Comprehensive Preoperative Risk Stratification Components
Preoperative risk stratification should include medical history review, physical examination, laboratory tests, functional capacity assessment, and cardiac risk evaluation to identify patients at elevated risk (≥1% risk of major adverse cardiovascular events) who may require additional testing or optimization. 1
Medical History Components
Patient-Specific Factors
- Previous medical records review 2
- Presence of congenital or acquired blood disorders 2
- History of ischemic heart disease, heart failure, cerebrovascular disease 2
- Medication history, particularly:
- Vitamin or herbal supplement use affecting coagulation 2
- Previous drug exposures that could cause allergic reactions (e.g., aprotinin) 2
Surgical Risk Factors
- Urgency of procedure (emergency, urgent, time-sensitive, or elective) 1
- Type of surgery (low risk <1%, intermediate risk 1-5%, high risk >5% for cardiac events) 2
- Duration of procedure 2
Physical Examination
- Assessment for organ ischemia 2
- Evaluation for signs of coagulopathy 2
- Cardiovascular examination 2
- Pulmonary examination 2
Laboratory Testing
- Hemoglobin/hematocrit 2
- Coagulation profile (prothrombin time, platelet count) 2
- Renal function (creatinine) 2
- Additional laboratory tests based on patient's condition or institutional policy 2
Functional Capacity Assessment
- Evaluation using two-flight stairs test or Duke Activity Status Index (DASI) 2, 1
- Poor functional capacity defined as DASI <34 or <4 METs 1
- Good functional capacity defined as DASI ≥34 or ≥4 METs 1
Cardiac Risk Evaluation
- 12-lead ECG for intermediate and high-risk patients 2
- Use of validated risk prediction tools:
Special Populations Assessment
- Frailty assessment for patients >70 years using validated tool 2
- BMI evaluation (both high and low BMI associated with increased risk) 2
- Pulmonary hypertension assessment (if suspected) 2
Risk Modifiers Identification
- Severe valvular heart disease 1
- Severe pulmonary hypertension 1
- Elevated-risk congenital heart disease 1
- Prior coronary stents/CABG 1
- Recent stroke 1
- Presence of cardiovascular implantable electronic devices 1
Biomarker Assessment (for high-risk patients)
Additional Testing Based on Risk Level
- For low-risk patients without risk modifiers: proceed to surgery without further cardiac testing 1
- For elevated-risk patients without risk modifiers: consider 12-lead ECG 1
- For patients with risk modifiers: consider appropriate team-based consultation and echocardiography 1
- For patients with poor functional capacity: consider preoperative biomarker assessment 1
- For patients with abnormal biomarkers: consider noninvasive stress testing or coronary CT angiography 1
Documentation Requirements
- Patient preferences regarding blood transfusion 2
- Discussion of risks and potential outcomes with patients and families 1
- Multidisciplinary team involvement documentation for high-risk patients 1
Common Pitfalls to Avoid
- Routine preoperative testing without clinical indication increases costs without improving outcomes 4
- Discontinuing beta-blockers abruptly before surgery (can cause exacerbation of angina or MI) 3
- Failure to identify and optimize modifiable risk factors before elective procedures 2
- Over-reliance on a single risk calculator (no single calculator is universally superior) 1
- Performing routine evaluation of left ventricular function in asymptomatic and clinically stable patients 1
By following this comprehensive approach to preoperative risk stratification, clinicians can identify patients at elevated risk for perioperative complications and implement appropriate management strategies to improve outcomes.