What is the algorithm for preoperative cardiac risk assessment in 2025?

Algorithm for Preoperative Cardiac Risk Assessment 2025

The 2024 AHA/ACC guideline recommends a stepwise approach to perioperative cardiac risk assessment that focuses on identifying and managing patients at elevated risk for major adverse cardiovascular events (MACE). 1

Step 1: Initial Risk Stratification

1. Calculate baseline risk using a validated risk-prediction tool:

   • Revised Cardiac Risk Index (RCRI)
   • American College of Surgeons NSQIP risk calculator
   • AUB-HAS2 cardiovascular risk index
   • Consider elevated risk when RCRI >1 or calculated MACE risk >1% 1

2. Identify risk modifiers that increase perioperative risk:

   • Severe valvular heart disease
   • Severe pulmonary hypertension
   • Elevated-risk congenital heart disease
   • Prior coronary stents/CABG
   • Recent stroke
   • Presence of cardiovascular implantable electronic devices
   • Frailty 1

Step 2: Functional Capacity Assessment

1. Assess functional capacity using Duke Activity Status Index (DASI):
   • Poor functional capacity: DASI <34 or <4 METs
   • Good functional capacity: DASI ≥34 or ≥4 METs 1
   • Specific activities to assess: ability to climb 2 flights of stairs, perform household chores, participate in recreational activities

Step 3: Diagnostic Testing Based on Risk Profile

1. For low calculated risk and no risk modifiers:

   • Proceed to surgery without further cardiac testing 1

2. For elevated calculated risk without risk modifiers:

   • Consider 12-lead ECG in elevated-risk asymptomatic patients without established CVD
   • 12-lead ECG is reasonable in patients with established CVD or symptoms 1

3. For any risk level with risk modifiers present:

   • Consider appropriate team-based consultation
   • Echocardiography for suspected moderate/severe valvular disease, new dyspnea, or suspected new/worsening ventricular dysfunction 1

4. For patients with poor functional capacity:

   • Consider preoperative biomarker risk assessment:
     • BNP/NT-proBNP (abnormal if BNP >92 ng/L or NT-proBNP ≥300 ng/L)
     • Consider troponin (abnormal if >99th percentile URL) 1

5. For abnormal biomarkers:

   • Consider noninvasive stress testing or coronary computed tomography angiography (CCTA) 1

Step 4: Perioperative Management Based on Assessment

1. For low-risk findings:

   • Proceed to surgery
   • Consider guideline-directed medical therapy (GDMT) for long-term cardiovascular risk reduction 1

2. For high-risk findings (e.g., stress test or CCTA suggestive of left main or multivessel CAD):

   • Consider alternative strategies:
     • Deferral of surgery
     • Noninvasive or invasive treatment
     • Palliation
     • Proceed to surgery with heightened monitoring 1
   • Consider postoperative troponin surveillance 1

Important Considerations

1. Surgical timing definitions:

   • Emergency: <2 hours, immediate threat to life/limb
   • Urgent: 2-24 hours, threat to life/limb
   • Time-sensitive: can delay up to 3 months
   • Elective: can be delayed for complete evaluation 1

2. Surgical risk categories:

   • Low risk: <1% risk of MACE
   • Elevated risk: ≥1% risk of MACE 1

3. Avoid unnecessary testing:

   • Routine preoperative evaluation of LV function is not recommended in asymptomatic and clinically stable patients 1
   • Testing should only be performed if results would change perioperative management 2

4. Special populations requiring additional attention:

   • Adults aged ≥75 years (higher risk of perioperative MI and MACE)
   • Patients with coronary stents
   • Patients with heart failure 2

This algorithm provides a structured approach to preoperative cardiac risk assessment based on the most recent guidelines. The key is to identify patients at elevated risk, perform appropriate testing only when necessary, and implement risk-reduction strategies for those who need them.