2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery
Authors, Journal, Affiliations, Type, DOI
- Authors: Thompson A, Fleischmann KE, Smilowitz NR, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, and colleagues
- Journal: Circulation 2026;154:e413–e504 (copublished in JACC); published 29 September 2026
- Affiliations: ACC/AHA Joint Committee on Clinical Practice Guidelines, with ACS, ASNC, HRS, SCA, SCCT, SCMR and SVM
- Type: Clinical practice guideline — reaffirmation of the 2024 guideline (Circulation 2024;150:e351–e442, DOI 10.1161/CIR.0000000000001285)
- DOI: 10.1161/CIR.0000000000001472
- Grading: formal COR/LOE; 40 recommendation tables containing 103 numbered recommendations
Overview
The 2026 document is the Joint Committee's reaffirmation of the 2024 perioperative guideline, republished under the new dynamic-surveillance model. Its front page states that a Surveillance Committee reviewed evidence published through March 2026 and found "no new evidence … that changed the existing recommendations," with recommendations, supportive text, figures, tables and references "identical to those in the 2024 publication." No recommendation was added, removed, upgraded, downgraded or otherwise modified. The clinical content is therefore fully described by sources/periop-aha-2024 and by the recommendations recorded on concepts/Perioperative-Cardiovascular-Assessment; this page exists to record the reaffirmation as a distinct citable document and to note what the 2026 text clarifies.
Keywords
Perioperative management · noncardiac surgery · cardiovascular risk score · preoperative evaluation · diagnostic testing · biomarkers · major adverse cardiovascular events · myocardial protection · revascularization · MINS
Key Takeaways
- Nothing changed at the recommendation level. The appendices, tables and figures are identical to 2024; the LOE distribution is unchanged (C-LD 33, B-NR 42, B-R 14), and the nine top take-home messages — including the SGLT2 inhibitor stop rule, the restrictive-bridging statement and the "MINS should not be ignored" message — are word-for-word the same.
- What the reaffirmation records is a governance change: a named Surveillance Committee (chair Annemarie Thompson, with Nathaniel R. Smilowitz, Daniel Munoz, Abdul R. Abdullah and Niya Jones) reviewed the literature in February 2026, and the Joint Committee reaffirmed the guideline in March 2026. The document also points to the 2026 ACC/AHA Methodology and Policies Manual and phases out the "full revision" and "focused update" designations in favour of continuous surveillance.
- The clinical framework is unchanged: stepwise assessment, the principle that cardiovascular screening and treatment should follow the same indications as in non-surgical patients, stress testing only where it would be appropriate independent of surgery, selective biomarkers, the SGLT2i 3–4 day stop, GLP-1 receptor agonist hold, restrictive bridging, no aspirin initiation, no clonidine, the ≥7-day beta-blocker rule, and MINS as a named disease entity. See concepts/Perioperative-Cardiovascular-Assessment and sources/periop-aha-2024.
- No new evidence is reviewed. The literature search remains August 2022–March 2023 with additional studies to November 2023; the "evidence through March 2026" claim is a surveillance assertion with no published search strategy, flow diagram or evidence table.
Limitations of the document
- No documented evidence review. The 2026 label conceals a search that ended in 2023, and self-declaration is the only support for "no change" — no delta table, no list of studies screened and rejected, no per-recommendation rationale.
- Boilerplate was not updated. The abstract methods, the structure statement and the introduction still describe the document as superseding the 2014 guideline and never name 2024; the appendix tables are still headed "2024".
- Only three recommendations carry LOE A — routine pulmonary artery catheterisation, tranexamic acid, and volatile versus TIVA — and two of those are negative or neutral.
- Several common questions still have no graded recommendation: heart transplantation, calcium channel blocker continuation, transplant candidates and cardiopulmonary exercise testing.
- As a republication it consumes a citation slot without advancing the evidence base, which is a real concern for bibliographies and for source indexes that count entries.
Key Concepts Mentioned
- Perioperative risk assessment and the unvalidated stepwise algorithm
- MINS and the Fifth Universal Definition of MI
- Time-based anticoagulant interruption versus heparin bridging
- SGLT2 inhibitor and GLP-1 receptor agonist perioperative rules
Key Entities Mentioned
- concepts/Perioperative-Cardiovascular-Assessment — the wiki page carrying the recommendations
- sources/periop-aha-2024 — the substantive document this reaffirms
- sources/periop-cied-aha-2024 — the companion CIED statement
Wiki Pages Updated
wiki/sources/periop-aha-2026.md— createdwiki/concepts/Perioperative-Cardiovascular-Assessment.md— reaffirmation recorded; nine summarisation defects in the existing 2024-derived content correctedwiki/sourceindex.md— new rowwiki/wikiindex.md— new row