Assessment and Optimization of Cardiovascular Risk and Frailty Before Noncardiac Surgery: A Comparative Analysis of Recent European and American Guidelines

Perioperative cardiovascular complications and frailty are major drivers of morbidity, mortality, and loss of functional independence after noncardiac surgery, particularly in older adults. Updated European and American guidelines published between 2022 and 2025 address these challenges with differing approaches. This review provides a comparative analysis of contemporary European (European Society of Cardiology 2022, European Society of Anaesthesiology and Intensive Care 2025) and American (American Heart Association 2024) guidelines on preoperative cardiovascular risk and frailty assessment and optimization, highlighting clinically relevant differences for anesthesiologists managing adult patients undergoing elective noncardiac surgery. All guideline sets aim to improve perioperative risk stratification but differ in key domains. European guidelines discourage subjective estimation of functional capacity using metabolic equivalents and emphasize validated tools and objective assessment of cardiorespiratory fitness, whereas American guidelines retain a contextual role for subjective assessment. Recommendations regarding measuring natriuretic peptides, use of cardiac imaging, and thresholds for further evaluation also differ. A major innovation of the 2025 European guidelines is routine preoperative frailty screening, recognizing frailty as an independent predictor of postoperative complications, disability, and mortality. Furthermore, increasing emphasis is placed on multimodal prehabilitation and comprehensive geriatric assessment as multimodal strategies to optimize high-risk and frail patients before surgery. Current guidelines reflect a shift toward integrated, patient-centered perioperative assessment that combines cardiovascular risk evaluation with frailty and functional status. For anesthesiologists, incorporating frailty screening, objective functional assessment, and targeted optimization strategies may improve perioperative decision making and postoperative outcomes. However, harmonization of cardiovascular and frailty-based approaches is needed to consistently support implementation in daily clinical practice.