The 2014 perioperative guideline is superseded, and tenecteplase gets a bleeding nomogram

The edition in brief

The 2026 AHA/ACC perioperative cardiovascular guideline for noncardiac surgery formally supersedes the 2014 document, consolidating evaluation, drug management, monitoring and devices into one source. Twelve years of cardiology - DOACs, transcatheter valves, SGLT2 inhibitors, GLP-1 agonists and the troponin assays that made routine screening possible - have accumulated since the last version, and any local preoperative protocol still written against 2014 needs rereading. A pooled individual-patient analysis of 15,954 patients from six tenecteplase trials identified 169 intracranial haemorrhages and built a risk nomogram. Above a systolic pressure of 110 mmHg each additional 1 mmHg raised risk by 2% (adjusted OR 1.02, 95% CI 1.01-1.03), accelerating beyond 160 mmHg. The age effect depended on dose: risk rose about 1% per year of age at 30 mg but nearly 7% per year at 50 mg. Women had 49% higher odds (aOR 1.49, 1.06-2.11), and each 5 kg less body weight 16% higher odds (aOR 1.16, 1.03-1.30). Discrimination was moderate, C index 0.718. An English cohort of 7,836 patients followed three years found CT-derived fractional flow reserve associated with infarction, cardiovascular death and all-cause death independent of stenosis severity, with 0.67 the optimal risk threshold and a 1.5% three-year event rate when the value was normal. The ACC's nutrition statement moves guidance from nutrients to dietary patterns. A Class II recall affects one presentation of intravenous amiodarone.