What are the key recommendations of the 2024 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for cardiovascular care?

Key Recommendations of the 2024 AHA/ACC Guidelines for Cardiovascular Care

The 2024 AHA/ACC guidelines provide comprehensive updates across multiple cardiovascular conditions, with significant new recommendations for hypertrophic cardiomyopathy (HCM), perioperative cardiovascular management, and peripheral artery disease (PAD).

Hypertrophic Cardiomyopathy (HCM) Guidelines

Major Updates in HCM Management

• Extended ambulatory monitoring is now recommended (Class 1) for AF screening in high-risk HCM patients who are eligible for anticoagulation, both at initial evaluation and annual follow-up 1. This represents an upgrade from the previous Class 2a recommendation.
• Exercise stress testing is now recommended (Class 1) for all pediatric HCM patients regardless of symptom status to determine functional capacity and provide prognostic information 1.
• Shared decision-making is emphasized as essential for optimal clinical care, involving thoughtful dialogue among patients, families, and healthcare teams 1.

Risk Stratification and ICD Placement

• For patients with ≥1 major SCD risk factor, discussion of estimated 5-year sudden death risk is useful during shared decision-making for ICD placement (Class 2a) 1.
• The age restriction (≥16 years) for this recommendation has been removed, expanding its application to younger patients 1.

Exercise Recommendations

• Evidence increasingly affirms that beneficial effects of exercise extend to HCM patients 1.
• Light, moderate, and vigorous recreational exercise has not been associated with increased risk of ventricular arrhythmia events in short-term studies 1.
• For patients pursuing rigorous exercise training for performance or competition, careful planning and regular reevaluation are important 1.

Perioperative Cardiovascular Management Guidelines

Stepwise Approach to Assessment

• A stepwise approach to perioperative cardiac assessment is recommended to determine when surgery should proceed or when further evaluation is warranted 1.
• Cardiovascular screening and treatment should adhere to the same indications as for nonsurgical patients, carefully timed to avoid surgical delays 1.

Stress Testing Recommendations

• Stress testing should be performed judiciously in patients undergoing noncardiac surgery, especially those at lower risk 1.
• Testing should only be done in patients in whom it would be appropriate independent of planned surgery 1.

Risk Assessment Tools

• Several validated cardiovascular risk indices are available, including the RCRI and the NSQIP MICA risk calculator 1.
• The 12-lead ECG may contain important prognostic information but rarely adds information beyond risk assessment tools 1.

Peripheral Artery Disease (PAD) Guidelines

Clinical Classification and Detection

• The guideline defines four clinical subsets of PAD: asymptomatic PAD, chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia, and acute limb ischemia 1.
• Detection of PAD in most patients is accomplished through history, physical examination, and resting ankle-brachial index 1.

Health Disparities and Treatment

• Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at individual and population levels 1.
• Effective medical therapies should be prescribed to prevent major adverse cardiovascular events and major adverse limb events 1.

Hypertension Management Guidelines

New BP Categories and Targets

• The 2024 ESC guidelines introduce a new BP category called 'Elevated BP' defined as office systolic BP of 120-139 mmHg or diastolic BP of 70-89 mmHg 1.
• A major evidence-based change is the recommendation to pursue a target systolic BP of 120-129 mmHg among adults receiving BP-lowering medications 1.
• Important caveats include: treatment must be well tolerated, more lenient targets may be considered in specific populations (symptomatic orthostatic hypotension, age ≥85 years, moderate-to-severe frailty), and out-of-office BP measurement is emphasized 1.

Heart Failure Guidelines

Expanded Medical Therapy

• Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) now includes four medication classes including sodium-glucose cotransporter-2 inhibitors (SGLT2i) 1.
• SGLT2i have a Class 2a recommendation in heart failure with mildly reduced ejection fraction (HFmrEF) 1.
• New recommendations for HFpEF include SGLT2i (Class 2a), MRAs (Class 2b), and ARNi (Class 2b) 1.

Common Pitfalls and Implementation Challenges

1. Failure to implement extended ambulatory monitoring for AF detection in high-risk HCM patients
2. Overly restrictive exercise recommendations for HCM patients despite evidence supporting benefits of appropriate exercise
3. Unnecessary preoperative cardiac testing in low-risk noncardiac surgery patients
4. Not addressing health disparities in PAD management
5. Failing to pursue the new lower BP targets (120-129 mmHg) when appropriate and tolerated
6. Not updating heart failure treatment regimens to include newer recommended agents like SGLT2i

The 2024 AHA/ACC guidelines represent significant advances in cardiovascular care across multiple conditions, with particular emphasis on personalized risk assessment, shared decision-making, and incorporation of newer therapeutic options with proven benefits for morbidity, mortality, and quality of life.