2026 AHA Preoperative cardiovascular Risk assessment

 

2026 AHA/ACC Guideline for Preoperative Cardiovascular Risk Assessment Before Noncardiac Surgery

The 2026 AHA/ACC Guideline for Perioperative Cardiovascular Management of Patients Undergoing Noncardiac Surgery provides a structured, stepwise approach to evaluating cardiovascular risk before surgery. Importantly, the 2026 guideline is a reaffirmation of the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline. After reviewing evidence published during the preceding two years, the ACC/AHA Joint Committee concluded in September 2026 that the 2024 recommendations remain valid and current. The recommendations and supporting material are unchanged.

The central principle is simple: preoperative cardiovascular assessment should identify patients who may benefit from optimization or additional testing without unnecessarily delaying surgery or exposing patients to low-value investigations.

1. Goals of Preoperative Cardiovascular Assessment

The purpose of preoperative cardiovascular evaluation is to:

• Estimate the risk of perioperative major adverse cardiovascular events (MACE)

• Identify unstable cardiovascular conditions requiring treatment before surgery

• Determine whether additional cardiovascular testing is necessary

• Optimize established cardiovascular disease

• Guide perioperative medication and monitoring

• Avoid unnecessary testing and delays in surgery

• Facilitate shared decision-making between the patient, cardiologist, anesthesiologist and surgical team

The guideline emphasizes that cardiovascular screening and treatment before noncardiac surgery should generally follow the same indications used outside the surgical setting. Testing should not be performed simply because surgery is planned.

2. First Step: Define the Surgical Urgency and Risk

The timing of surgery is an important component of cardiovascular assessment.

Urgent surgery

Surgery is required because of a threat to life or limb, but there may still be limited time for cardiovascular evaluation and risk reduction.

Time-sensitive surgery

Surgery can generally be delayed for a period of time to allow appropriate cardiovascular assessment and optimization without adversely affecting the surgical outcome.

Elective surgery

Surgery can be delayed to allow a complete cardiovascular evaluation and optimization.

Surgical risk should then be considered together with patient-specific cardiovascular risk.

The guideline generally considers:

Low-risk surgery → expected MACE risk <1%

Elevated-risk surgery → expected MACE risk ≥1%

Validated risk calculators can help determine whether an individual patient has elevated perioperative cardiovascular risk.

3. Identify Active or Unstable Cardiovascular Conditions

Before proceeding to routine risk calculation, clinicians should look for conditions that may substantially alter perioperative management.

Important conditions include:

• Acute coronary syndrome

• Decompensated heart failure

• Unstable or uncontrolled arrhythmias

• Severe symptomatic valvular disease

• Severe pulmonary hypertension

• Other unstable cardiovascular conditions

If such a condition is present, the immediate priority is assessment and management of that condition rather than simply calculating a preoperative risk score.

4. Clinical Risk Assessment

The next step is to assess:

• History of coronary artery disease

• Previous myocardial infarction

• Heart failure

• Cerebrovascular disease

• Peripheral arterial disease

• Diabetes mellitus

• Chronic kidney disease

• Hypertension

• Smoking

• Dyslipidemia

• Obesity

• Previous arrhythmias

• Valvular heart disease

• Congenital heart disease

• Pulmonary hypertension

• Presence of a pacemaker or ICD

• Previous cardiac surgery or PCI/CABG

A validated perioperative risk calculator can then be used.

Commonly used tools include:

• Revised Cardiac Risk Index (RCRI)

• ACS NSQIP MICA calculator

• ACS NSQIP Surgical Risk Calculator

In patients with known cardiovascular disease undergoing noncardiac surgery, the guideline states that a validated risk-prediction tool can be useful for estimating perioperative MACE risk.

5. Assess Functional Capacity

Functional capacity is one of the most important components of the preoperative assessment.

It can be assessed by:

• Patient history

• Metabolic equivalents (METs)

• Duke Activity Status Index (DASI)

A functional capacity of approximately 4 METs is an important threshold.

Examples of activities corresponding to approximately ≥4 METs include:

• Climbing a flight or two of stairs

• Walking uphill

• Walking at a reasonable pace

• Performing moderate household activities

Poor functional capacity is generally considered:

<4 METs

or

DASI ≤34

A structured assessment such as DASI is considered reasonable in patients undergoing elevated-risk noncardiac surgery.

An important practical point is that inability to perform physical activity may result from arthritis, obesity, pulmonary disease or other noncardiac conditions. Therefore, poor functional capacity does not automatically indicate cardiac disease.

6. When Is an ECG Needed?

Routine ECG is not required for every patient undergoing surgery.

A preoperative 12-lead ECG is reasonable in patients with known:

• Coronary heart disease

• Significant arrhythmia

• Peripheral arterial disease

• Cerebrovascular disease

• Significant structural heart disease

or cardiovascular symptoms when undergoing elevated-risk surgery.

If a preoperative ECG demonstrates a new abnormality, further evaluation may be reasonable.

In asymptomatic patients without known cardiovascular disease undergoing elevated-risk surgery, a preoperative ECG may also be considered.

7. Should Everyone Have an Echocardiogram?

No.

Routine assessment of LV systolic function in clinically stable, asymptomatic patients before noncardiac surgery is not recommended simply because surgery is planned.

Echocardiography should instead be performed when clinically indicated, such as when there is:

• New or worsening dyspnea

• Suspected heart failure

• Significant valvular disease

• Change in clinical status

• Other indication for assessment of cardiac structure or function

Special attention is required in suspected significant aortic stenosis.

For patients with suspected moderate or severe aortic stenosis undergoing elevated-risk surgery, preoperative echocardiography is recommended before elective surgery.

Patients with severe aortic stenosis should be evaluated for whether valve intervention is appropriate before elective noncardiac surgery.

8. Role of Biomarkers

One of the important developments in the modern perioperative approach is selective use of cardiac biomarkers.

BNP or NT-proBNP

In patients undergoing elevated-risk noncardiac surgery, preoperative BNP or NT-proBNP measurement is reasonable in:

• Patients with known cardiovascular disease

• Patients ≥65 years

• Patients ≥45 years with symptoms suggestive of cardiovascular disease

Cardiac troponin

Preoperative cardiac troponin measurement may also be reasonable in similar higher-risk patients.

These biomarkers can improve perioperative risk assessment, but they should not be indiscriminately measured in low-risk patients because abnormal results may lead to unnecessary downstream investigations.

9. When Should Stress Testing Be Performed?

This is one of the most important messages of the guideline.

Stress testing should NOT be routinely performed before noncardiac surgery.

Stress testing may be considered when ALL of the following are present:

• Elevated-risk noncardiac surgery

• Poor or unknown functional capacity

• Elevated perioperative cardiovascular risk based on a validated risk calculator

• The result of the test would potentially change management

Poor functional capacity is generally:

<4 METs or DASI ≤34.

Routine stress testing is not recommended in:

• Low-risk patients

• Patients with adequate functional capacity and stable symptoms

• Patients undergoing low-risk surgery

The guideline specifically emphasizes avoiding stress testing simply because surgery is planned.

10. Choice of Stress Test

If stress testing is indicated, the modality should be individualized.

Exercise stress testing is generally preferred when the patient can exercise adequately.

Pharmacological stress testing can be used when the patient cannot exercise sufficiently.

Possible modalities include:

• Exercise ECG

• Stress echocardiography

• Nuclear myocardial perfusion imaging

• Pharmacological stress echocardiography

• Pharmacological nuclear imaging

Dobutamine stress echocardiography can be useful in selected patients who cannot exercise, particularly when elevated perioperative risk and poor functional capacity are present.

Stress testing should generally be avoided in unstable conditions such as acute coronary syndrome, decompensated heart failure, severe symptomatic aortic stenosis, uncontrolled arrhythmias and severe uncontrolled hypertension.

11. Role of Coronary CT Angiography

Coronary CT angiography may have a role in selected patients undergoing elevated-risk surgery when additional coronary assessment is clinically appropriate.

However, routine CCTA is not recommended for low-risk patients, patients undergoing low-risk surgery or patients with adequate functional capacity and stable symptoms.

The reason is that indiscriminate CCTA may identify abnormalities that do not improve perioperative outcomes and can lead to unnecessary downstream investigations and delays.

12. Preoperative Coronary Revascularization

A major principle is:

Do not perform coronary revascularization solely to make surgery safer unless there is an independent indication for revascularization.

Routine prophylactic coronary revascularization before noncardiac surgery has not been shown to improve outcomes in stable patients.

Revascularization should therefore be considered when it would be indicated even if the patient were not undergoing surgery.

Examples include selected patients with:

• Acute coronary syndrome

• Significant left main disease

• Other established indications for coronary revascularization

The decision should be individualized according to the coronary anatomy, symptoms, LV function and urgency of the noncardiac operation.

13. Heart Failure

Patients with heart failure have increased perioperative cardiovascular risk.

Assessment should include:

• Symptoms and clinical stability

• Volume status

• LV systolic function when clinically indicated

• Current guideline-directed medical therapy

• Recent heart failure hospitalization

• Functional capacity

Patients with decompensated heart failure require stabilization before elective surgery whenever possible.

Routine echocardiography is not required in stable, asymptomatic patients solely for preoperative clearance.

14. Valvular Heart Disease

Significant valvular disease can substantially influence perioperative risk.

Particular attention should be paid to:

• Severe aortic stenosis

• Severe mitral stenosis

• Significant mitral regurgitation

• Significant aortic regurgitation

• Significant tricuspid regurgitation

• Pulmonary hypertension secondary to valvular disease

Severe aortic stenosis is especially important.

Patients with severe AS should be evaluated for the need for valve intervention before elective noncardiac surgery.

In suspected moderate or severe AS undergoing elevated-risk surgery, echocardiography is recommended before elective surgery.

15. Hypertension

Hypertension should be assessed and managed as part of routine cardiovascular optimization.

The presence of hypertension alone does not necessarily require cancellation of surgery.

The severity of hypertension, evidence of end-organ disease, overall cardiovascular risk and urgency of surgery should be considered.

Severe uncontrolled hypertension can also make certain stress-testing procedures inappropriate.

16. Perioperative Medication Considerations

Medication management is an important component of cardiovascular risk reduction.

Beta-blockers

Patients already taking beta-blockers for an established indication should generally continue therapy.

Starting a beta-blocker immediately before surgery without sufficient time for assessment and titration can be harmful.

Statins

Patients with established indications for statin therapy should generally remain on therapy.

Routine initiation of high-dose statin therapy solely because surgery is planned is not supported for all patients.

ACE inhibitors/ARBs

Management should be individualized according to the indication, blood pressure and risk of perioperative hypotension.

Antiplatelet therapy

Patients with previous PCI or coronary stenting require individualized assessment of antiplatelet therapy and the timing of surgery because interruption may increase thrombotic risk.

The risks of bleeding and stent thrombosis must be balanced.

Anticoagulants

Warfarin and direct oral anticoagulants require individualized perioperative interruption and resumption according to:

• Indication for anticoagulation

• Thromboembolic risk

• Renal function

• Bleeding risk of surgery

• Timing of surgery

17. SGLT2 Inhibitors: An Important Modern Recommendation

SGLT2 inhibitors should be discontinued before surgery to reduce the risk of perioperative ketoacidosis.

The guideline recommends stopping these drugs approximately:

3–4 days before surgery

This applies to commonly used agents such as:

• Empagliflozin

• Dapagliflozin

• Canagliflozin

• Ertugliflozin

The emergence of SGLT2 inhibitors as an important perioperative consideration reflects the changing cardiovascular and metabolic profile of modern surgical patients.

18. Patients With Pacemakers and ICDs

Patients with cardiovascular implantable electronic devices require specific perioperative planning.

Assessment should consider:

• Device type

• Pacemaker dependence

• Indication for implantation

• Battery status

• Recent device interrogation

• Presence of ICD therapies

• Type of surgery

• Expected electromagnetic interference from electrocautery

Coordination between cardiology/electrophysiology, anesthesia and surgery is important for patients at significant device-related risk.

19. Pulmonary Hypertension and Right Ventricular Disease

Pulmonary hypertension increases perioperative risk.

Assessment should include:

• Severity of pulmonary hypertension

• RV function

• Functional status

• Current pulmonary hypertension therapy

• Type and urgency of surgery

Routine assessment of RV function is not recommended in asymptomatic, clinically stable patients. However, echocardiography is frequently useful when pulmonary hypertension, significant tricuspid regurgitation or RV dysfunction is suspected.

20. A Practical Stepwise Algorithm

A simple clinical approach can be remembered as:

STEP 1

What surgery is planned?

→ Low-risk or elevated-risk?

STEP 2

How urgent is the surgery?

→ Urgent, time-sensitive or elective?

STEP 3

Are there active/unstable cardiovascular conditions?

→ ACS?

→ Decompensated HF?

→ Uncontrolled arrhythmia?

→ Severe symptomatic valvular disease?

If YES → stabilize/evaluate before elective surgery when feasible.

STEP 4

Estimate perioperative risk.

→ RCRI

→ ACS NSQIP MICA

→ Other validated risk calculator

STEP 5

Assess functional capacity.

→ ≥4 METs / DASI >34

or

→ <4 METs / DASI ≤34 / unknown

STEP 6

Determine whether additional testing would change management.

Consider:

→ ECG

→ BNP/NT-proBNP

→ Troponin

→ Echocardiography

→ Stress testing

→ CCTA

STEP 7

Optimize cardiovascular disease.

→ HF

→ CAD

→ Hypertension

→ Arrhythmia

→ Valvular disease

→ Anticoagulation/antiplatelet therapy

→ CIED management

→ Diabetes medications

STEP 8

Proceed with surgery when the expected benefit of further cardiovascular testing or intervention does not outweigh the delay and potential harm.

21. What Should NOT Be Done Routinely?

The modern guideline strongly emphasizes avoiding unnecessary preoperative testing.

Do not routinely perform:

• Stress testing in low-risk patients

• Stress testing in patients with adequate functional capacity and stable symptoms

• Echocardiography in stable asymptomatic patients without an indication

• CCTA in low-risk patients

• Coronary angiography simply because surgery is planned

• Coronary revascularization solely to reduce perioperative risk

• Biomarker testing indiscriminately in low-risk patients

The objective is not to find every possible cardiovascular abnormality.

The objective is to identify clinically meaningful abnormalities that could change management or perioperative outcomes.

22. Key Take-Home Messages From the 2026 Guideline

23. The 2026 AHA/ACC perioperative guideline is a reaffirmation of the 2024 guideline, with no changes to the recommendations.

24. Preoperative cardiovascular assessment should be stepwise rather than test-based.

25. First assess surgical risk, urgency and the patient's clinical cardiovascular status.

26. Use a validated risk calculator when appropriate.

27. Functional capacity remains a major component of risk assessment.

28. <4 METs or DASI ≤34 represents poor functional capacity.

29. BNP/NT-proBNP and troponin can provide additional risk information in selected higher-risk patients.

30. Routine stress testing is not recommended for low-risk patients or those with adequate functional capacity and stable symptoms.

31. Routine echocardiography is not recommended in stable asymptomatic patients without a clinical indication.

32. Coronary revascularization should not routinely be performed solely to reduce perioperative risk.

33. Severe aortic stenosis requires specific evaluation before elective noncardiac surgery.

34. SGLT2 inhibitors should generally be stopped 3–4 days before surgery.

35. Cardiovascular medications should be managed according to the underlying indication and perioperative risks rather than stopped or started indiscriminately.

36. Shared decision-making and multidisciplinary management are particularly important in patients with complex or unstable cardiovascular disease.

Conclusion

The 2026 AHA/ACC approach to preoperative cardiovascular assessment represents a shift away from the traditional concept of “cardiac clearance” toward structured perioperative risk assessment.

The key question is no longer:

“Does this patient need cardiac clearance?”

Instead, the clinician should ask:

“What is the patient's cardiovascular risk, is there an unstable condition that requires treatment, and would additional testing change management?”

For most stable patients, particularly those undergoing low-risk surgery or those with adequate functional capacity, extensive cardiovascular testing is unnecessary.

For patients with elevated surgical risk, poor or unknown functional capacity, established cardiovascular disease, significant symptoms or major cardiovascular comorbidity, targeted testing and optimization may substantially improve perioperative decision-making.

The ultimate goal is not to delay surgery unnecessarily, but to identify modifiable cardiovascular risk and safely guide the patient through the perioperative period.

References

1. 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. JACC. Published September 2026.

2. Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Circulation. 2024;150:e351–e442.

3. American Heart Association. 2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.