functional, asymptomatic patients may proceed with planned NCS without further cardiovascular testing.

Older patients undergoing NCS are at increased risk for numerous cardiac and noncardiac complications, including myocardial injury and infarction, atrial fibrillation (AF), acute kidney injury, and delirium. Frailty is a syndrome characterized by physiological declines across multiple organ systems that result in increased vulnerability to stressors. It is an independent risk factor for adverse outcomes after NCS across the age spectrum, including cardiac complications, infections, bleeding, falls, functional decline, increased length of stay, and mortality.^1,3,4 In a systematic review of 21 studies, the weighted prevalence of frailty was 10.7% among community-dwelling individuals ≥65 years of age.⁶ That rate exceeds 25% among community-dwelling adults ≥85 years of age. Women have an almost 2-fold higher prevalence of frailty than men,⁶ and the rates are markedly higher among older patients with HF (>40%).^7,8 A formal diagnosis of frailty using a validated screen instrument (Table 6) may impact perioperative management and inform benefit-risk discussions with patients and their families.^2,9 Emerging evidence suggests that prehabilitation (ie, physical conditioning, nutritional support, or both) before NCS may be associated with improved outcomes in selected patients with frailty.^10,11

cTn and BNP are inexpensive and widely available biomarkers that can detect and quantify myocardial injury and cardiac wall stress, respectively. Several large prospective studies have demonstrated that both biomarkers have high prognostic value and excellent negative predictive value for perioperative cardiac complications. To date, there have been no studies in patients with elevated preoperative biomarkers to recommend management that improves perioperative cardiovascular outcomes. The utility of preoperative biomarkers in low-risk patients has not been evaluated. Biomarker measurement poses the potential for increased risk via downstream tests predicated on the resulting value. For cost–value consideration, please refer to Section 11.1.1 (“Cost–Value Considerations for Biomarkers”).

The resting 12-lead ECG may contain important prognostic information related to short- and long-term morbidity and mortality among patients with coronary heart disease undergoing NCS.¹ However, it rarely adds prognostic information beyond what can be determined with risk assessment tools. For clarification of low-, intermediate-, or high-risk surgery and associated risk assessment tools, please refer to Section 1.5 (“Definitions of Surgical Timing and Risk”) and Section 3 (“Risk Calculators”) of this guideline. For cost–value consideration, please refer to Section 11.1.2 (“Cost–Value Considerations for 12-Lead ECG”).

The presence of reversible myocardial ischemia on a preoperative stress test is associated with increased risk for perioperative cardiac events.¹ However, the positive predictive value of an abnormal test is modest, and it is not clear that an abnormal test provides incremental prognostic value beyond standard risk assessment tools (eg, RCRI) or biomarkers (eg, natriuretic peptides).^1,4–11 Testing is also expensive and may lead to unnecessary downstream testing or delays in performing the indicated surgery.¹² Moreover, preoperative revascularization has not been shown to reduce perioperative MACE or cardiac mortality, and there is high potential for overtesting and overtreatment unless further perioperative testing is limited to patients in whom high-risk coronary lesions are likely.^3,13,14 Therefore, the goal of preoperative testing for ischemia is not to identify undiagnosed CAD but to identify patients for whom revascularization is believed to improve clinical outcomes, specifically those with left main disease or severe multivessel disease with a reduced LVEF.¹³ These patients have been excluded from studies of preoperative revascularization, and the utility of revascularization in this context is unknown. Thus, in select patients in whom high-risk ischemia is suspected based on symptoms or other factors, stress testing may be useful for risk stratification and to guide management.^1,15,16 However, an abnormal stress test should not prompt coronary angiography or revascularization unless the study has high-risk features.^7,8,11,17 For cost–value consideration, please refer to Section 11.1.4 (“Cost–Value Considerations for Stress Testing”).

In high-risk patients undergoing elevated-risk procedures in whom objective functional capacity is reduced and where additional physiological data are needed to inform perioperative care or guide preoperative optimization, CPET may be beneficial for risk assessment of perioperative morbidity and mortality.^1,2 Reduced cardiorespiratory fitness increases the risk of postoperative complications.³ CPET is the gold-standard assessment of the physiological response to exercise, providing an objective measure of functional capacity.⁴ CPET can be used to diagnose the etiology of exercise intolerance (cardiac versus pulmonary pathology), guide preoperative optimization, and inform prehabilitation.⁴ CPET predicts all-cause morbidity, which is more common than cardiovascular complications alone,⁵ and supports risk prediction in major abdominal, vascular, bariatric, and thoracic surgery, although the definitions of morbidity differ across studies.^1,4 Most studies in perioperative CPET are retrospective and single center and vary in predictive precision.^6,7 The thresholds for identifying high-risk patients also vary between cohorts and surgical procedures. Over time, the risk threshold for reported indices has fallen (eg, the anaerobic threshold decreased from 11 to 9-10 mL/min/kg), reflecting an evolution in surgical and perioperative practice.⁸ Alternative measures of functional capacity exist (eg, 6-minute-walk-test) that are also used in risk prediction.⁹ These have the advantage of being easier to perform than CPET, without the need for specialized equipment. CPET and the 6-minute-walk-test demonstrate variable correlation, possibly reflecting the need for both tests to be conducted in a standardized manner by trained personnel.⁹ Consensus guidance has been released on the indications, organization, conduct, and reporting of perioperative CPET.⁴ Additional physiological data beyond the 6-minute-walk-test are provided by CPET that may support its use in high-risk patients with objectively reduced functional capacity undergoing elevated-risk procedures.

In patients with acute chest pain and no known CAD, CCTA may be useful to exclude atherosclerotic plaque and obstructive CAD and is recommended as an alternative to invasive angiography.⁶ However, the role of CCTA in the perioperative setting before NCS is less well established. A positive CCTA has a low predictive value (ie, overestimates the risk for perioperative MACE), thereby possibly contributing to delays in surgery and potential harm.¹ Furthermore, there is no demonstrable benefit of prophylactic coronary revascularization to mitigate the risk of MACE in stable patients undergoing NCS.⁵ As a result, routine preoperative risk assessment with CCTA is not recommended. Further, if a patient has a prior coronary artery calcium score of 0 within 2 years, proceeding to surgery without additional testing would be reasonable. CCTA may be considered in select patients with elevated risk or to exclude high-risk coronary anatomy in patients undergoing elevated-risk surgery.⁶ Although CCTA is a cost-effective strategy for evaluating patients with chest pain compared with stress testing, the cost analysis has not been evaluated in stable patients undergoing NCS.⁷ Studies using CT-based vulnerable plaque characteristics or CT perfusion imaging are currently limited to nonsurgical literature, and their role in perioperative risk assessment are not well established. CCTA is contraindicated and may be harmful in patients who require urgent or emergency surgery, as the need and urgent timing for surgery outweighs any benefit that might be obtained by performing a CCTA and delaying surgery.¹ For cost–value consideration, please refer to Section 11.1.3 (“Cost–Value Considerations for Coronary Computed Tomography Angiography”).

ICA is used to define epicardial coronary artery anatomy, diagnose atherosclerotic CAD, and assess the location, extent, and severity of obstructive coronary stenoses. ICA is necessary to determine the feasibility and necessity of percutaneous or surgical revascularization.³ Preoperative ICA may be performed in selected patients to detect coronary stenoses that pose significant risks in the perioperative period. Data are insufficient to recommend routine coronary angiography in patients scheduled for NCS, including those undergoing elevated-risk surgery or pretransplant evaluation.⁴ Even in patients undergoing vascular surgery, independent of preoperative risk, ICA is not consistently associated with improved early postoperative clinical outcomes.^1,2,5

Figure 1 represents a suggested framework for perioperative risk stratification and management that incorporates best practices and recommendations described throughout this guideline. Recommendations are supported by various levels of evidence. Clinical outcomes of perioperative care guided by this algorithm have not been prospectively studied or validated and therefore should not replace clinical judgment and individualized clinical care.

CAD is prevalent in approximately 18% of patients undergoing major NCS,¹ is associated with increased risk of perioperative MACE, and is a common element in preoperative risk estimation.^2–6 The location, extent, and severity of atherosclerotic CAD informs perioperative risks, and a history of an ACS confers greater perioperative risks than chronic coronary disease (CCD) does. Among >3500 patients included in the RCRI derivation and validation cohorts, a history of MI was associated with a 3.5-fold increased risk of perioperative MACE.⁴

Patients with CAD treated with coronary stents also have increased risk of MACE.³ In a retrospective cohort of approximately 28 000 patients undergoing NCS, the odds of perioperative MACE was 2-fold higher in patients with coronary stents placed in the prior 2 years compared with matched controls without stents.⁷ The risks of MACE are inversely proportional to the time interval between coronary revascularization and NCS (Section 6.1.1, “Coronary Revascularization”).⁸ Careful attention to optimal medical management for ASCVD is important before elective NCS in patients with CAD.⁹ The perioperative diagnostic evaluation and management of patients with a history of CAD undergoing NCS is outlined in Section 3 through Section 7.

Perioperative hypertension affects an estimated 25% of patients who undergo major NCS and is a leading cause for postponement of elective surgery.¹³ Uncontrolled hypertension contributes to increased myocardial demand via elevated LV end-diastolic pressure, leading to subendocardial myocardial ischemia. In the perioperative period, uncontrolled hypertension increases the risk of CVD, cerebrovascular events, and bleeding.^14,15 Evidence from large cohort studies indicates that intraoperative^6,8,16,17 and postoperative^6,17 hypotension also increases the risk for adverse cardiovascular and renal outcomes and death. There are comparatively fewer data that attribute the risk to intraoperative hypertension^5,16 and intraoperative BP variability.¹⁸ However, no high-quality RCTs have shown that acute lowering of perioperative BP reduces rates of cardiovascular events or mortality and, in fact, may be harmful.¹⁹ The most appropriate approaches to BP assessment (systolic,^2,5,6,20 diastolic,^2,5,21,22 mean,^4,5,10,23 or pulse pressure²⁴), thresholds (absolute^{2,4–6,10,20} or relative^4,25), and frequency of measurement²⁶ to guide care have not been established.²⁷ In addition to baseline BP, an assessment of total cardiovascular risk, age, clinical comorbidities, surgery type, anesthetic approach, and short-term risk of complications should be considered when individualizing perioperative BP management.

Patients with HF are at increased risk for perioperative complications.^9,10 In a study of 38 047 patients with nonischemic HF, ischemic HF, CAD, or AF, the crude 30-day postoperative mortality was significantly higher in patients with nonischemic HF (9.3%) or ischemic HF (9.2%) compared with patients with CAD (2.9%), suggesting that patients with HF have a 3-fold greater risk for perioperative death than those with CAD alone.¹¹ In addition, patients with active HF symptoms or signs are at higher risk for adverse outcomes than those with compensated HF or history of HF.⁹ In another study of patients undergoing NCS, those with an HF diagnosis (n=47 997) had 67% higher adjusted odds of 90-day mortality compared with those without HF (n=561 738), and lower LVEF was associated with higher 90-day mortality (Table 8).¹⁰ Accordingly, history of HF has been integrated into both the RCRI and NSQIP preoperative risk assessment indices.

There are established guideline-directed therapies for all forms of HF,¹² and there is evidence that optimizing HF treatment before elevated-risk surgery is associated with reduced risk for perioperative complications.¹⁰ Moreover, interruption or discontinuation of HF GDMT without a specific indication to do so is associated with increased mortality.^4–7,13 However, SGLT2i have been associated with increased risk for metabolic acidosis in the perioperative period and should be withheld for 3 to 4 days before surgery when feasible.^1–3,14 In patients with advanced HF (New York Heart Association [NYHA] class III-IV) who are clinically decompensated or hemodynamically unstable, consideration should be given to postponing elective surgery and obtaining cardiology consultation to assist with perioperative management.

For the complete set of recommendations and specific definitions for disease severity, please refer to the “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.”¹

AF is the most common arrhythmia, with an estimated prevalence of undiagnosed AF in 2009 of approximately 13% of the US population.^13,14 Patients with preexisting AF undergoing NCS have higher risks of all-cause mortality, HF, and ischemic stroke within 30 days of surgery than patients without preexisting AF.¹⁵ If hemodynamically stable, patients with AF who are planned for NCS generally do not require any changes in medical management other than interruption of oral anticoagulation (OAC) (Section 7.6, “Oral Anticoagulation”).¹⁶ According to the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation,” patients with preoperative AF and poor rate control should have medical management optimized before surgery.¹² New-onset perioperative/postoperative AF (POAF) in the setting of NCS is also common, with an incidence that varies widely depending on the type of surgery and patient population.^17,18 POAF can be asymptomatic or can lead to hemodynamic instability. Management of new-onset POAF requires identifying and treating known triggers (eg, pain, sepsis, anemia) and consideration of rate and/or rhythm control strategies to optimize patient hemodynamics. POAF is associated with increased risk of short- and long-term stroke and mortality, and anticoagulation should be considered to reduce thromboembolic risks.^5,18,19 Patients with paroxysmal POAF have a high risk of recurrent AF after discharge. Future studies are needed to address optimal surveillance and long-term management of POAF after NCS.²⁰ For additional information on AF and associated recommendations, please refer to the 2023 ACC/AHA/ACCP/HRS AF guideline.¹²

A CIED may be identified by history and physical examination, review of records, and chest radiography. The closer the electrosurgery unit (ESU) is to the pulse generator or leads of the CIED, the more likely EMI will occur.⁹ The risk of EMI dissipates with distance away from the CIED.⁹ An ESU below the umbilicus is unlikely to cause EMI with transvenous devices.^2,13,14 Failure to identify a CIED can lead to adverse outcomes from EMI, inhibition of pacing, inappropriate tachycardia detection, inappropriate shocks, and damage to the device.^1,2 Use of intermittent, irregular bursts of monopolar ESU at the lowest feasible energy can limit EMI. Bipolar ESU and ultrasonic scalpels are unlikely to cause EMI.¹⁴ Even if EMI is not anticipated, there may be circumstances when patient movement from an CIED shock is undesirable, such as during intracranial, intraspinal, or intraocular surgeries. EMI may obscure pacing spikes and QRS complexes on the ECG. Magnets should not be relied on without preoperative confirmation of their effects on CIEDs.¹ Some devices have programmable magnet responses that have effects other than forcing asynchronous pacing. It is important to ensure the CIED is functioning properly before surgery.¹⁵ Patients with CIED frequently have cardiac diseases that are equally important to evaluate, such as arrhythmias, structural or congenital heart disease, ischemic and nonischemic cardiomyopathies, and HF. For emergencies with anticipated EMI, a magnet should be used, and the CIED type, manufacturer, and programmed parameters should be identified as soon as possible. A magnet will not force asynchronous pacing in an ICD.

Patients with prior stroke or transient ischemic attack are at higher perioperative risk of a recurrent stroke or worsening of neurological deficits.³ This increased risk appears to diminish over time, with reduction of inflammation, decreased hemorrhage risk, and reestablishment of cerebral autoregulation.⁴ However, there is limited observational evidence that determines the optimal time interval to delay elective NCS after a stroke. Prior studies compared elective noncardiac surgical patients with and without prior stroke, rather than prior stroke with and without NCS; patients with prior stroke have a baseline 5-year risk of recurrence of 12%.⁵ For management of stroke risk, please refer to the 2021 AHA/ASA stroke prevention guideline.⁵

The pathophysiology of OSA is complex, multifactorial, and associated with several cardiovascular complications, including hypertension, AF, HF, CAD, stroke, PH, metabolic syndrome, diabetes, and cardiovascular mortality.^4,5 Approximately 34% of men and 17% of women between the ages of 40 and 60 years meet the diagnostic criteria for OSA.⁴ In a recent meta-analysis of 22 studies evaluating outcomes of NCS in patients with (n=184 968) and without OSA (n=2 848 846),⁶ a preoperative diagnosis of OSA was associated with an increased incidence of a composite of postoperative cardiac and cerebrovascular complications. In comparison to patients without OSA, patients with OSA had a 2.5-fold greater risk of developing postoperative pulmonary complications. A diagnosis of OSA was also associated with an increased incidence of perioperative MI and AF but not HF. In a separate meta-analysis of 46 studies, OSA was associated with risks of postoperative pulmonary complications and cardiac complications that increased with greater OSA severity. Specifically, OSA was associated with an increased incidence of MI, AF, and HF but not an increased incidence of stroke.⁷ Among patients with a diagnosis of OSA who require the use of noninvasive positive airway pressure ventilation before surgery, positive airway pressure should be restarted postoperatively as early as possible.^8–10 In patients with OSA undergoing NCS, regional anesthesia is reasonable to reduce the use of systemic opioids, sedatives, and the risk of pulmonary complications.^2,10

The use of long-term lipid-lowering therapies for primary and secondary prevention of atherosclerotic cardiovascular events is well established. Hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) reduce atherogenic low-density lipoprotein-cholesterol, confer pleiotropic anti-inflammatory effects, and may confer benefits to patients in the perioperative period and beyond. Multiple small RCTs, observational cohorts, and meta-analyses demonstrate that perioperative statin use is safe and may reduce cardiovascular outcomes, particularly in patients undergoing major vascular surgery. However, the benefit of routine preoperative administration of statins remains uncertain in patients undergoing nonvascular surgery, as compelling observational data and meta-analyses are counterbalanced by a small but more scientifically rigorous RCT in which statin use did not confer benefit.^2,3,6–10 The LOAD (Lowering the Risk of Operative Complications using Atorvastatin Loading Dose) trial, the largest RCT to date, randomly assigned 648 statin-naïve patients to atorvastatin 80 mg loading (within 18 hours preoperatively) followed by 40 mg daily for 7 days versus placebo and evaluated the composite of all-cause mortality, nonfatal MI, and stroke at 30 days.¹⁰ There was no difference in short-term perioperative MACE; long-term benefits of therapy were not evaluated in this study. Future large RCTs are needed to elucidate the role of perioperative statin initiation on outcomes in lower-risk patients or procedures, as well as the ideal timing and dosing regimens (eg, reloading), before routine statin initiation can be recommended. Of note, the measurement of low-density lipoprotein-cholesterol concentrations to guide initiation of statin therapy in patients with appropriate indications, should not delay surgery; however, the NCS setting is an excellent opportunity to initiate therapies with the objective to improve long-term outcomes.

ACEi and ARBs are widely used for their antihypertensive and cardiac benefits; therefore, the safety and efficacy of the perioperative use of RAASi is of importance. RCTs comparing omission to continuation of RAASi have enrolled a variety of low- to intermediate-risk patients undergoing major NCS. In these studies, intraoperative hypotension (MAP <60 mm Hg) occurred more commonly when these agents were continued; however, continuation compared with omission did not result in worse clinical outcomes (eg, myocardial injury after NCS [MINS]). Of note, patients with high (SBP >160 mm Hg) or low (SBP <105 mm Hg) BP are often excluded from RCTs, and there has been limited enrollment of high-risk patients including those with HFrEF. No data currently exist regarding the perioperative role (harm or benefit) of the angiotensin receptor/neprilysin inhibitor, sacubitril/valsartan. Given the important role of RAASi in preventing MI, stroke, HF, and decline in kidney function, larger RCTs are still needed before recommending routine interruption of RAASi in all patients before planned surgery; thus, an individualized approach to perioperative management of ACEi or ARBs is warranted.

CCBs comprise a heterogenous class of medications that can be subdivided into nondihydropyridine (verapamil, diltiazem) and dihydropyridine agents (eg, amlodipine, felodipine, nifedipine extended release). Dihydropyridines are largely used to manage hypertension, while nondihydropyridines are important for management of cardiac dysrhythmias, and both play a role in symptom relief in patients with chronic stable angina. Perioperative CCB administration has been explored in small RCTs. In 2003, a meta-analysis of 11 RCTs encompassing 1007 patients evaluated the benefit of perioperative CCBs versus placebo on perioperative MACE.¹ Most trials tested perioperative intravenous diltiazem or intravenous verapamil. Initiation of CCBs failed to reduce perioperative mortality or perioperative MI, although they were associated with reductions in the composite of MI and death, as well as postoperative supraventricular tachycardia. Significant hypotension and bradycardia were observed in individual studies but not in the overall pooled analysis, possibly owing to the varying medication and dosage regimens chosen. A more recent meta-analysis evaluated CCBs (largely dihydropyridines), compared with other antihypertensive agents, to treat postoperative hypertension.² Of the 14 studies included, no significant differences in postoperative hemodynamics were noted.² Although these data do not support the benefit of perioperative CCB initiation, continuation may be reasonable with recognition of the potential for intraoperative hypotension (for dihydropyridines) and/or bradycardia (for nondihydropyridines).³

A single large, well-designed RCT showed no benefit of initiation of clonidine to prevent perioperative MACE. This same trial raised concerns regarding the safety of this approach. New administration is thus not recommended; however, perioperative continuation of chronic therapy has not been addressed in RCTs. Chronic use of clonidine, and other alpha-2 receptor agonists, is reserved for patients with severe resistant hypertension or special populations (eg, CKD, impulse control disorders). Abrupt discontinuation can lead to norepinephrine surge and resultant rebound hypertension.² Short-term interruption for surgery has not been studied.

Management of antiplatelet therapy in the perioperative period of NCS is complex, particularly for patients with CAD and prior PCI, as the timing of antiplatelet interruption must be balanced against competing risks of thrombotic complications (Table 12 and Figure 5). The risk of perioperative stent thrombosis is greatest in the first 4 to 6 weeks post-PCI, with excess risks that decline over time but persist to 6 months. For most patients with CCD, DAPT is recommended for 6 months, followed by single antiplatelet therapy (either with aspirin or P2Y12 inhibitor).^37–39 Selected patients may be eligible for shorter durations of DAPT (28-31 days or 90 days) post-PCI based on recent data,^40–42 but the safety of this approach in patients planned for NCS requires further study. Patients with PCI performed for MI have nearly 3-fold higher risks of postoperative MACE versus those with CCD as the indication for PCI.^16,17 Ideally, NCS should be postponed ≥1 year after PCI for ACS, although NCS can be considered ≥6 months after DES placement for CCD^12,15 and after 3 months for time-sensitive NCS if the benefits of surgery outweigh the risk of MACE. If a patient requires urgent NCS requiring interruption of DAPT, balloon angioplasty without stents may be considered, with NCS delayed for a minimum of 14 days due to higher perioperative MACE risk very early after PCI.^15,43

In the POISE-3 trial, among patients undergoing NCS, the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo.⁶⁵ The net clinical benefit of tranexamic acid appears patient-specific; that is, it is worthwhile for those at increased risk for bleeding outcomes but harmful for those at increased risk for adverse cardiovascular events.⁶⁶

Both major bleeding and thrombosis (eg, stroke and venous thromboembolism) are important surgical outcomes and key contributors to death in NCS.¹² Balancing these perioperative risks is particularly challenging in patients receiving chronic OAC, including VKA and direct oral anticoagulants (DOAC). Development of a perioperative plan for elective NCS should include evaluation of patient-specific factors (eg, age, thrombotic risk, renal function, history of bleeding), procedural factors (eg, timing of surgery, bleeding risk), and drug properties (eg, dosing, drug interaction, onset/offset).^12,13 Whenever feasible, multidisciplinary assessments (eg, OAC prescriber, cardiologist, vascular specialist, hematologist, surgeon, anesthesiologist) should be performed to better understand patient characteristics and surgical risk. Such approaches, applied as part of a standardized preoperative screening process, may greatly improve patient safety.¹⁴ Finally, guidance on monitoring for residual drug effects and hemostasis as well as approaches to OAC reversal is highlighted, particularly when surgical interventions must occur urgently.

Initial optimism regarding the efficacy of perioperative beta blockers on ischemia and subsequent major cardiac events was significantly tempered by large RCTs, suggesting that their moderate benefit of reducing ischemic cardiac events and atrial arrhythmias was offset by harm (eg, stroke) and was associated with increased all-cause mortality. As a result, the practice of perioperative beta blockers to reduce perioperative risk is not advised.^3,5 There are no large RCTs of adequate size or power to determine the optimal timing of beta-blocker initiation in the perioperative period, an approach to dose titration pre- or postoperatively, whether specific patient subgroups benefit (eg, based on RCRI), or whether surgery alone is an indication for beta-blockade outside of acceptable indications (eg, HF, history of CAD). Absent this evidence, an optimal strategy should restrict the use of beta blockers in patients with clear long-term or acute indications, initiating beta blockers at least 1 week before surgery, managing chronic beta blockers as appropriate to patients’ perioperative hemodynamics, and ensuring they are continued at discharge.

In the United States, 34.1 million adults have diabetes, representing 13% of the population.^14,15 Additionally, undiagnosed diabetes is present in 7.3 million adults, or 2.8% of the population.¹⁴ It is estimated that up to 20% of general surgery patients have diabetes, and 23% to 60% have prediabetes or undiagnosed diabetes.⁵ Patients with diabetes have an increased prevalence of ASCVD, including CAD, CKD, and HF. Diabetes confers increased risks of perioperative cardiovascular events and surgical site infections. The finely regulated balance between hepatic glucose production and glucose utilization in peripheral tissue is altered by the stress of anesthesia and surgery, thereby affecting regulatory hormones and inflammatory cytokines.^15,16 Thus, management of perioperative hyperglycemia is imperative; however, the optimal blood glucose targets for intraoperative glycemic control are not well-defined.¹⁷

Emerging data suggest that glucagon-like polypeptide-1 (GLP-1) agonists, increasingly used for the management of diabetes, can cause clinically significant gastroparesis and delayed gastric emptying.¹⁸ A recent consensus statement from the ASA recommends that weekly formulations of GLP-1 agonists be held >1 week before elective NCS for weekly dosed GLP-1 agonists and the day before for daily dosed GLP-1 agonists to reduce the risk of pulmonary aspiration of gastric contents at the time of surgery.

Broadly, there are 4 major classes of anesthesia: local anesthesia, regional anesthesia (eg, neuraxial blockade and peripheral nerve block), monitored anesthesia care (sedation with or without local anesthesia), and general anesthesia (either volatile or intravenous anesthesia). A combination of anesthetic class agents is frequently used. Neuraxial anesthesia can be performed as a primary anesthetic technique alone or with sedation or as a supplement to general anesthesia. An evaluation of risk factors (other than cardiac), including type and duration of surgical procedure, comorbidities, patient preference, and coagulation status, is crucial for determining the risk versus the benefits of each type of anesthetic technique.

The concentration of oxygen administered has also been studied in the perioperative period. Several studies investigated the impact of 30% versus 80% of fraction of inspired oxygen on myocardial injury and infarction during surgery. Two separate RCTs independently reported that oxygen concentration was not associated with increased risk of myocardial injury within 3 days or postoperative release of NT-proBNP.^7,8 These results confirm those of a previously published retrospective analysis including 1617 surgical patients that demonstrated no association between increased oxygen concentration and incidence of myocardial injury, cardiac arrest, and 30-day mortality.⁹

Pain is a common experience after surgery, and physiological manifestations, such as tachyarrhythmias and hypertension, can have serious consequences in patients with preexisting cardiac disease. In patients with CAD, increased myocardial oxygen demand from sympathetic effects of acute pain could lead to the development of type 2 MI (supply-demand imbalance without acute atherothrombotic plaque disruption).⁴ Intravenous or regional administration of analgesics are the mainstay of pain control in the postoperative period. Epidural analgesia and catheter-based regional anesthetics allow for medication administration for acute pain relief up to several days after surgery. Thoracic epidural analgesia (TEA) is preferred for most abdominal incisions, while lumbar epidural analgesia is commonly used for hip fractures and lower extremity orthopedic injuries. The benefits of TEA for the prevention of postoperative MI after abdominal surgery have been demonstrated.^1,2 Enhanced recovery after NCS protocols are increasingly using TEA as part of a multimodal pain management strategy to reduce both intravenous and oral administration of opioid-based analgesics.⁵ The use of gabapentin or pregabalin as adjunct medications has been less successful in promoting an opioid-sparing technique, with adverse effects that include visual disturbances, dizziness, respiratory depression,^6,7 and postoperative delirium in patients ≥65 years of age.⁸

Even mild preoperative anemia is an independent risk factor for postoperative morbidity and mortality, including respiratory, urinary, wound, septic, and thromboembolic complications.^10,19–22 Patients with CKD, diabetes, CVD, and HF have a high prevalence of anemia.^23–26 Limited tissue oxygen delivery is a common mechanism of adverse outcomes in patients with anemia.²⁷ Anemia may contribute to myocardial ischemia, particularly in patients with CAD.²⁰ Postoperative hemoglobin is associated with myocardial injury, type 2 MI, and mortality.^20,28 The World Health Organization defines anemia as a hemoglobin concentration <13 g/dL in men and <12 g/dL in women. Up to 64% of surgical patients have anemia,^19,29 more than half of which is moderate to severe.³⁰ Iron deficiency is responsible in 40% to 50% of cases.^15,29–31 A ferritin concentration <100 ng/mL, transferrin saturation <20%, and/or microcytic hypochromic red cells (mean corpuscular volume <80 fL, mean corpuscular hemoglobin concentration <27 g/dL) are indicative of iron deficiency. A screening system in which anemia automatically triggers evaluation for iron deficiency using previously collected blood identifies iron-deficiency anemia far better than clinicians using normal procedures.³¹ Most anemias are correctable within 2 to 4 weeks. Anemia management programs decrease the rate of transfusions, complications, and mortality.⁹

Perioperative myocardial injury occurs in approximately 20% of patients undergoing NCS and spans a spectrum of clinical presentations from asymptomatic myocardial injury to overt postoperative MI, defined by ischemic symptoms or electrocardiographic changes, pathologic Q-waves, or evidence on imaging of a loss of viable myocardium (Figure 6).^1,4,12–14 MINS encompasses both type 1 and type 2 MI, including asymptomatic myocardial injury, because surgical patients may be unable to report symptoms due to anesthesia, analgesia, or distracting pain at the surgical site.^4,14 A diagnosis of MINS requires >1 elevated cTn (>99th percentile of the upper reference limit) of presumed ischemic origin (excluding nonischemic etiologies such as pulmonary embolism, stroke, and sepsis) and is associated with adverse short- and long-term outcomes.^1,12,14–17 Overall, 30-day mortality associated with MINS is high (approximately 10%),⁹ with risks proportional to the peak cTn concentration (17% in the highest quartile versus 1% in the lowest)¹⁵ and a 34% population attributable risk of 30-day postoperative mortality.^1,16 Even among the 80% to 90% of patients with MINS without ischemic signs or symptoms, 30-day mortality is substantial.^1,4,14 Predictors of MINS include cardiovascular risk factors and disease, kidney disease, and urgent or emergent surgery.^9,16,17 Although mechanisms of MINS may be heterogeneous, atherosclerotic CAD is the presumed etiology in most cases and medical therapy may be warranted in patients with MINS to mitigate postoperative cardiovascular risks. For additional details, see the AHA scientific statement “Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery.”¹²

The incidence of perioperative MI ranges widely from 0.9% to 15% depending on the definitions, patient risk factors, and surgical type.^2,4–8 Patients presenting with perioperative MI after NCS are more likely to present with type 2 MI due to supply-demand mismatch compared with type 1 MI (eg, acute plaque rupture).^1,9,10 Recognition of MI may be difficult in the perioperative period because sedation and analgesia can limit patients’ symptoms, the ability to report them, or both.¹¹ Patients with perioperative STEMI and NSTEMI have a substantial mortality risk, with nearly one-third of patients either dying or being readmitted at 30 days.^4,6,11–16 Risk factors for mortality include the peak cTn concentration, bleeding events, and the presence of peripheral artery disease.¹³ Ideally, management of perioperative type 1 MI should include medical therapy as recommended for patients with spontaneous MI due to ASCVD. In patients with suspected type 2 MI, management should address the underlying cause of supply-demand mismatch (eg, hypertension, hypotension, tachycardia, anemia). Cardiac troponin elevation may also occur due to nonischemic causes, such as HF, sepsis, or pulmonary embolism. ICA may be indicated when acute coronary occlusion is suspected, after individualized risk stratification that accounts for factors including residual bleeding risk, type of surgery, and time since surgery. See Figure 6 for an algorithm depicting the diagnosis and management of patients with myocardial injury or infarction after NCS.

Patients with end-stage kidney or liver disease have a higher prevalence of cardiovascular risk factors and CAD than the general population^1–6 and are at risk for other cardiovascular conditions, such as HF and PH.⁷ Recent studies suggest that a targeted approach to preoperative screening for CAD before kidney transplantation appears to be associated with similar postoperative outcomes than with routine preoperative testing for CAD. Data from the US Renal Data System and Medicare claims reported that more frequent invasive or noninvasive CAD testing in the year before kidney transplantation was not associated with lower rates of 30-day posttransplant death or acute MI.⁸ In the ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease) trial, which enrolled nonsurgical adults with advanced CKD, CCD, and moderate to severe ischemia on stress testing, an initial invasive approach of coronary angiography with revascularization plus medical therapy did not reduce the risk of death or MI versus initial medical therapy alone at a median follow-up of 2.2 years.⁹ The 2022 AHA scientific statement “Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates”¹ summarizes the contemporary data and defines approaches to screening and management of CAD in candidates for kidney and liver transplantation.

Obesity is a growing global epidemic and affects more than one-third of the US adult population.^1–3 Bariatric surgery is the most effective and long-lasting weight loss intervention for patients with body mass index ≥35 kg/m², resulting in significant weight loss and the improvement or resolution of obesity-related diseases, including type 2 diabetes, hypertension, and dyslipidemia.^4–6 In a population-based retrospective cohort study (n=2638), bariatric surgery was associated with a lower incidence of MACE in patients with CVD and obesity over a median 4.6-year follow-up.⁷ Bariatric surgery patients tend to be young and may be selected for lower-risk features; however, bariatric surgery is not without risks. In large meta-analyses, perioperative MI was identified in 0.37% of bariatric surgeries, and the all-cause mortality rate was reported in 0.08%.^7–9 In a retrospective, multicenter study (n=494 611) of patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy,¹⁰ prior cardiac history was associated with greater risks of perioperative cardiac arrest and 30-day mortality. In this study, sleeve gastrectomy was associated with fewer adverse events than Roux-en-Y. Another observational study of patients with obesity undergoing bariatric surgery reported that a history of ACS or HF was associated with increased risks of perioperative cardiovascular complications.¹¹ Thus, careful attention to history and risk factors during preoperative assessments is essential. Patients with obesity are increasingly prescribed GLP-1 receptor agonists to achieve weight loss. Considerations regarding the discontinuation of these drugs before NCS are addressed in Section 7.8 (“Perioperative Management of Blood Glucose”).

Health economics seeks to assess the value (eg, cost versus health benefit) associated with use of medical technology. For medical therapies, the relationship between technology use and value is direct; however, for diagnostic tests, the relationship is indirect and contingent. This is because diagnostic tests produce data that must be used by clinicians to create value.¹ The value of a diagnostic test may be substantially affected by variations in the clinical context of patient and surgical risk levels in which the medical test is performed. In some contexts, clinicians can use the medical test results to improve patient health. Here, value is driven by tradeoffs between the cost of the medical test and the resulting improvements in patient health (ie, cost-effectiveness). In other contexts, a clinician’s knowledge of the test result does not lead to improvements in patient health, and in this instance, value may be created by not performing the test. Last, there are contexts in which administration of the diagnostic test may lead to patient harm (eg, incidental findings leading to additional testing, which may expose patients to additional risk or delays in treatment). These are also contexts in which value may be created by not performing the test. Thus, the key cost–value considerations for diagnostic tests are the cost of the medical test, the context of administration, and the extent to which clinicians can use the test results to improve patient health.