2024 AHA/ACC Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery

Authors, Journal, Affiliations, Type, DOI

• Chair: Annemarie Thompson, MD, MBA, FAHA
• Vice Chairs: Kirsten E. Fleischmann, MD, MPH; Nathaniel R. Smilowitz, MD, MS
• Journal: Circulation, 2024;150:e351–e442
• Type: Multi-society clinical practice guideline (AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM)
• DOI: 10.1161/CIR.0000000000001285
• Literature search: August 2022 – March 2023 (updated through November 2023)
• Supersedes: 2014 ACC/AHA Perioperative Guideline

Overview

The 2024 guideline provides a comprehensive, evidence-based framework for perioperative cardiovascular evaluation and management of adults (≥18 years) undergoing noncardiac surgery (NCS). It introduces a structured stepwise assessment algorithm, formally recognises myocardial injury after noncardiac surgery (MINS) as a distinct clinical entity, and provides updated recommendations on anticoagulation management, perioperative pharmacotherapy, and cardiovascular comorbidity management. The guideline emphasises avoiding overscreening in low-risk patients and team-based, patient-centred shared decision-making.

Keywords

AHA Scientific Statements · anesthetics · biomarkers · cardiac · preoperative evaluation · cardiovascular · diagnostic testing · cardiovascular diseases · cardiovascular risk score · heart failure · heart valve diseases · intraoperative period · major adverse cardiovascular events · myocardial protection · noncardiac surgery · perioperative management · postoperative complications · preoperative care · revascularization · risk assessment · treatment outcome

Key Takeaways

Epidemiology

• ~14.4 million inpatient and 19.2 million ambulatory surgeries performed annually in the United States
• Cardiovascular risk factors present in 45% of surgical inpatients ≥45 years; ASCVD in ~25%
• Perioperative death, MI, or ischemic stroke occurs in 1 in every 33 surgical admissions (>150,000 annual events in the US)
• Vascular, thoracic, and solid organ transplant surgeries carry highest cardiovascular event incidence

Surgical Risk Classification

• Emergency: Immediate threat to life, <2h window; no preoperative evaluation feasible
• Urgent: ≥2 to <24h window; limited time for risk reduction
• Time-sensitive: Delay up to 3 months possible
• Elective: Full preoperative evaluation can be completed
• Low risk: MACE <1%; Elevated risk: MACE ≥1% (traditionally RCRI >1)
• Highest-risk procedures: suprainguinal vascular, thoracic, transplant, neurosurgery
• Intermediate-risk: general, ENT, genitourinary, orthopaedic
• Lowest-risk: endocrine, breast, gynaecology, obstetrics

Risk Calculators (Section 3)

• RCRI: 6 predictors (ischaemic heart disease, cerebrovascular disease, HF, insulin-dependent diabetes, creatinine ≥2.0 mg/dL, high-risk surgery); COR 2a for known CVD
• NSQIP MICA: 5-variable model; ROC 0.88; accounts for procedure type and functional status
• Universal NSQIP: 21 components; best discriminatory performance (ROC 0.90 for cardiac arrest/MI)
• AUB-HAS2: 6 items; stratifies into low (0–1), intermediate (2–3), high (>3) 30-day risk
• No single risk index recommended over others — variability in predicted risk across tools
• Combining RCRI with coronary calcium from existing chest CT may enhance risk stratification

Functional Capacity (Section 3.2)

• Measured in METs; <4 METs = poor functional capacity
• DASI (Duke Activity Status Index): 12-item self-report; DASI ≤34 associated with increased 30-day death or MI (COR 2a)
• Subjective clinician assessment of functional capacity is NOT associated with outcomes (METs trial)
• Poor functional capacity (<2 flights of stairs) → 1.63× higher 30-day MACE (BASEL-PMI)

Frailty (Section 3.3)

• COR 2a: Validated frailty assessment in all patients ≥65 years and those <64 with perceived frailty undergoing elevated-risk NCS
• Frailty associated with 3.71× 30-day mortality and 2.39× 30-day complications in meta-analysis of 1.1 million patients
• Tools: Fried Phenotype, Clinical Frailty Scale, FRAIL Scale, Edmonton Frail Scale, SPPB
• Prehabilitation (exercise + nutritional optimisation) may improve outcomes in selected patients

Preoperative Biomarkers (Section 3.4)

• BNP/NT-proBNP: COR 2a in patients with known CVD, age ≥65, or age ≥45 with CVD symptoms undergoing elevated-risk NCS
  • Abnormal thresholds: BNP >92 ng/L, NT-proBNP ≥300 ng/L
  • NT-proBNP >100 pg/mL independently associated with all-cause mortality (VISION substudy)
• Cardiac troponin (cTn): COR 2b preoperative; provides baseline for postoperative interpretation
  • Preoperative high-sensitivity cTn identifies chronic myocardial injury and improves RCRI prediction
• No studies yet show that management based on elevated preoperative biomarkers improves outcomes

Preoperative Diagnostic Testing (Section 4)

• 12-lead ECG:
  • COR 2a: Patients with known coronary disease, arrhythmia, PAD, cerebrovascular disease, structural heart disease, or CVD symptoms undergoing elevated-risk surgery
  • COR 2b: Asymptomatic patients undergoing elevated-risk surgery without known CVD
  • COR 3 No Benefit: Asymptomatic patients undergoing low-risk procedures
  • Actionable ECG findings: Mobitz II+ AV block, new-onset AF, QT prolongation, new bundle branch block
• LV function (echo):
  • COR 1: New dyspnea, signs of HF, or suspected new/worsening ventricular dysfunction
  • COR 2a: Known HF with worsening symptoms or change in clinical status
  • COR 3 No Benefit: Asymptomatic stable patients — no benefit in large retrospective studies
• Stress testing:
  • COR 2b: Poor/unknown functional capacity AND elevated risk on validated tool, considering elevated-risk surgery — only if high-risk ischemia suspected (left main/multivessel disease)
  • COR 3 No Benefit (B-R): Low-risk patients, adequate functional capacity with stable symptoms, or low-risk surgery
  • An abnormal stress test should NOT prompt angiography unless high-risk features (left main/severe multivessel + reduced EF)
  • Pharmacological preferred if patient cannot exercise; dobutamine stress echo contraindicated in significant LVOT obstruction
• CCTA:
  • COR 2b: Elevated risk + poor/unknown functional capacity — only if high-risk coronary anatomy suspected
  • COR 3 No Benefit: Routine CCTA in low-risk patients; contraindicated in urgent/emergency surgery
  • CCTA overestimates risk in patients who do NOT experience MACE (5× more likely to over-estimate)
  • Coronary calcium score of 0 within 2 years → proceed without additional testing
• Invasive coronary angiography:
  • COR 3 No Benefit: Routine preoperative ICA not recommended; CARP trial showed no benefit

Stepwise Perioperative Assessment Algorithm (Figure 1)

1. Is surgery emergency? → Proceed, manage cardiac conditions perioperatively
2. Active cardiac conditions (ACS, decompensated HF, severe symptomatic AS, unstable arrhythmia)? → Evaluate and treat
3. Low-risk surgery? → Proceed
4. Assess functional capacity (DASI) and calculate risk (RCRI/NSQIP)
5. If elevated risk + poor/unknown functional capacity → consider biomarkers, ECG, selective imaging
6. Shared decision-making; proceed with surgery ± GDMT optimisation

Coronary Artery Disease (Section 6.1)

• CAD in ~18% of patients undergoing major NCS; history of MI → 3.5× MACE risk
• Coronary revascularisation:
  • COR 1: ACS → revascularise and defer surgery
  • COR 2a: CCD with left main stenosis ≥50% → revascularise before elective NCS
  • COR 3 No Benefit (B-R): Routine revascularisation for non-left main CAD — CARP trial: no benefit at 30 days or 1 year
• ISCHEMIA/COURAGE/BARI-2D: GDMT as effective as routine revascularisation in stable CCD

Hypertension and Blood Pressure Management (Section 6.2)

• COR 2a: Continue antihypertensive therapy throughout perioperative period in most patients (caution with ACEi/ARBs — see below)
• COR 2b: May defer elective elevated-risk surgery if SBP ≥180 or DBP ≥110 + ≥1 RCRI component
• Intraoperative targets (COR 1, B-NR): Maintain MAP ≥60–65 mmHg or SBP ≥90 mmHg
  • POISE-3: No benefit of targeting MAP ≥80 vs MAP ≥60 mmHg
  • Harm threshold: MAP <65 or SBP <90 sustained ~15 minutes
• COR 1: Treat postoperative hypotension (MAP <60–65 or SBP <90 mmHg)
• COR 1: Restart antihypertensive medications as soon as clinically reasonable postoperatively

Heart Failure (Section 6.3)

• HF confers 3× greater perioperative mortality than CAD alone; lower LVEF → higher 90-day mortality
• SGLT2i (COR 1, C-LD): Must stop 3–4 days before surgery (canagliflozin/dapagliflozin/empagliflozin ≥3 days; ertugliflozin ≥4 days) — risk of euglycemic ketoacidosis
• Continue GDMT (excluding SGLT2i) perioperatively — discontinuation without indication → increased mortality (COR 2a)
• Decompensated HF (NYHA III–IV) → postpone elective surgery + cardiology consultation

Hypertrophic Cardiomyopathy (Section 6.3.1)

• COR 3:Harm: Avoid factors aggravating LVOT obstruction: positive inotropes, tachycardia, reduced preload, reduced afterload
• Continue beta-blockers/non-dihydropyridine CCBs without interruption
• If hypotensive: IV fluids first, then vasopressors (phenylephrine/vasopressin); avoid beta-agonists
• Consider intraoperative TEE for hemodynamic instability to evaluate LVOT obstruction
• Maintain sinus rhythm; avoid excessive diuresis

Pulmonary Hypertension (Section 6.3.2)

• COR 1: Continue PAH-targeted therapies perioperatively (prostacyclins, ERAs, nitric oxide pathway mediators)
• COR 2a: Severe PH (mPAP >40 mmHg or PVR >5 WU or RV:LV diameter >0.8) → refer to specialised PH centre
• COR 2a: Invasive haemodynamic monitoring for severe PH undergoing elevated-risk NCS
• COR 2b: Short-acting inhaled pulmonary vasodilators (iNO, aerosolised prostacyclins) for precapillary PH to reduce RV afterload
• PH associated with 43% increased odds of death/MI/stroke; Group 1 PAH → 2.5× MACE, 5× cardiogenic shock

Adult Congenital Heart Disease (Section 6.3.3)

• COR 1 (B-NR): Preoperative ACHD specialist consultation for intermediate- to elevated-risk CHD lesions
• Risk stratification: low/intermediate/elevated based on anatomy and physiological status (Table 10)
• For Eisenmenger/Fontan: avoid ↑ intra-abdominal pressure, hypothermia, hypercapnia, metabolic acidosis, hypovolaemia
• Elevated-risk ACHD should be performed at centres with established ACHD programme

Valvular Heart Disease (Section 6.4)

Aortic Stenosis:

• COR 1: Severe AS → evaluate for valve intervention (SAVR or TAVI) before elective NCS
• COR 1: Suspected moderate/severe AS → echo before elevated-risk NCS
• COR 2a: Asymptomatic severe AS with preserved LV function (LVEF ≥50%) on echo within 1 year → safe to proceed with elective low-risk NCS
• Balloon aortic valvuloplasty: bridging option for urgent NCS when AVR not feasible
• Monitor closely: avoid hypotension, hypertension, tachycardia, dehydration/volume overload

Mitral Stenosis:

• COR 1: Severe MS → evaluate for MV intervention (PMC preferred if suitable) before elective NCS
• COR 2a: If MV intervention not feasible → invasive haemodynamic monitoring
• COR 2b: Heart rate control (beta-blockers, CCBs, ivabradine, digoxin) to prolong diastolic filling
• Perioperative goals: low-normal heart rate, high-normal SVR, adequate preload, sinus rhythm

Chronic AR and MR:

• COR 1: Suspected moderate/severe regurgitation → echo before elective NCS
• COR 1: Meets criteria for valve intervention → consider before elevated-risk NCS
• COR 2a: Asymptomatic moderate/severe MR + normal LV function + PA systolic <50 mmHg → proceed with NCS
• COR 2a: Asymptomatic moderate/severe AR + LVEF >55% → proceed with NCS
• In MR: avoid ↑ afterload and bradycardia; in AR: avoid bradycardia (prolongs diastolic regurgitation time)

Post-TAVI/TEER:

• COR 2a: NCS may proceed early (including within 30 days) after successful TAVI with acceptable outcomes
• COR 2a: NCS may proceed after successful MV TEER
• Continue aspirin perioperatively after TAVI to reduce thrombotic risk

Atrial Fibrillation (Section 6.5)

• Pre-existing AF: optimise rate control before surgery; interrupt OAC per Section 7.6
• New-onset perioperative AF (POAF):
  • COR 2a: Treat underlying triggers (sepsis, anemia, pain, electrolyte imbalance)
  • COR 2a: Consider postoperative anticoagulation (weighing thromboembolism vs bleeding risk)
  • COR 1: Outpatient follow-up after discharge — high recurrence rate (39% at 5 years)
  • POAF associated with 62% increased early stroke risk and 44% increased 30-day mortality vs no POAF
  • In NCS patients, POAF → HR 2.00 for stroke (stronger than cardiac surgery: HR 1.20)
  • Danish registry: OAC within 30 days post-discharge → 48% reduced thromboembolic risk

Cardiovascular Implantable Electronic Devices (Section 6.6)

• COR 1: Preoperative CIED management plan if EMI anticipated (identify device type, manufacturer, model, pacing dependency)
• COR 1: Pacemaker-dependent patients with surgery above umbilicus + EMI → reprogram to asynchronous (VOO/DOO) or apply magnet
• COR 1: ICD in pacemaker-dependent patient → reprogram (not just magnet); inhibit tachytherapies
• COR 1: Restore device function before hospital discharge (deaths from failure to reactivate tachytherapies)
• Bipolar ESU and ultrasonic scalpels unlikely to cause EMI
• Surgery below umbilicus unlikely to cause EMI with transvenous devices

Previous Stroke/TIA (Section 6.7)

• COR 2a: Delay elective NCS ≥3 months after stroke/TIA
• OR 14.23 for MACE if NCS within 3 months of stroke (Danish registry); stabilises at 9 months but risk persists to 12 months
• Delaying beyond 6 months provides only marginal additional protection

Obstructive Sleep Apnea (Section 6.8)

• COR 2a: Validated questionnaire screening (STOP-Bang) for OSA before NCS
• OSA associated with 2.5× increased postoperative pulmonary complications and increased perioperative MI/AF risk
• Severe OSA → increased 30-day composite (myocardial injury, cardiac death, HF, thromboembolism, AF, stroke)
• Restart positive airway pressure as early as possible postoperatively
• Regional anaesthesia reasonable to reduce opioid/sedative use and pulmonary complications

Perioperative Medical Therapy (Section 7)

Statins:

• COR 1: Continue statins throughout perioperative period if already prescribed (B-NR)
• COR 1: Initiate statin if meets ASCVD criteria, with intention for long-term use (B-R)
• LOAD trial (n=648): Acute statin loading showed no short-term MACE benefit in statin-naïve patients
• Benefit of statin reloading/intensification before surgery requires further study
• Do NOT delay surgery to obtain LDL-C; NCS setting is opportunity to initiate long-term therapy

RAASi (ACEi/ARBs) (Section 7.2):

• COR 2b: May omit RAASi 24h before elevated-risk NCS in patients on chronic therapy for hypertension — reduces intraoperative hypotension but no proven MACE benefit (PREOP-ACEI, POISE-3)
• COR 2a: Continue RAASi in patients with HFrEF — dose-dependent mortality reduction; limited trial data for interruption
• Individualised approach; ongoing STOPorNOT trial

Calcium Channel Blockers:

• No data supporting perioperative initiation; continuation reasonable with awareness of hypotension (dihydropyridines) or bradycardia (non-DHP)

Alpha-2 Agonists (Clonidine):

• COR 3 No Benefit (B-R): Clonidine initiation perioperatively not recommended
• POISE-2: No MACE benefit; increased nonfatal cardiac arrest, bradycardia, hypotension
• Do NOT abruptly discontinue chronic clonidine (rebound hypertension)

Antiplatelet Therapy and PCI Timing (Section 7.5):

• COR 1: Multidisciplinary team approach for all patients with CAD on antiplatelet therapy undergoing NCS
• Timing after PCI (elective NCS requiring interruption of ≥1 antiplatelet agent):
  • Balloon angioplasty only: ≥14 days
  • DES for ACS: ≥12 months (COR 1, B-NR)
  • DES for CCD: ≥6 months (COR 2a, B-NR)
  • Time-sensitive NCS: ≥3 months acceptable if benefit > risk (COR 2b)
  • COR 3:Harm: Elective NCS requiring antiplatelet interruption ≤30 days post-BMS or DES
• Perioperative antiplatelet management:
  • COR 1: Continue aspirin (75–100 mg) if prior PCI — reduces death/MI by absolute 5.5%
  • COR 1: If OAC monotherapy must stop → substitute aspirin until OAC can restart
  • COR 3 No Benefit: Routine aspirin initiation in CAD without prior PCI (POISE-2: no benefit, 23% increased major bleeding)
  • P2Y12 inhibitor discontinuation windows: clopidogrel 5–7 days; prasugrel 7–10 days; ticagrelor 3–5 days; aspirin 4 days

Oral Anticoagulants (Section 7.6):

• COR 1: Team-based time-based interruption for elective NCS (Tables 13 and 14)
• DOAC interruption (no bridging needed for most patients with AF):
  • Factor Xa inhibitors: hold ≥3 days for high bleeding risk (≥5 days if CrCl <30); ≥2 days for low/moderate
  • Dabigatran (CrCl ≥50): same as Factor Xa; CrCl <50: hold ≥4 days for high risk
  • PAUSE trial (n=3007): Low rates of bleeding and thromboembolism with time-based interruption
• VKA bridging:
  • COR 2a: Bridging with parenteral heparin for high thrombotic risk patients on VKA (mechanical mitral valve, recent VTE, high CHA2DS2-VASc)
  • COR 3:Harm: Routine bridging in most patients — BRIDGE trial: bridging noninferior for thromboprevention but increased major bleeding
• Resumption: VKA restart 12–24h after low/moderate bleeding risk; DOAC restart as early as 6h if haemostasis achieved (48–72h after high-risk procedures)
• Reversal agents: Vitamin K + 4F-PCC for warfarin; andexanet alfa for factor Xa inhibitors; idarucizumab for dabigatran

Beta Blockers (Section 7.7):

• COR 1: Continue beta-blockers perioperatively if on chronic therapy (abrupt discontinuation is harmful)
• COR 2b: If new indication, initiate ≥7 days before surgery (not within 7 days → higher mortality; not on day of surgery)
• COR 3:Harm (B-R): Do NOT initiate beta-blockers on day of surgery — POISE trial: moderate MACE reduction offset by increased stroke and all-cause mortality

Blood Glucose Management (Section 7.8):

• COR 2a: Check HbA1c if not done in ≤3 months before elective NCS; may postpone if HbA1c >8%
• COR 1: Stop SGLT2i 3–4 days before surgery (euglycemic ketoacidosis risk)
• COR 2a: Continue metformin perioperatively (no lactic acidosis risk; cardiovascular mortality benefit from UKPDS)
• GLP-1 agonists: ASA consensus — stop weekly formulations >1 week before elective NCS; daily formulations the day before (delayed gastric emptying → aspiration risk)

Anesthetic Considerations (Section 8)

• COR 2a: Volatile anaesthetic vs TIVA — no difference in cardiovascular events (multiple RCTs including ENIGMA)
• COR 2a: Neuraxial vs general anaesthesia — no meaningful difference in cardiovascular outcomes (REGAIN trial)
• Thoracic epidural analgesia (COR 2a): Reduces perioperative MI in major abdominal surgery; opioid-sparing strategy
• Normothermia (COR 2a): Maintain perioperatively — hypothermia is proarrhythmogenic and increases myocardial O₂ demand
• Intraoperative TEE/FoCUS (COR 2a): Use for unexplained haemodynamic instability when expertise available; NOT for routine monitoring
• PA catheters (COR 3 No Benefit): Routine use not recommended — no mortality/morbidity benefit in multiple RCTs
• Tranexamic acid (COR 2a): Reduces intraoperative blood loss and transfusions in NCS with expected blood loss (POISE-3: lower bleeding but higher MACE in cardiovascular high-risk patients)
• Iron therapy (COR 2a): IV iron preferred over oral for preoperative iron-deficiency anaemia (higher efficacy, faster response); even single dose effective

MINS: Myocardial Injury After Noncardiac Surgery (Section 9)

• Definition: Elevated cTn (>99th percentile URL) of presumed ischaemic origin, without requirement for ischaemic symptoms; includes type 1 and type 2 MI; asymptomatic in 80–90% of cases
• Incidence: ~20% of patients undergoing NCS
• Mortality: 30-day mortality ~10%; proportional to peak cTn (17% in highest quartile vs 1% in lowest); 34% population attributable risk of 30-day postoperative mortality
• Surveillance (COR 2b): Measure cTn at 24h and 48h post-surgery in patients with known CVD, CVD symptoms, or age ≥65 with risk factors undergoing elevated-risk NCS
• COR 3 No Benefit: No routine troponin surveillance after low-risk NCS
• Management:
  • COR 2a: Outpatient cardiology follow-up for GDMT optimisation
  • COR 2b: Antithrombotic therapy (MANAGE trial: dabigatran 110 mg BID reduced major vascular events; increased minor/GI bleeding)
  • Cardiology consultation or transfer → reduced 30-day mortality
  • Statins and aspirin associated with reduced 30-day mortality in observational data
  • Algorithm: elevated postop troponin → assess for ischaemic features/ECG changes → classify MINS vs STEMI/NSTEMI vs nonischaemic injury

Postoperative MI (Section 9.2)

• Perioperative MI incidence 0.9–15%; predominantly type 2 MI (supply-demand mismatch) rather than type 1 (plaque rupture)
• Perioperative STEMI: in-hospital mortality 30–35%; emergent ICA should be strongly considered
• Perioperative NSTEMI: GDMT as for spontaneous MI; ICA in selected patients (weigh bleeding vs thrombotic risk)
• Team-based decision: surgeon + anaesthesiologist + cardiologist

Special Populations (Section 10)

• Kidney/Liver transplant: Targeted (not routine) CAD screening; ISCHEMIA-CKD showed no benefit from invasive strategy vs GDMT alone
• Obesity/Bariatric surgery: 0.37% perioperative MI; prior ACS/HF → highest risk; sleeve gastrectomy fewer adverse events than Roux-en-Y; GLP-1 agonist discontinuation applies

Limitations of the Document

• Most evidence is observational/retrospective; few large RCTs specifically designed for perioperative settings
• Risk scores not validated for guiding management changes (only prediction)
• No studies show that managing elevated preoperative biomarkers improves outcomes
• MINS management strategies based on single RCT (MANAGE) with high discontinuation rates and post-hoc changes to primary outcome
• Limited data for timing of NCS after LVAD, TEER, and bariatric surgery
• Optimal perioperative BP thresholds not established by high-quality RCTs
• Perioperative management of sacubitril/valsartan not studied
• GLP-1 agonist guidance based on ASA consensus statement, not RCT data

Key Concepts Mentioned

• concepts/Perioperative-Cardiovascular-Assessment — core stepwise framework described in this guideline
• concepts/DAPT-Strategies — PCI timing and perioperative antiplatelet management
• concepts/Aortic-Stenosis — perioperative AS management algorithm
• concepts/Mitral-Stenosis — perioperative MS management
• concepts/Aortic-Regurgitation — perioperative AR management
• concepts/Primary-Mitral-Regurgitation — perioperative MR management
• concepts/TAVI — NCS timing after TAVI
• concepts/HFpEF — SGLT2i perioperative discontinuation
• concepts/OSA-Arrhythmogenic-Substrate — perioperative OSA screening and management

Key Entities Mentioned

• entities/Atrial-Fibrillation — perioperative AF management; new-onset POAF stroke risk
• entities/Heart-Failure — HF perioperative risk; SGLT2i discontinuation; GDMT continuation
• entities/Pulmonary-Hypertension — perioperative PH management; continue PAH therapies
• entities/HCM — avoid LVOT aggravating factors; vasopressors preferred over inotropes
• entities/Chronic-Coronary-Disease — perioperative revascularisation thresholds

Wiki Pages Updated

• wiki/sources/periop-aha-2024.md (this file — created)
• wiki/concepts/Perioperative-Cardiovascular-Assessment.md (created)
• wiki/entities/Atrial-Fibrillation.md (updated — perioperative AF section)
• wiki/entities/Heart-Failure.md (updated — SGLT2i periop, GDMT continuation)
• wiki/entities/Pulmonary-Hypertension.md (updated — perioperative PH management)
• wiki/entities/HCM.md (updated — perioperative HCM management)
• wiki/concepts/Aortic-Stenosis.md (updated — perioperative AS algorithm)
• wiki/concepts/Mitral-Stenosis.md (updated — perioperative MS management)
• wiki/concepts/TAVI.md (updated — NCS timing after TAVI)
• wiki/concepts/DAPT-Strategies.md (updated — PCI timing and perioperative antiplatelet)
• wiki/wikiindex.md (updated)
• wiki/sourceindex.md (updated)
• log.md (updated)