What is the process for performing preoperative (pre-op) risk stratification?

From the Guidelines

Preoperative risk stratification should be performed using a stepwise approach, as outlined in the 2014 ACC/AHA guideline, which includes assessing the urgency of noncardiac surgery, evaluating the patient's clinical predictors of risk, and considering functional capacity and surgery-specific risk. This approach is based on the most recent and highest quality evidence available, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

The process begins with assessing the urgency of noncardiac surgery, as certain emergencies may not allow time for a preoperative cardiac evaluation. The next steps involve evaluating the patient's clinical predictors of risk, including major and intermediate predictors such as unstable coronary syndrome, decompensated heart failure, symptomatic arrhythmias, and severe valvular disease. The presence or absence of previous myocardial infarction, angina pectoris, compensated or previous heart failure, preoperative creatinine level, and diabetes mellitus also helps to further stratify clinical risk for perioperative coronary events.

• Key considerations in preoperative risk stratification include:
  • Evaluating the patient's functional capacity and level of surgery-specific risk
  • Considering the need for noninvasive testing, such as electrocardiogram, echocardiogram, or stress testing, in patients with intermediate predictors of clinical risk and moderate or excellent functional capacity
  • Assessing the patient's overall risk using tools like the Revised Cardiac Risk Index (RCRI) and the American Society of Anesthesiologists (ASA) Physical Status Classification
  • Evaluating the patient's pulmonary risk, including smoking history, chronic lung disease, and possibly pulmonary function tests for high-risk patients

The 2014 ACC/AHA guideline provides a comprehensive framework for preoperative risk stratification, emphasizing the importance of communication among all relevant parties, including the surgeon, anesthesiologist, primary caregiver, and consultants, as well as the patient 1. By following this stepwise approach, healthcare providers can identify potential risks and develop tailored perioperative management strategies to minimize complications and improve patient outcomes.

• The most critical aspect of preoperative risk stratification is to prioritize the patient's safety and well-being, and to make informed decisions based on the most recent and highest quality evidence available. In this case, the 2014 ACC/AHA guideline provides the most up-to-date and comprehensive guidance on preoperative risk stratification, and should be used as the primary reference for healthcare providers 1.

From the Research

Preoperative Risk Stratification Process

The process for performing preoperative (pre-op) risk stratification involves several key steps, including:

• Evaluation of the patient's medical history and physical examination to assess cardiac risk and identify potential complications 2, 3, 4, 5, 6
• Use of risk indices, guidelines, and algorithms to further assess the patient's risk and determine the need for additional testing or medical therapy 2, 5
• Consideration of the procedure-specific risk and the patient's overall health status to guide perioperative management 5
• Performance of additional technical tests, such as blood chemistry, electrocardiography, spirometry, or chest x-ray, only if they are likely to provide relevant information and alter the patient's management 3, 4, 6

Key Components of Preoperative Risk Assessment

The key components of preoperative risk assessment include:

• History-taking and physical examination, which remain the central components of preoperative risk assessment 6
• Evaluation of the patient's cardiac risk, including assessment of known or suspected major cardiovascular disease 3, 4, 5
• Consideration of the patient's long-term medication and potential perioperative management strategies 3, 4
• Use of advanced age as a factor in determining the need for ancillary testing, with testing only performed if relevant organ disease is known or suspected 6

Guidelines and Recommendations

Several guidelines and recommendations are available to guide preoperative risk stratification, including:

• The American College of Cardiology and the American Heart Association Task Force guidelines for preoperative cardiac evaluation 5
• The German Scientific Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine, and Surgery joint recommendations for preoperative evaluation of adult patients prior to elective noncardiothoracic surgery 3, 4
• The German specialty societies' consensus-derived recommendations for preoperative risk assessment 6